gk’s notes

gk’s notes – part 1

Based on Masterclass by Dr. Lovaan - October 2024

Compiled and edited with OpenAI Whisper and Anthropic Claude AI

gk’s notes – part 1

Table of Contents
INTRODUCTION .................................................................................................................................... 1
INITIAL APPROACH ............................................................................................................................... 2
BREAKING BAD NEWS ......................................................................................................................... 26
BREAKING BAD NEWS SCENARIOS 1 : INTRACEREBRAL BLEED ..................................................................................... 28
Variation 1: Wife in Person............................................................................................................................. 36
Variation 2: Wife on Phone ............................................................................................................................ 37
Variation 3: Son in Hospital Room .................................................................................................................. 37
Variation 4: Son on Phone (Hassan Ali) .......................................................................................................... 37
Variation 5: English Version ........................................................................................................................... 39
BILATERAL STROKE SCENARIO .............................................................................................................................. 40
PALLIATIVE CARE SCENARIO - MOHAMMAD KHAN .................................................................................................... 43
POST-OPERATIVE COMPLICATION SCENARIO 1 - BLEEDING ........................................................................................ 48
POST-OPERATIVE COMPLICATION SCENARIO 2 - STROKE .......................................................................................... 53
OSTEOSARCOMA SCENARIO ................................................................................................................................. 59
NOSEBLEED SCENARIOS ......................................................................................................................70
SCENARIO 1: LGBT-RELATED TRANSGENDER TAKING TESTOSTERONE ........................................................................ 70
SCENARIO 2: PATIENT TAKING APIXABAN ............................................................................................................... 70
SCENARIO 3: SPONTANEOUS NOSEBLEED (NO APIXABAN, NO NOSE PICKING) ............................................................. 72
TEENAGE PREGNANCY SCENARIO .......................................................................................................................... 73
NURSING HOME SCENARIO - ELDERLY PATIENT WITH CONFUSION ............................................................................... 76
NURSING HOME SCENARIO - ELDERLY PATIENT WITH CONFUSION (NO INFECTION)........................................................ 81
OBSTRUCTIVE SLEEP APNEA ................................................................................................................................. 85
TIA, STROKE, AND BELL'S PALSY ......................................................................................................... 93
TRANSIENT ISCHEMIC ATTACK (TIA) IN GP SETTING ............................................................................................... 100
TIA DISCHARGE SCENARIO (A&E SETTING) .......................................................................................................... 106
STROKE CALL SCENARIO (TELEPHONE CONSULTATION) ........................................................................................... 111
BELL'S PALSY SCENARIO (GP SETTING) .................................................................................................................115
ENCEPHALITIS VS MENINGITIS SCENARIO (A&E SETTING) ................................................................... 119
BREAST LUMP SCENARIOS ................................................................................................................. 125
SCENARIO 1: SUSPECTED BREAST CANCER (NO MANNEQUIN) ................................................................................. 129
SCENARIO 2: SUSPECTED BREAST CANCER (WITH MANNEQUIN) .............................................................................. 130
SCENARIO 3: REASSURANCE (NO LUMP, NO FAMILY HISTORY) .................................................................................. 131
SCENARIO 4: MAMMOGRAM REQUEST (AGE ~50) .................................................................................................. 132
SCENARIO 5: MAMMOGRAM REQUEST (AGE ~32) ................................................................................................... 133
SCENARIO 6: BREAST ENGORGEMENT ................................................................................................................... 133
SCENARIO 7: MASTITIS (WITH MANNEQUIN) ............................................................................................................135
SCENARIO 8: MASTITIS (NO MANNEQUIN) ............................................................................................................. 136
IRRITABLE BOWEL SYNDROME (IBS) SCENARIO .................................................................................. 138
COLONIC CANCER SCENARIOS ........................................................................................................... 142
PALPITATIONS ...................................................................................................................................146
SCENARIO 1: MIDDLE-AGED MAN (50 YEARS OLD).................................................................................................. 148

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SCENARIO 2: OLDER MAN (70 YEARS OLD) ............................................................................................................ 149

SCENARIO 3: YOUNG MAN (30 YEARS OLD) ........................................................................................................... 149
SCENARIO 4: YOUNG PERSON (19 YEARS OLD) ....................................................................................................... 150
SIDE EFFECTS SCENARIOS .................................................................................................................. 153
OXYBUTYNIN SIDE EFFECTS SCENARIO ..................................................................................................................153
VAGINAL DISCHARGE SCENARIOS ...................................................................................................... 156
CANDIDA INFECTION ...........................................................................................................................................157
BACTERIAL VAGINOSIS ....................................................................................................................................... 159
ECG TEACHING SCENARIO .................................................................................................................. 163
FOUR BOX SYSTEM FOR MEDICAL CONSULTATIONS ........................................................................... 167
8-WEEK VACCINATION CONSULTATION .................................................................................................................. 173
PAP SMEAR CONSULTATION SCENARIOS ................................................................................................................179
Scenario 3: 25-year-old Transgender Man..................................................................................................... 182
SURGICAL ABORTION CONSULTATION .................................................................................................................. 184
DERMATOLOGY ................................................................................................................................. 190
MOLES AND BASAL CELL CARCINOMA .................................................................................................................. 197
I. Mole (Benign Nevus) ................................................................................................................................ 197
BASAL CELL CARCINOMA (BCC) .......................................................................................................................... 199
Scenario 1: BCC on Back of Head ................................................................................................................. 200
Scenario 2: BCC on Nose ............................................................................................................................. 201
Scenario 3: BCC on Forehead/Hairline .......................................................................................................... 202
SQUAMOUS CELL CARCINOMA (SCC)................................................................................................................... 204
MELANOMA ..................................................................................................................................................... 205
Scenario 1: Melanoma on Shoulder .............................................................................................................. 205
Scenario 2: Melanoma Behind the Ear ......................................................................................................... 207
SEBORRHEIC KERATOSIS .................................................................................................................................... 208
Seborrheic Keratosis - Male Patient ............................................................................................................. 210
RASH CONSULTATIONS IN DERMATOLOGY ............................................................................................................. 213
Cholinergic Urticaria ................................................................................................................................... 218
Scabies....................................................................................................................................................... 221
Acne Vulgaris .............................................................................................................................................. 223
Impetigo ..................................................................................................................................................... 228
Herpes Labialis ........................................................................................................................................... 229
Tinea Manuum ........................................................................................................................................... 232
Measles ...................................................................................................................................................... 234
Hemangioma.............................................................................................................................................. 237
Cellulitis ..................................................................................................................................................... 239
Chickenpox (Varicella) ................................................................................................................................. 241
Erythema Nodosum .................................................................................................................................... 243
PARONYCHIA .................................................................................................................................................... 246
PSORIASIS ....................................................................................................................................................... 248
Case Presentation 1: Elbow Psoriasis ........................................................................................................... 248
LYME DISEASE .................................................................................................................................................. 251
FOLLICULITIS .................................................................................................................................................... 254
ORAL CANDIDIASIS (ORAL THRUSH)..................................................................................................................... 256

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Case Presentation 1: Child ........................................................................................................................... 256

Case Presentation 2: Elderly Patient ............................................................................................................ 258
SYPHILIS .......................................................................................................................................................... 259
Case Presentation 1: Primary Syphilis in GP Setting ...................................................................................... 259
Case Presentation 2: Secondary Syphilis in GUM Clinic ................................................................................. 261
GENITAL HERPES .............................................................................................................................................. 265
GENITAL WARTS ............................................................................................................................................... 267
INTERTRIGO ..................................................................................................................................................... 270
MOLLUSCUM CONTAGIOSUM .............................................................................................................................. 272
HERPETIC WHITLOW ...........................................................................................................................................273
VULVAL CARCINOMA ..........................................................................................................................................275
TINEA CAPITIS ................................................................................................................................................... 277
TINEA PEDIS (ATHLETE'S FOOT) .......................................................................................................................... 279
ABUSE AND SAFEGUARDING .............................................................................................................. 282
ELDERLY ABUSE SCENARIO ................................................................................................................................. 284
SUSPECTED NON-ACCIDENTAL INJURY IN CHILDREN ............................................................................................... 287
DOMESTIC VIOLENCE WITH PV BLEEDING SCENARIO .............................................................................................. 292
DOMESTIC VIOLENCE WITH VAGINAL BLEEDING ..................................................................................................... 296
DOMESTIC VIOLENCE PRESENTING AS INSOMNIA.................................................................................................... 303
PATIENT-COUNSELLOR RELATIONSHIP CASE ......................................................................................................... 310
WORKPLACE HARASSMENT CASE (LGBT)..............................................................................................................315
RAPE CASE SCENARIO ....................................................................................................................................... 320
CLINICAL AND ETHICAL EXPLANATION SCENARIOS ............................................................................ 327
SICK NOTE REQUEST SCENARIOS ........................................................................................................................ 329
Scenario 1: Sick Note for Child's Chickenpox ................................................................................................. 329
Scenario 2: Sick Note for School Holidays..................................................................................................... 331
CHANGING NOTES SCENARIOS .............................................................................................................................333
Scenario 1: Ankle Pain ................................................................................................................................. 333
Scenario 2: Wrist Pain ................................................................................................................................. 335
WHIPLASH INJURY SCENARIOS ............................................................................................................................. 337
Scenario 1: Whiplash Malingering ................................................................................................................ 337
Scenario 2: Real Whiplash Injury .................................................................................................................. 339
MINI-MENTAL STATE EXAMINATION (MMSE) SCENARIO ........................................................................................ 342
CONFIDENTIALITY SCENARIO - DEPRESSION .......................................................................................................... 344
CONFIDENTIALITY SCENARIO - CONTRACEPTION FOR MINOR ................................................................................... 348
CONFIDENTIALITY SCENARIO - CONSULTANT SURGEON REQUESTING INFORMATION .....................................................351
HEAD INJURY SCENARIOS ................................................................................................................................... 354
Child Head Injury Scenario .......................................................................................................................... 355
Adult Head Injury Scenario .......................................................................................................................... 356
TONSILLECTOMY............................................................................................................................................... 358
ANTIBIOTIC REQUEST FOR VIRAL INFECTION .......................................................................................................... 363
DKA (DIABETIC KETOACIDOSIS) ...........................................................................................................................367
Scenario 1: Acute Medicine DKA Case .......................................................................................................... 368
Scenario 2: Paediatric DKA Case .................................................................................................................. 372
HYPOGLYCAEMIA .............................................................................................................................................. 376
COLONOSCOPY/SIGMOIDOSCOPY CASE................................................................................................................ 380
REFUSING BREAST CANCER TREATMENT ............................................................................................................... 385

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ECTOPIC PREGNANCY ........................................................................................................................................ 388

COLLEAGUE-RELATED SCENARIOS ..................................................................................................... 392
MEDICAL STUDENT COMING LATE ....................................................................................................................... 396
TWITTER POSTS ................................................................................................................................................ 401
FACEBOOK ACTIVITIES SCENARIO ........................................................................................................................ 405
DOCTOR POSTING ABOUT PATIENT ON FACEBOOK ................................................................................................. 409
MEDICAL STUDENT TAKING DRUGS ..................................................................................................................... 414
DOCTOR SMELLING OF ALCOHOL......................................................................................................................... 418
LGBTQ+ SCENARIOS ........................................................................................................................... 427
GENDER DYSPHORIA ......................................................................................................................................... 427
URINARY TRACT INFECTION (UTI) ........................................................................................................................ 432
PULMONARY EMBOLISM (PE) ............................................................................................................................. 434
NOSEBLEED AND HEADACHE .............................................................................................................................. 436
SEXUALITY CONCERNS ....................................................................................................................................... 439
FOLLOW-UP CONSULTATIONS ............................................................................................................ 443
SCENARIO 1: POLYMYALGIA RHEUMATICA FOLLOW-UP CONSULTATION ...................................................................... 446
SCENARIO 2: FOLLOW-UP WITH ELEVATED ESR AND CRP ....................................................................................... 450
SCENARIO 3: PATIENT-INITIATED CONTACT ........................................................................................................... 450
EPILEPSY FOLLOW-UP CONSULTATION ................................................................................................................. 452
Scenario 2: Non-Compliant Patient ............................................................................................................. 456
Scenario 3: Annual Review in GP ................................................................................................................. 456
Scenario 4: Discharge Scenario - Child with Epilepsy ..................................................................................... 457

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gk’s notes
gk’s notes

Introduction
UKMLA vs PLAB

• PLAB and UKMLA are the same exam in terms of content, questions, style,
method, and simulation
• UK graduates will take UKMLA in the future, but it will be different from the exam
for international medical graduates
• Key differences:
o UK graduates will take the exam at the end of their F1 year, not throughout
the year
o They will take it at their university, not at the GMC in Manchester
o They may sometimes interact with real patients, while international
graduates will always use simulators/actors

Marking System Changes

• The new system has removed decimal points from the passing marks
• Now, passing scores are whole numbers (usually 5, 6, or 7)
• Candidate marks have always been in whole numbers

Exam Fundamentals

PLAB2/UKMLA requires three key elements:

1. English

• Good command of English is crucial

• Avoid careless mistakes, especially with pronouns (he/she)
• Be clear when asking about timing
o Example: "How long has each episode lasted for?"
• Use proper language when taking history about someone from another person
o Example: "Has she had any long-term medical problems?" when asking about
someone's mother
o "Who does she live with?"
o "Does she take any regular medication?"

2. Emotions

• Be sensible and sensitive

• Show rapport and friendliness

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• Display empathy in difficult situations

• Avoid using stock phrases
• A stock phrase is a phrase you use without really meaning it
• A phrase can be meaningful in one context but a stock phrase in another

3. Energy

• Show interest and passion for the job

• Demonstrate positive body language
• Avoid a withdrawn approach
• They need to see that you are interested in and enjoying the job
• Show that you are happy to meet people, even if the situation is not good

Initial Approach
• Greet the patient with "Hello" (never use "Hi")
• Introduce yourself: "I am Dr. [Last Name]"
o Always use your last name, not first name (especially important for female
doctors)
o Incorrect: "I am Dr. Fatima" or "I am Dr. Aisha"
o Correct: "I am Dr. Javed" or "I am Dr. Abid"
• State your role: "I'm one of the doctors in this practice/department/surgery/clinic"
• Ask for the patient's full name: "Are you [Full Name]?"
o If the patient has a title, include it: "Are you Mrs. Sandra Jones?"
• Confirm the patient's age separately: "Can you please confirm your age for me?"
• To use the patient's first name, ask for permission: "Can I call you [First Name]?" or
"What can I call you?"
• After introductions, say "Nice to meet you, [Agreed Name]" and wait for the
patient's response

Common mistakes to avoid:

• Don't use casual greetings like "You must be John" or "Are you Sarah?"
• Don't combine name and age in one question (e.g., "Name and age, please")
• Don't use titles incorrectly (e.g., "Mrs. Rebecca" or "Mr. John")

Telephone Scenarios

• It's always the doctor who calls

• Calls are made according to appointment
• Calls are always considered anonymous initially

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Five Steps for Telephone Scenarios

1. Verify the patient's identity:

o "Hello, am I speaking to [Full Name]?"
2. Introduce yourself:
o "I'm Dr. [Last Name], one of the doctors from [Practice/Hospital]"
3. State the purpose of the call:
o "The reason I'm calling you today is..."
o Examples:
§ "I understand you brought your son to the hospital yesterday."
§ "I've been asked to speak to you about your father."
4. Get consent to continue:
o For non-urgent matters: "Is it a good time to talk?" or "Do you have a
minute?"
o For urgent matters: "Can I talk to you for a minute?"
5. Check identity:
o "Before I continue, I'd like to check some details to make sure I'm speaking
to the right person."
o "Can you please confirm your date of birth for me?"
o "And your first line of address as well, please."

Things to Avoid in Telephone Scenarios:

• Don't use the "If this call drops" phrase unless it's a genuine emergency triage call
• In colleague scenarios (e.g., speaking with a nurse), don't ask for personal details like
date of birth or address

Acknowledging Patient Concerns

Examples of proper acknowledgment:

• If a patient says: "My husband asked me to see you"

o Respond: "Why did your husband ask you to see us?"
• If a patient says: "I have an embarrassing problem"
o Respond: "Nothing to be embarrassed about, Mrs. Johnson. As doctors, we
encounter a variety of our patients' problems on a daily basis."
• If a patient says: "I have some personal problem"
o Respond: "Would you like to tell us more about your personal problem?"

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Observing and Addressing Body Language

• If the patient is fidgeting or shaking:

o Say: "You seem to be a little bit anxious. Is there anything you'd like to tell
us?"
o Don't say: "I can see you're fidgeting with your hands."
• If the patient is looking down or avoiding eye contact:
o Say: "It seems like something is bothering you. Is there anything going on?"
o Don't say: "You're not making eye contact."
• If the patient appears depressed:
o Say: "You seem to be a little down. Is there anything you would like to talk
about?"

Offering Confidentiality

• When the patient seems hesitant to share information, offer confidentiality

• Say: "[Patient Name], whatever we discuss will remain confidential. It seems like
something is bothering you. Would you like to talk about anything?"
• Don't say: "This is just between you and me"
• Confidentiality is like an official contract, not a personal promise

Critical Thinking and Logical Reasoning

• The exam tests your ability to think critically and communicate effectively
• It's not just about memorizing scenarios
• Be aware of contradictory information in scenarios - it's designed to test your critical
thinking
• Being illogical can lead to failing even if you reach the correct diagnosis
• Example: Don't immediately diagnose tension headache if a patient mentions a
"band-like headache"

Competitiveness and Mindset

• Approach the exam with a competitive mindset

• Think: "I am better than the person standing in front of me or behind me"
• The exam is like an interview - you need to impress in every aspect

Additional Important Points

• The exam is judgmental - they judge your character as a doctor

• Always demonstrate how you arrive at your conclusions

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• Be aware that the exam may include contradictory information to test your critical
thinking
• Remember that you're demonstrating readiness for UK medical practice
• The exam tests both critical thinking and effective communication

Dealing with Angry Patients

• A full set of angry patient scenarios will be covered in a separate class

• Learn to acknowledge the patient's emotions:
o "I can see that you are quite upset."
o "I can see that you are not very happy."
o "I can see that, Mr. Johnson, you are really angry about this."
o "I see that, Mr. Johnson, that you are really angry about this."
• It's important to learn how to acknowledge emotions properly

Starting Scenarios

• Starting scenarios is crucial as it shows understanding of the task

• Being disoriented can cause you to lose the scenario
• These things are very sensitive

Critical Points to Be Careful About

1. Using the wrong name

o Example: calling George as John
o This can cause you to lose the entire scenario
o You may apologize if you use the wrong name, but most of the time, it will
significantly impact the scenario
2. Disorientation
o You need to know:
§ What department you are in
§ What position you are in
§ The context of the meeting
o Understanding these fundamentals is important even if you haven't practiced
a specific scenario
o With good fundamentals, you can handle new scenarios better than others

Doctor's Plan vs Patient's Plan

• Determine if the meeting is due to the doctor's plan or the patient's plan
• Read and comprehend the scenario to understand why you are meeting this patient

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Doctor's Plan Examples:

1. Follow-up appointment
2. Referral to a specialist department
3. You've given the patient an appointment

If it's the doctor's plan, paraphrase:

• "I understand you are here for follow-up today."

• "I understand you have been referred by your GP."
• "I understand you have been asked to come to the doctors today."

Don't ask "How may I help you?" if it's a follow-up appointment you scheduled. This shows
disorientation and can negatively impact your performance.

Patient's Plan:

If the patient made the appointment or wants to speak to you:

• Start with "How may I help you?"

Example scenario: Colonoscopy/sigmoidoscopy

• Patient has had a sigmoidoscopy

• Consultant wants to do a colonoscopy
• Some polyps were removed previously
• Today's meeting is the patient's idea

Approach:

1. Understand that it's the patient's idea to meet you today

2. You can paraphrase the background information: "I understand you have had a
procedure earlier, and I've been told that you wanted to speak to one of the doctors
today. Is there anything in particular you would like to discuss?"

Understanding Your Role in the Scenario

• PLAB2 is essentially a role-play

• Simulators are trained to play their specific role
• You need to understand your position to engage in the role-play effectively
• If you're disoriented or take a different approach, it becomes difficult for simulators
to respond appropriately

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• This can lead to a chaotic scenario where you might discuss reXt topics (like
colonoscopy, sigmoidoscopy, polyps) but in a disoriented manner

Speaking to Relatives

• Don't assume relationships; always ask how they are related

• Read the task carefully

Correct Approach:

1. If given a name, use it: "Are you Hasan Ali?"

2. If no name is provided: "May I know your name, please?"
3. Then ask about the relationship:
o "I understand you are related to Mr. Williams. How are you related to him?"
o "I understand you are a close relative of Mr. Muhammad Ali. How are you
related to him?"
4. Always confirm the patient's age, not the relative's age: "Is it possible to confirm his
age as well?"

Things to Avoid:

• Don't ask "How are you related to my patient?"

• Avoid referring to the person as "patient" when speaking to relatives
o It's okay to use "patient" when discussing concepts or speaking with
colleagues, but not with family members
• Don't ask for the relative's age (e.g., don't ask for the son's age)

Correct Examples:

• "I understand you're related to Mohammed Khan. How are you related to Mr.
Mohammed Khan?"
• "I understand you are related to Emma White. How are you related to Emma
White?"
• After confirming the relationship: "Is it possible to confirm her age as well?"
• Ask how they would like to be addressed: "What can I call you?"

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P2MAFTOSA Framework for History Taking

Overview of P2MAFTOSA

• P1: Presenting Complaint

• P2: Past Medical History
• M: Medications
• A: Allergies
• F: Family History
• T: Travel History
• O: Occupation
• S: Social History
• A: Anything else

Note: P3 is not used in this framework. It's considered irreXt and can make people robotic.

Exploring the Presenting Complaint (P1)

Importance

• Failure to explore the presenting complaint properly is considered a failure

• Crucial for history scenarios

SOCRATES Approach for Pain

• Use SOCRATES for pain-related complaints

• Must be mastered for various types of pain:
o Headache
o Chest pain
o Back pain
o Ear pain
o Eye pain
o Hip pain
o Neck pain
o Testicular pain
o Ankle pain
o Any other pain

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Non-SOCRATES Scenarios

Some scenarios require a different approach than SOCRATES:

1. Constipation
2. Confusion
3. Weight gain
4. Weight loss
5. Insomnia

These are referred to as "non-FODPARA". Simple FODPARA will not work for these
scenarios.

Impact of Poor Data Gathering

• Poor data gathering can affect marks in the management section

Structure Between P1 and P2

Differential Diagnosis

• Place differential diagnosis questions between P1 and P2

• No set number of differentials to cover
• Approach to differentials:
1. Think of something serious first (e.g., MI or PE for chest pain, meningitis for
headache)
2. Then consider common conditions
3. Finally, consider rare conditions
• Time management is crucial in deciding how many differentials to explore
• PLAB2 is all about decision making. So you decide which one to include, which one
to exclude, which questions to be asked

Asking Differential Questions

• Ask the first question for a differential

• If negative, ask a second question
• If both are negative, move on to the next differential
• Don't ask five questions for one differential, then only one for the next
• Be bold in eliminating differentials based on negative responses

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Example (Headache differential for meningitis):

1. "Do you have a fever?" (If no)

2. "Do you have a rash?" (If no, move to next differential)
3. "There is no fever. There is no rash. This cannot be meningitis at all."

Additional example:

• "Have you had rash and flu?"

• "Is there any greenish discharge from the nose?"
• You've already asked in SOCRATES if leaning forward makes it worse

X, Y, Z Approach Between P1 and P2

X: Risk Factors

• Ask about reXt risk factors before reaching P2

• Don't wait until MAFTOSA if it's a crucial risk factor
• If you do it in the MAFTOSA, okay, that is fine.
• PLAB2 is all about reflecting on your thinking

Examples of risk factor questions:

• For TB suspicion in cough and fever: "Have you had any recent travel?"
• For PE suspicion in chest pain and shortness of breath: "Have you had any flight
journeys? Have you had any long flights?"
• For nose bleeding: "Do you take any blood thinner medication?"
• For HIV suspicion: Ask about sexual history before past medical history
• For plantar fasciitis: "Do you stand quite a long time?" or "What do you do for a
living?"

If you have a risk factor, it's better to reflect on that first, rather than asking later. It's not a
hard or fast rule, but if you miss it, it's okay. You ask in the MAFTOSA that is fine.

Y: Systemic Review

• Systemic review is going through the system, reviewing the system

• Examples of systemic review questions:
1. Neuro: "Do you have any headache, any dizziness, any balance problem,
maybe visual problem?"
2. Chest/Cardiac: "Any chest pain, any raising of the heart?"

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3. Respiratory: "Any cough, any shortness of breath, any wheezing, any

phlegm?"
4. GIT symptoms
5. Genital urinary symptoms
6. Joints-related symptoms
7. Skin-related symptoms
• First question in systemic review: "Have you been recently unwell? Any fever, flu?"
• Ask two to three questions on each system
• Not needed in every scenario, but important to know

When to do Systemic Review

1. When struggling with diagnosis

2. For suspected or diagnosed cancers
3. Conditions affecting multiple systems (e.g., HIV, TB, psoriasis, erythema nodosum)

Z: Cancer Symptoms

• Don't ask everywhere, only when cancer is suspected

• Include questions about fever, weight loss, tiredness, pain, anemia symptoms

Structure of History Taking

• X, Y, Z comes between presenting complaint and past medical history

• Once started with past medical history (P2), don't interrupt
• Follow a logical order

Consultation in Result Sheet

• Consultation means logical order, not just sitting down and talking
• If "consultation" is ticked in result sheet along with diagnosis, it means diagnosis is
right but logic is lacking
• Consultation tick can mean:
1. No structure or logic
2. Jumping between topics (e.g., family history to presenting complaint)
• Consultation being ticked can also mean:
1. Diagnosis is wrong
2. Diagnosis not explained
3. No logic in approach to reaching diagnosis (e.g., chronic fatigue syndrome)

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Language Use in Consultation

Avoid using these terms with patients:

1. "History" (use "long-term medical problem/condition" instead)

2. "Investigations" (use "testing" instead)
3. "Management" (use "what needs to be done" instead)

Asking about Past Medical History

• "Do you have any long-term medical problem/condition?"

• "Have you ever been diagnosed with any long-term medical conditions?"

Asking about Medications

• Don't use "drug"

• Ask: "Do you take any regular medications?"

Asking about Allergies

• "Do you have any allergies for any medications?"

• "Any food allergy?"

Asking about Family History

• Don't use "family history"

• Ask: "Anyone in your family ever been diagnosed with...?"
• Ask for diagnosed conditions, not symptoms (except for infections)
• For cancer: "I'm sorry to ask about this, but has anyone in the family ever been
diagnosed with [specific cancer]?"
• Family history is asked for three things:
1. Genetic/gene-related conditions
2. Infections (ask about symptoms in this case)
3. Cancers

Examples:

• For heart conditions: "Anyone in the family had any heart-related conditions like
heart attack, stroke?"
• For ear problems: "Anyone in the family had any long-term ear conditions?"
• For clots: "Anyone in the family had any clots in their lungs or legs?"

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• For glaucoma: "Anyone in the family had any eye problem, an eye condition called
glaucoma?"
• For depression: "Anyone in the family diagnosed with depression?"
• For infections: "Anyone in the family had a similar cough, similar fever, similar
diarrhea?"

Travel History

• "Have you had any recent travel?"

Occupation

• "What do you do for living?"

Social History

• Varies depending on age and context (30-year-old different from 50 or 70-year-old)

• Can include occupation, smoking, alcohol, recreational activities, living conditions

Anything Else

• "Is there anything else you think we should know about?"

ICE (Ideas, Concerns, Expectations)

• Important concept in patient-centered management

• Do ICE in the latter part of history, not at the beginning
• Don't answer ICE questions immediately, but don't ignore them
• Signpost that you'll address their concerns later: "I will be explaining this to you in a
while" or "I will answer your question in a while"

Asking ICE Questions

• Idea: "What do you think could be the cause/reason for your symptom?"
• Concern: "Are you concerned/worried about anything?" "Is there anything that
bothers you about this?"
• Expectation: "Is there anything you're hoping we should do for you today?" or "Is
there anything particularly you are expecting in this consultation?"

Note: Ask expectation questions in a nice way, with emotion and flavor. Don't sound
robotic.

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Effect of Symptoms

• Ask: "How has this been affecting your life in general?" or "How has this impacted
your life?"
• For long-term conditions, explore impact on work, sleep, relationships, sexual life

Final Structure of History Taking

1. Presenting complaint
2. Differentials
3. Past history and MAFTOSA (don't bring presenting complaint in between)
4. Last part (ICE and effect of symptoms)

Additional Points

• Ask about driving if relevant(e.g., for dizziness, not for PCOS)

• PLAB2 is about being specific in questions
• Implement ICE properly for good data gathering and management scores
• When they write scripts for simulators, they include specific ICE answers
• English is a language of tone - the same sentence can sound rude or extremely nice
depending on how it's said

Physical Examination

Approaching the Examination

• Inform the patient about the examination: "I would like to examine you" or "I
would like to do some physical examination on you. Is that OK?"
• Avoid saying: "I will examine you" or "I am going to examine you"
• Don't use the term "vitals"
• Explain what the observation includes:
o "That includes checking your blood pressure, temperature, oxygen levels in
your body (not 'saturation'), breathing rate (not 'respiratory rate'), and pulse
(or heart rate)"
• Avoid saying "head to toe examination"
• Be specific about what you want to examine, e.g.:
o "I would like to examine your lungs/chest"
o "I would like to listen to your heart"
o "I would like to examine your tummy"
o "I would like to examine your back passage"
o "I would like to examine your leg"
o "I would like to do a testicular examination"

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gk’s notes – part 1

o "I would like to do a hearing test"

o "I would like to check the back of your eye"
o "I would like to examine the nerves on your head and neck"
• For specific examinations, mention them explicitly, e.g.:
o "I would like to do a speculum examination to check the neck of your cervix"
• Being specific is crucial as findings are in different clipboards
o Example: For abdominal aortic aneurysm, say "I would like to examine your
tummy" to get the finding of a pulsatile mass
o For hyperemesis gravidarum, mention "I would like to check for substantial
ketones in the urine"
o For bulimia, ask "Do you know anything about your BMI?" or "I would like
to check your BMI"

Explaining Findings

• If given findings, explain them to the patient

• Example for Parkinson's: "You have some slowness of movement, stiffness in your
hand, and you're taking small steps when you walk"
• Example for acoustic neuroma: "We have examined your hearing. On the right side,
you are not able to hear properly"
• Failure to explain findings to the patient will result in a tick on the result sheet

Blood Tests and Investigations

• Don't include blood tests with the physical examination (except in A&E setup)
• Blood tests are generally part of later management
• In GP settings, you can't do immediate blood tests
• Scenarios are designed for clinical diagnosis without immediate blood tests
• If blood tests are needed for diagnosis, it will be part of the scenario or on the table
from the beginning
• Bedside tests (can be done without a laboratory) include:
1. Urine dipstick
2. Pregnancy test
3. ECG

Examiner Interaction

• Don't look at the examiner for validation

• Examiners are "invisible" once the scenario starts
• Examiners won't show facial expressions or give feedback during the exam

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Diagnosis

Approaching the Diagnosis

• After history and examination, thank the patient for the information
• Tell the diagnosis without justification
• Don't summarize symptoms when telling the diagnosis
• Use phrases like: "This could be" or "Our impression is that this could be"
• Avoid saying "suspecting" or "suspected"
• Example: "This could be a condition called obstructive sleep apnea/Meniere's
disease/Parkinson's/meningitis"

Steps for Communicating Diagnosis

1. Tell: State the name of the condition

2. Ask: "Have you heard about it?" or "Do you know anything about it?"
3. Explain: Give the definition of the condition
4. Check understanding

Importance of Definition

• Shows your understanding of pathology and pathophysiology

• Helps the patient understand their condition
• Demonstrates your communication skills and ability to explain
• Every scenario has a definition, you must know it
• Definition is important because:
1. It shows your understanding of the pathology and pathophysiology
2. It helps the patient understand what's going on
3. It demonstrates your ability to explain and communicate effectively

Definition in Diagnosis

When providing a definition for a condition, include three key elements:

1. Where is the problem?

2. What is happening there?
3. Any obvious risk factors

Where is the problem?

• Specify the part of the body affected

o Example: Parkinson's affects the brain

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gk’s notes – part 1

o Example: Meniere's disease affects the inner ear

o Example: Dementia affects the brain

What is happening there?

Five common pathophysiological processes:

1. Inflammation
2. Infection or inflammation due to infection
3. Autoimmune reaction (inflammation due to autoimmune)
4. Abnormal or altered function
5. Neoplasia (growth)

Additional possibilities:

• Damage to glands
• Continuous irritation (e.g., Morton's neuroma)

Examples:

• Epilepsy: Abnormal electrical activity of the brain

• Trigeminal neuralgia: Altered function of the nerve
• Chronic fatigue syndrome: Altered function
• IBS (irritable bowel syndrome): Functional disorder

Risk Factors

Include any obvious risk factors in the definition if applicable

Examples of definitions:

• Parkinson's: "It's a condition of the brain that affects the movements of the body.
This is due to lack of a substance called dopamine in the brain."
• Sleep apnea: "It's a condition of the airways. During sleep, the throat muscles
become over-relaxed and collapse, closing the airway. This process makes people
wake up from sleep and gasp for air."
• Tuberculosis: "It's an infection of the lungs."
• Pericarditis: "It's inflammation of the covering of the heart, usually caused by viral
infection."
• Meningitis: "It's inflammation of the covering of the brain."
• Encephalitis: "It's inflammation of the brain tissue, usually caused by infections."

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• Endometriosis: "It's a condition where tissue similar to the lining of your womb can
be present in other parts of the body. When you have a period, due to hormonal
changes, these tissues can become sensitive and cause symptoms."
• Polymyalgia rheumatica: "It's an inflammation of mainly the large joints like hip and
shoulder and the muscles surrounding them. It's an autoimmune condition where
the defense against infections mistakenly attacks our own tissue and causes
inflammation. Sometimes it can run in the family, and if you have one autoimmune
condition, that can cause another autoimmune condition."

Additional conditions to study definitions for:

• ARMD (Age-related Macular Degeneration)

• Trigeminal neuralgia
• Premenstrual syndrome
• Endometriosis

Note: You don't need to memorize all definitions. If you know medicine and have studied
pathology, you need to formulate the right sentences and deliver them. However, for
conditions like chronic fatigue syndrome and IBS, you may need to memorize the
definitions as they can be more challenging to explain.

Management

• Management covers:
1. Diagnosis
2. Explaining to the patient
3. Formulating a management plan
• Focus on improving management marks
• Good management marks can lead to overall better performance
• Understanding and implementing good management strategies can significantly
improve exam results

Result Sheet Analysis

• Consultation section in the result sheet is crucial

• If "consultation" is ticked along with diagnosis, it means:
1. Diagnosis is right but logic is lacking
2. No structure or logic in approach
3. Jumping between topics (e.g., family history to presenting complaint)
• Diagnosis can be ticked if:
1. The diagnosis is wrong
2. The diagnosis is not explained

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Structure of Management

1. Type of condition (e.g., medical emergency, self-limiting)

2. Confirmatory tests
3. Main medication/treatment
4. Other treatments
5. Advice to the patient
6. Safety netting
7. Follow-up
8. Patient information leaflets

Approaching Management

• Start with: "Let me explain to you what we need to do for you now."
• Avoid asking: "Do you want to know what we are going to do for you?"
• Don't say: "We have a couple of options. Which one would you like to discuss?"
• Lead the conversation as the doctor and advisor
• Formulate a structure that allows patients to understand:
o What's going on with them
o What this is about
o What the doctor is going to do
o How they are going to be treated

• Avoid saying things like:

o "We will refer to the specialist. They will do some testing, and they will treat
accordingly."
o "I refer to the hospital. In the hospital, they will do the testing, and they will
do treatment for you."

Medical Emergencies

Specify if the condition is a medical emergency. Examples:

• Septic arthritis
• Pulmonary embolism (PE)
• Carbon monoxide poisoning

Actions for medical emergencies:

• Ask the patient to go to the hospital

• Call an ambulance

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gk’s notes – part 1

• Get an urgent appointment in a specialist department (e.g., TIA clinic within 24

hours)

Confirmatory Tests

Explain what tests will be done to confirm the diagnosis. Examples:

• Meningitis: "They need to do MRI, PCR on blood or fluid from the spine (lumbar
puncture)."
• Toxoplasmosis: "It's confirmed by a blood test for antigen and antibody."
• Lyme disease: "The specialist will do a test called ELISA, which is a blood test to
look for specific markers."
• Ankylosing spondylitis: "We'll do a test called HLA-B27 before referring you to a
specialist."
• Pneumonia: "We take a throat swab and urine sample for antigen, along with x-ray
and blood reports."

Note: Some conditions don't require confirmatory tests (e.g., sinusitis). Avoid unnecessary
tests as it can negatively impact your marks.

Main Medication/Treatment

Specify the main treatment, including medication names when appropriate. Examples:

• Sleep apnea: "The main treatment is CPAP (Continuous Positive Airway Pressure)."
• Migraine: "The main medication is sumatriptan."
• Parkinson's: "The main medication is carbidopa."
• Ankylosing spondylitis: "The main treatment initially is painkillers."
• Acute bacterial sinusitis: "We give an antibiotic called phenoxymethyl penicillin."
• Trigeminal neuralgia: "The main medication is carbamazepine."
• Gonorrhea: "It's treated with an antibiotic called ceftriaxone, given as a single
injection."

Other Treatments

Mention additional treatments or interventions. Examples:

• Migraine: "We also give metoclopramide for nausea, regardless of whether you're
experiencing it. We may also discuss propranolol for prevention."
• Parkinson's: "Other treatments include physiotherapy, speech and language therapy,
and occupational therapy. There's a multidisciplinary team involved."

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• Ankylosing spondylitis: "Other treatments include physiotherapy and exercise

programs. If these don't work, we may need to consider steroid medication given by
a specialist."
• Sinusitis: "You can use painkillers and nasal steroids in addition to the antibiotic."

Advice to the Patient

Provide advice on how to manage or improve the condition. Use soft language and avoid
giving orders. Examples:

• "We will advise you to avoid driving."

• "We will advise you to cut down on red meat."
• "It is advisable to do regular exercise."
• "It is better to do at least 30 minutes of exercise five times a week."
• "It is better to cook rather than getting food from outside."
• "Avoid eating fatty foods, oily food, fast food, processed food."

Safety Netting

Provide safety netting for potential complications or adverse outcomes, not for patient
concerns. Examples:

• For sinusitis: Warn about potential progression to meningitis (ascending infection)

• For urticaria: Warn about potential progression to anaphylaxis

Don't provide safety netting for patient concerns if they're not reXt. For example:

• If a patient with cholinergic urticaria asks about meningitis, explain why it's not
meningitis but don't provide safety netting for meningitis.

Follow-up

Specify if and when follow-up is needed. Examples:

• UTI: "Your child should feel better within 48 hours. If there's no improvement
within 48 hours, you need to inform us. If the child gets better, you don't need to
see us again."
• Mumps: "Follow-up in one week. Patients should self-isolate for seven days."
• Simple tinnitus: "If there's no improvement in six weeks, we may need to refer you
to a specialist."
• Morton's neuroma/metatarsalgia: "If there's no improvement with physiotherapy
and painkillers within three months, we need to refer you."

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• Primary dysmenorrhea: "Try painkillers and OCP for 3-6 months. If there's no
improvement within six months, we'll refer you to a specialist."
• Polymyalgia rheumatica: "Initially, monthly follow-up."
• Depression: "For patients under 30, follow-up within one week if started on
medication. For patients over 30, follow-up in two weeks. For postpartum
depression, follow-up in one week."
• Parkinson's: "Follow-up in about three to four months."
• Hypothyroidism: "Follow-up in three months."
• Gonorrhea: "Follow-up in one week to ensure you've been tested and treated, and
that the treatment is working."

Patient Information Leaflets

Offer information leaflets to patients. Say:

• "We will give you some information to read about this."

• "We will offer you some information to read."
• For telephone consultations: "We will send some information to read to your
email."

Note: Leaflet is a concept, not a physical item in the exam room.

Answering Patient Questions

• Start answers with "Well" (it's a diplomatic start and implies "not really" or "given the
circumstances")
• Use "we" instead of "I" in management discussions
• Avoid calling for senior colleagues unless absolutely necessary (e.g., suicidal
ideation, subarachnoid hemorrhage, meningitis, domestic violence)

How to answer questions:

• For "no": "Well, it doesn't look like..." or "It is highly unlikely..."

• For "yes": "Well, that shouldn't be a problem." or "You should be fine." or "You
should be able to..."
• For uncertain situations: "It is difficult to say..." or "Unfortunately, it is not very
clear to us..."
• Avoid saying "I don't know." Instead, use "We are not really sure yet." or "We are
not really sure exactly what went wrong."

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Examples:

• "Well, it doesn't look like meningitis."

• "It is highly unlikely that a dose of antibiotic will cause any long-term problem."
• "You should be able to go to work by next week."
• "Unfortunately, it is not very clear why she developed this stroke. Stroke is quite
common in elderly people."

Checking Understanding

After explaining the definition or management plan, always check the patient's
understanding:

• "Do you understand?"

• "Is it clear?"
• "Are you able to follow me?"
• "Is it understandable so far?"
• "Do you want me to repeat anything for you?"

Avoid saying:

• "How does that sound to you?" (when checking understanding)

• "Are you getting my point?"
• "I'm sorry, we are using too many medical terms."

Specific Management Examples

1. Gonorrhea management:
o Refer to GUM (genitourinary medicine) clinic
o Ask for consent: "Are you okay to go there?"
o If patient refuses, ask why and offer alternatives
o Explain the process: swab from penis, blood test for confirmation
o Specify treatment: "Gonorrhea is treated with an antibiotic called
ceftriaxone, given as a single injection."
o Mention partner notification
o Follow up in one week
2. Depression management:
o For patients under 30: follow-up within one week if started on medication
o For patients over 30: follow-up in two weeks
o For postpartum depression: follow-up in one week

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Timing of Management Discussion

• Don't wait to start management until the last six minutes

• The two-minute bell is to indicate time remaining, not to start management
• When you hear the two-minute remaining bell, you should be explaining the
condition to the patient
• Management is where examiners can really see who you are, your explanation skills,
formulation of management, organization skills, and ability to answer questions
• The more you do in management, the more marks you're likely to get

Language Use in Management

• Use "we" instead of "I" in management discussions

o Example: "We would like to offer" instead of "I will do this"
• The only place to use "I" is during examination: "I would like to do an examination"

Avoiding Senior Consultation

• Avoid saying you'll consult seniors for simple scenarios

• Calling for seniors can negatively affect your marks
• Examiners want to hear your advice, not what a senior might say
• Exceptions where mentioning seniors is appropriate:
o Suicidal ideation
o Subarachnoid hemorrhage
o Meningitis diagnosis in your clinic
o Discharging someone with suicidal ideas
o Domestic violence cases

General Advice for PLAB2/UKMLA

• Start management well before the last two minutes

• Focus on improving management marks
• Pay attention to small details in your performance
• Aim for error-free, quality performance with logical and good communication
• Eliminate minor issues, especially if you're borderline
• Build confidence, but avoid overconfidence
• Understanding the setup and direction of the exam helps in performing better
• Create your own notes with understanding rather than memorizing others' notes
• Implement the concepts learned to build confidence in facing any scenario
• The exam is about satisfying the examiner and building their confidence in you
• Understand that this is a medical licensing exam, requiring substantial medical
knowledge

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gk’s notes – part 1

• Be aware that if the diagnosis is wrong, it's very difficult to pass the scenario
• Practice speaking and giving advice - the way you articulate and formulate sentences
is crucial for management marks
• Your performance should be entertaining and fun to watch, not boring
• Communication should be smooth with nice logic
• People should be able to learn something while watching your performance
• Avoid using these terms with patients:

1. "History" (use "long-term medical problem/condition" instead)

2. "Investigations" (use "testing" instead)
3. "Management" (use "what needs to be done" instead)

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Breaking Bad News

Introduction to Breaking Bad News

• Breaking bad news scenarios were very common in PLAB exams

• Frequency has decreased recently, but could increase again
• Being proficient in breaking bad news is crucial for overall performance
• If you can handle breaking bad news, other scenarios become easier
• In Breaking Bad News, a clear message is crucial. The news you're going to deliver is
based on the pathology. You need to know the pathology to ask about risk factors
and deliver the right message.

Types of Breaking Bad News Scenarios

1. Intracerebral bleed (with variations)

2. Post-operative bleed
3. Post-operative stroke
4. Breast cancer
5. Bilateral stroke
6. Terminal dementia
7. Osteosarcoma
8. Another stroke scenario (MK scenario)
9. HIV (not typically discussed in detail)

Not Breaking Bad News Scenarios

• Multiple myeloma
• Leukemia
• Premature ovarian failure
• Missed miscarriage

These are considered suspected cancers or different conditions, not breaking bad news.

Key Messages in Breaking Bad News

1. Terminal condition leading to palliative care (3 scenarios):

o Intracerebral bleed
o Bilateral stroke
o Stroke
2. Post-operative complications (2 scenarios):
o Bleeding

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gk’s notes – part 1

oStroke
3. Cancers:
o Breast cancer
o Osteosarcoma (suspected pathologically)

The FOUR Question System

The FOUR question system is used to assess a patient's previous visit, admission, or
treatment. It is based on four key elements:

1. Symptoms
2. Investigation
3. Diagnosis
4. Treatment

How to Use the FOUR Question System:

Start with open-ended questions, then follow up with closed-ended questions for each
element.

Symptoms:

• Open-ended: "What sort of symptoms did you have when you were last admitted?"
• Closed-ended: "Did you experience any chest pain? Shortness of breath? Numbness?
Weakness? Speech problems? Swallowing difficulties?"

Investigation (referred to as "tests" when speaking to patients):

• Open-ended: "What kind of tests did the doctors do?"

• Closed-ended: "Did they do an X-ray? A CT scan? Any blood tests?"

Diagnosis:

• Open-ended: "What did they tell you was wrong?"

• Closed-ended: "Did they mention any specific condition?"

Treatment:

• Open-ended: "How were you treated?"

• Closed-ended: "Were you given any medication? Did you have any procedures
done?"

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Follow-up questions:

• "Was the treatment helpful?"

• "Did you improve after the treatment?"
• "What made you come back to the hospital?"

Important Notes:

• Use "tests" instead of "investigations" when talking to patients.

• Don't tell patients you're asking yes/no questions; simply ask them.
• This system is part of interpersonal skills assessment.
• 50% of management is based on speaking and language skills.

Interpersonal Skills in Medical Scenarios

Key elements of interpersonal skills:

1. Initial approach to the station

o Greet the patient/family member
o Establish rapport (use the three E's: Eye contact, Empathy, Engagement)
2. Use of open-ended and closed-ended questions
o Start with open-ended questions
o Follow up with specific closed-ended questions
3. Understanding of ethical principles
o Reflect on and apply ethical considerations in patient care

Breaking Bad News Scenarios 1 : Intracerebral bleed

Background

• 77-year-old man
• Collapsed at home
• Brought to hospital by ambulance
• Unconscious but breathing independently
• Neurosurgeons have assessed and classified condition as terminal
• CT scan shows massive intracerebral bleed
• Surgeons believe it's due to burst of perianeurysm
• Task: Speak to his wife, Mrs. Ali

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gk’s notes – part 1

1. Introduction and Paraphrasing

• Introduction: "Hello, I'm Dr. [Last Name], one of the doctors. May I know your
name, please?" "Mrs. Ali, I understand you are related to Mr. Muhammad Ali. How
are you related to him?" "Is it possible to confirm his age as well?"
• Always paraphrase for breaking bad news scenarios
• It's your plan, not the patient's
• Paraphrase: "I understand Mr. Muhammad Ali was brought in this morning by an
ambulance. Would you like to tell us exactly what happened?"

The FOUR Question System

The FOUR question system is used to assess a patient's previous visit, admission, or
treatment. It is based on four key elements:

5. Symptoms
6. Investigation
7. Diagnosis
8. Treatment

How to Use the FOUR Question System:

Start with open-ended questions, then follow up with closed-ended questions for each
element.

Symptoms:

• Open-ended: "What sort of symptoms did you have when you were last admitted?"
• Closed-ended: "Did you experience any chest pain? Shortness of breath? Numbness?
Weakness? Speech problems? Swallowing difficulties?"

Investigation (referred to as "tests" when speaking to patients):

• Open-ended: "What kind of tests did the doctors do?"

• Closed-ended: "Did they do an X-ray? A CT scan? Any blood tests?"

Diagnosis:

• Open-ended: "What did they tell you was wrong?"

• Closed-ended: "Did they mention any specific condition?"

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gk’s notes – part 1

Treatment:

• Open-ended: "How were you treated?"

• Closed-ended: "Were you given any medication? Did you have any procedures
done?"

Follow-up questions:

• "Was the treatment helpful?"

• "Did you improve after the treatment?"
• "What made you come back to the hospital?"

Important Notes:

• Use "tests" instead of "investigations" when talking to patients.

• Don't tell patients you're asking yes/no questions; simply ask them.
• This system is part of interpersonal skills assessment.
• 50% of management is based on speaking and language skills.

Interpersonal Skills in Medical Scenarios

Key elements of interpersonal skills:

4. Initial approach to the station

o Greet the patient/family member
o Establish rapport (use the three E's: Eye contact, Empathy, Engagement)
5. Use of open-ended and closed-ended questions
o Start with open-ended questions
o Follow up with specific closed-ended questions
6. Understanding of ethical principles
o Reflect on and apply ethical considerations in patient care

2. Taking History

Three main elements: a) Incident history (if applicable) b) Prior knowledge c) Signs and
symptoms

a) Incident History

• Focus on timing: before, during, and after the incident

• Ask questions like:
o "How did it happen?"

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gk’s notes – part 1

o "Did you witness it?"

o "Where did he collapse?"
o "Was there any injury or bleeding?"
o "Did he develop any fits?"
o "When did this happen?"
o "How long ago did this happen?"
o "When were you able to bring him to the hospital?"

b) Prior Knowledge

• Ask about symptoms just before the incident

• Example: "Has he had any symptoms at all today? Was he unwell today?"
• If they mention headache: "When did he develop the headache? Did he take any
medication? Was it helpful?"

c) Signs and Symptoms

• Important for cancer-related scenarios

Additional History Questions

• Past medical history: "Has he had any long-term medical problems?" (Focus on
blood pressure, blood sugar, kidney conditions, brain scans)
• Medications: "Does he take any blood thinner medications like warfarin or aspirin?"
• Family history: "Has anyone in the family had a similar situation or sudden death?"
(Preface with "I'm sorry to ask about this")
• Social history: "What does he do for living? Was he working? Was he active?"

Important Questions to Ask

1. Next of kin: "Who is his next of kin?"

2. Lasting Power of Attorney: "Does he have a Lasting Power of Attorney?"

Note:

• Next of kin: Everyone has a next of kin. It's nominated by the patient to the GP for
their records. It could be anyone - a friend, family member, partner, or neighbor.
Next of kin doesn't have any legal rights; it's just a communication point.
• Lasting Power of Attorney: Not everyone has this. It's more common for people
after pension age (68-70) or those with long-term medical conditions. It's a legal
document signed with solicitors that gives someone the legal right to decide on
behalf of the patient when they're not able to decide for themselves.

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• Ask about next of kin directly, but for Lasting Power of Attorney, first ask if they
have one.

3. Preparing and Delivering the Message

Follow these steps: a) Invite b) Narrate c) Warn d) Deliver the news with "sorry"

a) Invite

• "I have an important update about Mr. Muhammad Ali that I've been asked to
discuss with you. Can I talk to you?"
• "Are you on your own? Is there anybody with you? Before we discuss, would you like
to call anybody?"

b) Narrate

• Start with "As we understand..."

• Tell the story in chronological order
• Example: "As we understand, Mr. Muhammad Ali unfortunately collapsed at home.
An ambulance was called, and he was brought to the hospital unconscious. He was
assessed by a team of specialists, including brain surgeons and a multidisciplinary
team. We have also done a CT scan of his head."

c) Warn

• Give a warning shot based on the biggest test or examination

• Example: "I'm afraid unfortunately we don't have very good news regarding his CT
scan."

d) Deliver the News

• Be empathetic and use appropriate body language

• Raise eyebrows, have wrinkles on forehead, maintain serious and sympathetic eye
contact
• Use a clear but empathetic tone
• Avoid medical terms
• Example: "I'm sorry to tell you, he suffered from a major bleed in his brain."
• Pause and observe the patient's reaction
• Follow up with: "Unfortunately, I'm sorry to tell you his condition is terminal."

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4. Managing the Situation

• Offer tissues if the patient is crying

• Offer water if necessary
• Ask if there's anyone you can call for them
• After delivering the news, observe a "golden silence". Wait for the patient's reaction
and let them process the information. Don't rush to fill the silence.
• Wait for a signal from the patient to continue the conversation

Explaining Palliative Treatment

• Definition: "We are planning to offer palliative treatment. This is a form of

supportive care. The aim of palliative treatment is to take care of the symptoms,
ensuring he's not in pain or distress. We'll try to treat the symptoms that cause
distress to improve the quality of life."
• Avoid mentioning spiritual treatment, psychological treatment, or treatment for the
family in this context

Answering Common Questions

1. "Why don't you do surgery?" Answer: The bleeding is severe, and surgery would not
be helpful. He would not benefit from surgical intervention. Any invasive treatment
could cause more distress than benefit.
2. "Why don't you treat him in the ICU?" Answer: Any treatment such as intubation
or ventilation would not be beneficial and could cause more distress.
3. "Is he going to die?" Answer: Unfortunately, he's not going to make it.
4. "When is he going to die?" Answer: It's difficult to say exactly, but unfortunately,
this can happen within the next few days or next few hours.
5. "Why did this happen to him?" Answer: He had a bursting of blood vessels in his
brain. He likely had some malformed or abnormal blood vessels in his brain that,
due to blood pressure, can easily break and bleed.
6. "Should I tell my sons who live in Australia?" Answer: It is better to inform other
important family members about his situation.
7. "Can I take him home?" Answer: Death and birth mainly happen in hospitals now.
It's better for him to be in the hospital where professionals can provide palliative
care and monitor him closely. However, we should consider if Mr. Muhammad Ali
had any wishes about spending his last days at home or elsewhere.

Important Points to Remember

• Don't say the condition is "critical" - it's "terminal"

• Avoid mentioning IV fluids or other invasive treatments

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• Sometimes, letting someone die peacefully is the best treatment option

• Be confident in your approach and decisions
• Answer all questions clearly and sensitively
• Maintain a professional demeanor while showing empathy
• Don't be overly nice to bystander family members - focus on the patient and
immediate situation
• Avoid unnecessary "painting" or decoration of responses
• When answering questions, start with "Well" and give a direct answer
• Don't use the phrase "I understand your concern" - just answer the question
• The last impression is crucial - answer final questions confidently and ethically

Additional Scenarios (Brief Overview)

Post-operative Complications

• Focus on explaining what happened during or after the surgery

• Emphasize that all possible measures were taken
• Explain the current situation and prognosis clearly

Cancer Diagnoses

• Be clear about the diagnosis

• Explain the next steps, including further tests and treatment options
• Provide information about support services available

Stroke Scenarios

• Explain the type of stroke and its impact

• Discuss the immediate treatment plan and long-term prognosis
• Provide information about rehabilitation options if applicable

Communication Skills and Techniques

Body Language

• Maintain appropriate eye contact

• Use open body posture
• Show empathy through facial expressions

Tone of Voice

• Speak clearly and at a moderate pace

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• Use a soft, empathetic tone

• Avoid sounding rushed or impatient

Language Use

• Avoid medical jargon

• Explain technical terms if you must use them
• Use simple, clear language
• When referring to the patient, use their name rather than saying "your husband" or
"your wife" when speaking to spouses. This shows respect.
• It's okay to use "your father" or "your mother" when speaking to children of the
patient.

Handling Emotions

• Allow for silence and pauses

• Acknowledge the patient's or family's emotions
• Offer support without being overly familiar
• Empathy is different from being sad. You can't be sad for the patient, but you can
show empathy by letting them know you understand their situation is difficult.

Ethical Considerations

Patient Autonomy

• Respect the patient's wishes if known

• Discuss with family members respectfully

Beneficence and Non-maleficence

• Explain why certain treatments are not being pursued (e.g., surgery in terminal
cases)
• Focus on comfort and quality of life in palliative scenarios
• Doctors need to have the conscience that letting some people die peacefully can be
the right thing to do.

Confidentiality

• Ensure you're speaking to the appropriate family member

• Be cautious about sharing information over the phone

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Cultural Considerations

• Be aware of different cultural attitudes towards death and dying

• Respect religious or cultural practices if mentioned by the family

Follow-up and Support

• Explain what will happen next

• Provide information about support services
• Offer to answer any additional questions they may have later

Common Mistakes to Avoid

• Rushing the conversation

• Using medical jargon excessively
• Offering false hope
• Ignoring emotional cues from the family
• Being overly pessimistic or optimistic
• Don't use the term "critical" instead of "terminal"
• Avoid mentioning IV fluids or other invasive treatments in palliative scenarios
• Don't say "nothing can be done" - always focus on what can be done
• Avoid being overly nice to bystander family members - focus on the patient and
immediate situation

Practice and Preparation

• Rehearse breaking bad news scenarios

• Practice with colleagues or in role-play situations
• Reflect on real-life experiences and learn from them

Variation 1: Wife in Person

Initial Interruption

• When you greet Mrs. Ali, she may interrupt: "How is he, doctor? How is Mr.
Muhammad Ali?"
• This interruption tests your ability to maintain formality under pressure
• It checks if you'll give out all information prematurely

Proper Response to Interruption

1. Apologize: "I'm so sorry. Please excuse me."

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gk’s notes – part 1

2. Ask to check details: "Can I please check some details before we discuss further?"
3. Introduce yourself: "Let me introduce myself. I'm Dr. X, one of the doctors."
4. Ask for her name: "May I know your name, please?"
5. Confirm relationship: "Mrs. Ali, I understand you are somehow related to Mr.
Muhammad Ali. How are you related to him?"
6. Confirm patient's age: "Is it possible to confirm his age as well?"
o Explain: "I wanted to double check the information."

Addressing the Initial Question

After formalities, address her initial question: "You did ask about Mr. Muhammad Ali.
Unfortunately, he's not doing very well. I've been actually asked to come and explain to you
about his current situation. I understand he has been brought by an ambulance. Would
you like to tell us exactly what happened this morning?"

Variation 2: Wife on Phone

• Follow the same steps as in-person scenario

• Ensure to verify identity over the phone

Variation 3: Son in Hospital Room

• Son knows what happened

• Take history as normal

Variation 4: Son on Phone (Hassan Ali)

Phone Call Steps

1. Greet: "Hello, hello."

2. Verify identity: "Is this Hassan Ali? Am I speaking to Hassan Ali?"
o Don't say: "Hey, who's on the other side?"
3. Introduce yourself: "I am Dr. X. I'm one of the doctors in the Manchester hospital."
4. State purpose: "The reason I'm calling you is to discuss something about your
father."
5. Ask for permission: "Can I talk to you? Do you have a minute? Are you in the
middle of doing something? Can I speak to you?"
6. Verify information: "Before I go into further detail, I would like to make sure that I
have the right information in front of me. Is it possible to confirm your father's full
name and date of birth?"

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Key Point: Son Unaware of Situation

• Son doesn't know father is in the hospital

• Cannot take incident history
• Start with risk factors: "Has he been recently unwell? Did you meet your father
recently? Has he got any ongoing medical problems such as high blood pressure,
high blood sugar?"

Important Questions

• "Are you the next of kin?"

• "Do you know whether your father appointed anybody as his lasting power of
attorney?"
• Note: Ask these even if they're not reXt, as you need the information

Delivering the News

1. Invite: "I have an important information that I've been asked to talk to you about
your father."
2. Ask about location: "Where are you at the moment? Are you at home? Is there
anybody at home?"
3. Offer options: "Would you like to come to the hospital for further discussion? Or is
it okay to discuss over the phone?"
4. Deliver news: "As I mentioned to you earlier, unfortunately, your father collapsed at
home. He was brought by an ambulance. He was unconscious and assessed by
specialists. We also have done a CT scan. Unfortunately, we didn't receive very good
news in the CT scan. I'm really sorry to tell you, unfortunately, he suffered from a
major bleed in his brain."
5. Explain terminal condition: "Unfortunately, his condition is terminal. This means
he's not going to show any improvement, unfortunately."

Handling Interruptions

If the son interrupts with questions like "Is he okay, doctor? I'm worried. Is my father
okay?":

• Don't push back with "Wait, wait, I'll come back to that."
• Instead, invite them to listen: "I have an important information that I've been asked
to talk to you about your father. Would you like to come to the hospital for further
discussion? Or is it okay to discuss over the phone?"

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Handling Emotional Responses

• If patient cries a lot: "Do you need a minute? Do you need a moment? Should I call
you back? Can I call you back?"

Variation 5: English Version

Key Differences

• Different name (not Mr. Muhammad Ali, but an English name)

• Instead of "terminal", the scenario might state: "He will not survive this admission"
• Do not use this exact phrase when speaking to family
• Instead say: "Unfortunately, he's not going to make it"
• Treatment is described as palliative

Explaining Cause

• "Bleeding can happen due to bursting of blood vessels"

• "High blood pressure can be a risk factor. If there is high blood pressure, blood
vessels can break and that can cause bleeding."
• Don't mention "perianeurysm" to the family

Important Points to Remember

1. Always complete formalities before giving information

2. Be sensitive in language use, especially when translating medical terms to layman's
terms
3. Adjust your approach based on whether the family member knows about the
situation or not
4. Always verify identity and relationship to the patient
5. Ask about next of kin and lasting power of attorney in all scenarios
6. Be prepared for interruptions or emotional responses
7. Offer to have the conversation in person if delivering news over the phone
8. Use empathetic language and tone throughout the conversation
9. Don't withhold necessary information due to confidentiality concerns when the
patient lacks capacity
10. Be confident in your approach and decision-making
11. Recognize that sometimes simulators may interrupt to test your ability to handle
pressure
12. Always think about the ethical implications of your communication

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Additional Notes

• The exam tests your ability to adapt to slight changes in scenarios

• Pay attention to the specific language used in the scenario (e.g., "will not survive this
admission") and translate it appropriately for the family
• Practice formulating responses that are both professional and empathetic
• Remember that the goal is not just to deliver information, but to do so in a way that
supports the family member

Bilateral Stroke Scenario

Patient Information:

• 72-year-old patient
• Suffered a stroke two weeks ago
• Initially recovering from the first stroke
• Suffered a second stroke and is now in a coma

MDT Summary:

• CT scan shows bilateral stroke

• Plan: Palliative treatment only
• Treatment: IV fluids and analgesics (painkillers)
• No CPR or assisted ventilation

Background:

• Speaking to the patient's daughter

• Daughter is aware of both strokes
• Daughter's expectation: father will recover as he did from the first stroke
• Daughter is 36 weeks pregnant

Approach to Breaking Bad News:

1. Introduction and Relationship Confirmation: Q: "Hello, are you Mrs. Jackson?" A:

"Yes, I am Mrs. Jackson." Q: "I understand you're related to Mr. George Parker.
How are you related to him?" A: "He's my father."
2. Prior Knowledge Assessment: Q: "I've been asked to come and speak to you about
your father's current situation. Before I explain everything, could you tell me what
you've been told so far?" A: (Patient's daughter explains her understanding)
3. FOUR Questions for Both Strokes: First Stroke: Q: "When your father had his first
stroke, what sort of symptoms did he develop?" A: (Daughter describes initial

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symptoms) Q: "What kind of tests did they do?" A: (Daughter mentions tests like
CT scan, blood tests, etc.) Q: "What did they tell you about the stroke?" A:
(Daughter explains the diagnosis) Q: "How was he treated? Did he improve?" A:
(Daughter describes treatment and improvement) Second Stroke: Q: "When did he
develop the second stroke? What have you been told about it?" A: (Daughter
explains current situation, mentions coma) Q: "Do you know what sort of treatment
they've offered so far?" A: (Daughter shares her understanding of current treatment)
4. Risk Factors Exploration: Q: "Does your father have any long-term medical
problems like high blood pressure, high blood sugar, or high cholesterol?" A:
(Daughter provides information on medical history) Q: "Has he ever had a stroke or
mini-stroke in the past? Any heart attacks?" A: (Daughter shares any history of
previous vascular events) Q: "Does he have any kidney or liver problems?" A:
(Daughter provides information on other medical conditions) Q: "Is he on any
medications, like for blood pressure or cholesterol?" A: (Daughter lists current
medications) Q: "Has anyone in your family had a stroke, mini-stroke, or heart
attack? Any other serious medical problems?" A: (Daughter shares family medical
history) Q: "Does your father smoke?" A: (Daughter provides information on
smoking history)
5. Social History: Q: "Who does your father live with?" A: (Daughter describes living
situation) Q: "What does he do? Is he retired?" A: (Daughter provides occupation
information) Q: "Where does he live? In his own house or a care home?" A:
(Daughter explains living arrangements) Q: "Who are the important family
members in your father's life?" A: (Daughter lists key family members) Q: "Are you
the next of kin?" A: (Daughter confirms or denies) Q: "Has your father appointed
anyone as lasting power of attorney?" A: (Daughter provides information if available)
6. Delivering the News: Statement: "As we understand, a few weeks ago, unfortunately,
your father had a stroke. He was on treatment and started showing improvement.
Then, unfortunately, he had another stroke and is now in a coma. Your father was
assessed by a team of specialists, and we've done a CT scan. Unfortunately, I'm
afraid we didn't receive very good news from the CT scan reports. I'm extremely
sorry to tell you that your father has suffered a stroke on both sides of his brain. I'm
afraid he's not going to make it this time." (Pause for reaction)
7. Explaining Palliative Care: Statement: "We will be offering palliative care, which is a
form of supportive treatment. The main aim is to take care of his symptoms and
improve his quality of life. We'll ensure he's not in pain or distress. For your father,
we are going to give him fluids and painkillers to keep him comfortable."

Addressing Common Questions:

1. Q: "Have you given up on him?" A: "I'm sorry if I've given that impression. We don't
give up on our patients. We try to offer whatever suitable treatment we can,

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according to their situation. In your father's case, we're offering palliative care to
ensure his comfort."
2. Q: "Can you please delay his death?" A: "When someone is in a terminal condition
like this, it's not possible for doctors to prolong their life. This has to happen
naturally. Our focus in palliative care is not to prolong life, as that might cause
unnecessary distress without any benefit. Instead, we focus on ensuring comfort and
quality of life for the time they have left."
3. Q: "Can you please talk to your seniors? Will they change their mind?" A: "I
understand you're looking for other options. I can speak to my seniors and ask them
to explain this to you. However, I want to be clear that it's unlikely to change the
plan. This decision was made based on your father's best interests after the team
looked into all options for treating him. But I'm happy to arrange for you to speak
with them if you'd like."
4. Q: "Are you going to feed him?" A: "In your father's current condition, we are not
going to feed him. This is because feeding through a tube wouldn't be beneficial
and could potentially cause unnecessary distress. It's not going to help improve his
condition at this stage."
5. Q: "Are you going to give him antibiotics?" A: "At the moment, he doesn't need
antibiotics. Sometimes, in palliative care, antibiotics might be given if the specialists
decide it's necessary, for example, if they want to prevent the patient from
developing sepsis. But in your father's current situation, we don't have plans to give
antibiotics right now."

Important Notes:

• Clearly communicate that the patient is not going to recover.

• Explain that in palliative care, the focus is on symptom management, not
prolonging life.
• Be prepared to address requests for life-prolonging measures with compassion and
clarity.
• Offer to involve senior staff if requested, but be clear that the plan is unlikely to
change.
• Explain that IV fluids and painkillers will be provided as part of palliative care.
• Avoid using the word "die"; instead, say "he's not going to make it".
• Use clear, simple language avoiding medical jargon.
• Be compassionate but honest about the prognosis.
• Allow time for the family to process information and ask questions.
• Emphasize the focus on comfort and quality of life in palliative care.

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Palliative Care Scenario - Mohammad Khan

Patient Information

• Name: Mohammad Khan

• Age: 70 years old
• Admitted: 7 days ago
• Diagnosis: Infarction (ischemic stroke)
• Treatment: Started on treatment with a nasogastric tube
• Current status: No clinical improvement noticed
• Recent development: CT scan shows a large part of the brain affected
• MDT decision: Stop treatment and remove the nasogastric tube

Scenario Background

• Patient collapsed at home while eating breakfast

• Family called an ambulance
• Diagnosed with stroke upon admission and started treatment
• Family has been told about the stroke and ongoing treatment
• You are speaking to the daughter, Saz Khan

Approach to Communication

1. Introduction and Relationship Confirmation

• Greet the daughter and introduce yourself

• Confirm her identity and relationship to the patient
• Verify the patient's age

Q: "Hello, I'm Dr. [Your Name], one of the doctors. Are you Saz Khan?" A: "Yes, I am Saz
Khan."

Q: "I understand you're related to Mohammad Khan. How are you related to him?" A:
"He's my father."

Q: "Is it possible to confirm his age?" A: "He's 70."

2. Prior Knowledge Assessment

• Paraphrase the situation

• Ask for permission to discuss the current situation
• Inquire about what she's been told so far

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Statement: "I understand your father has been admitted with us for the last one week and
has been receiving treatment. I've been asked to come and speak to you and explain his
current situation. Before I explain everything, I'd like to know what you've been told so
far."

Q: "What was the reason that he was brought into the hospital?" A: (Daughter explains
about the collapse at home)

Q: "How did he collapse? When did it happen?" A: (Daughter provides details about the
collapse)

Q: "Was he brought in immediately?" A: (Daughter confirms or explains any delay)

Q: "Did he have any symptoms prior to the collapse?" A: (Daughter shares any pre-collapse
symptoms)

Q: "After he was brought in, did anyone explain to you what was wrong with him?" A:
(Daughter shares her understanding of the diagnosis)

Q: "How has he been treated so far?" A: (Daughter explains the treatment she's aware of)

Q: "Has there been any improvement? Did anyone tell you how he was responding to the
treatment?" A: (Daughter shares her understanding of his condition and response to
treatment)

3. Risk Factor Assessment

• Ask about ongoing medical problems

• Inquire about previous strokes or mini-strokes
• Ask about medications
• Explore family history
• Ask about lifestyle factors (e.g., smoking)

Q: "Does your father have any ongoing medical problems like high blood pressure, high
blood sugar, or high cholesterol?" A: (Daughter provides information on existing
conditions)

Q: "Has he ever had a stroke or mini-stroke in the past? Any heart attacks?" A: (Daughter
shares any history of previous strokes or heart problems)

Q: "Is he on any medications? Any blood pressure or cholesterol medications?" A:

(Daughter lists any medications)

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gk’s notes – part 1

Q: "Has anyone in your family had a stroke, mini-stroke, or heart attack? Any other serious
medical problems?" A: (Daughter provides family medical history)

Q: "Does your father smoke?" A: (Daughter shares smoking history)

4. Social History

• Ask about living situation

• Inquire about occupation
• Confirm next of kin
• Ask about important family members
• Inquire about lasting power of attorney

Q: "Who does your father live with?" A: (Daughter describes living situation)

Q: "Was he working? What does he do for a living?" A: (Daughter provides occupation

information)

Q: "Are you the next of kin?" A: (Daughter confirms or denies)

Q: "Who are the important family members in your father's life?" A: (Daughter lists key
family members)

Q: "Has your father appointed anyone as lasting power of attorney?" A: (Daughter provides
information if available)

5. Invitation to Share Update

• Inform about the important update

• Check if she's alone or if she wants to call someone

Statement: "I have an important update about your father that I've been asked to discuss
with you. Is there anybody with you? Are you on your own? Would you like to call anybody
before we discuss further? Is your mother with you?"

6. Delivering the News

• Narrate the events

• Provide a warning shot
• Deliver the bad news clearly and compassionately
• Use pauses to allow for reaction

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Statement: "As we understand, unfortunately, your father had a stroke one week ago and
he was on treatment. Despite receiving treatment for the stroke for one week, he didn't
show any improvement. Because of that, we have done a CT scan today."

Warning shot: "Unfortunately, we didn't receive very good news from the CT scan."

Bad news: "I'm really sorry to tell you that the CT scan revealed a large part of his brain has
been affected. This means he has suffered a major stroke. I'm extremely sorry to tell you,
but he is not going to make it."

(Pause and wait for reaction)

7. Explaining Palliative Care

• Introduce the concept of palliative care

• Explain what it means
• Address potential misconceptions

Statement: "We will be offering palliative treatment for your father."

Q: "Do you know what palliative care means?" A: (If no, explain: "Palliative care is a form of
supportive treatment. The main aim is to take care of symptoms and improve the quality of
life as long as the patient lives. We make sure they are not in pain or distress. We'll try to
treat any symptoms that cause distress to improve the quality of life for as long as he lives.")

Q: "Is this something like euthanasia?" A: "No, it is not euthanasia. Euthanasia is when
doctors or healthcare professionals deliberately give medications or use methods to cause
death. In your father's situation, we are not doing that. The death will happen naturally.
Our focus is on keeping him comfortable and managing his symptoms."

8. Addressing Treatment Changes

• Explain the decision to stop ongoing treatment

• Provide reasons for stopping treatment

Statement: "We will be stopping the ongoing treatment, including the feeding through the
tube."

Q: "Why are you stopping the treatment?" A: "We're stopping because it's not going to
cause any improvement. Your father is not going to benefit from it, and continuing might
cause unnecessary distress without any benefit. Our focus now is on ensuring his comfort."

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9. Handling Emotional Responses

• Be prepared for different emotional reactions: sadness, anger, or guilt

• Acknowledge and validate emotions
• Respond with empathy

If the daughter becomes angry: Statement: "I can see that you're quite upset. It's
understandable. I'm so sorry you feel this way."

If she asks why they're only being told this after a week: Response: "I understand your
frustration. The doctors anticipated he might show some improvement with the treatment.
Unfortunately, despite our efforts, he didn't show any improvement. We continued the
treatment in hopes of seeing some positive change, but the recent CT scan has shown that
the stroke was more severe than initially thought."

Important Notes and Things to Avoid

1. Be clear that the patient is not going to recover. Avoid giving false hope.
2. Use the term "he's not going to make it" instead of saying "he's going to die."
3. Explain that palliative care focuses on comfort, not prolonging life.
4. When discussing euthanasia, avoid using the word "kill." Instead, use "cause death."
5. Don't discuss the legality of treatments unless directly asked. Focus on explaining
what the treatment involves and why it's being offered or withdrawn.
6. Avoid asking about irrelevant risk factors. For example, in this ischemic stroke
scenario, don't ask about blood-thinning medications.
7. Focus on relevant information; avoid unnecessary details that may confuse the
family.
8. Be compassionate and allow time for the family to process the information.
9. Don't use medical jargon. Explain terms like "infarction" in simple language (e.g., "a
type of stroke caused by blocked blood flow to the brain").
10. Avoid saying that you have "given up" on the patient. Instead, explain that you're
changing the focus of care to ensure comfort.
11. When explaining why you're stopping treatment, emphasize that it's to prevent
unnecessary distress, not because you're abandoning the patient.
12. Don't rush through the conversation. Give the family member time to ask questions
and express their concerns.
13. Avoid making assumptions about the family's understanding or wishes. Always ask
and clarify.
14. Don't forget to offer support resources or follow-up conversations if the family
needs more time to process the information.

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Post-Operative Complication Scenario 1 - Bleeding

Patient Information

• 60-year-old female patient (Mrs. Thompson)

• Had aorto-femoral bypass graft surgery one hour ago
• Noticed bleeding from the drain in recovery room
• Transfused 6 units of blood
• Taken back to theatre for exploration
• All theatre staff are scrubbing in

Scenario Background

• Patient had circulation problems in her leg

• Surgery was explained to the wife, not the husband
• Husband (Mr. Thompson) has come to visit
• No mistakes were made during the operation
• This is considered one of the most difficult breaking bad news scenarios

Approach to Communication

1. Introduction and Relationship Confirmation

• Greet the patient's husband and introduce yourself

• Confirm his identity and relationship to the patient

Q: "Hello, I'm Dr. [Your Name], one of the doctors. Are you Mr. Thompson?" A: "Yes, I'm
Mr. Thompson."

Q: "I understand you're related to Cynthia Thompson. How are you related to her?" A:
"She's my wife."

2. Prior Knowledge Assessment

• Paraphrase the situation

• Ask for permission to discuss the current situation
• Inquire about what he's been told so far

Statement: "I understand your wife had surgery today. I've been asked to come and explain
to you everything about the current situation. Before I do that, I'd like to understand what
you know so far."

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Important: Ask about three aspects:

1. Knowledge about the surgery

2. Understanding of what led to the surgery
3. Information received after the surgery

Q: "Do you know what surgery your wife was having today?" A: (Mr. Thompson explains
his understanding)

Q: "Did anyone explain to you what sort of surgery it was?" A: (Mr. Thompson shares what
he was told)

Q: "Did you have any discussions with your wife or the doctors before the surgery?" A: (Mr.
Thompson describes pre-surgery conversations)

Q: "Did anyone explain to you about possible complications of this type of surgery?" A:
(Mr. Thompson shares information about complications)

Q: "Before the surgery, what sort of symptoms had your wife been experiencing?" A: (Mr.
Thompson describes symptoms, likely mentioning pain or circulation issues)

Q: "How long had she been experiencing these symptoms?" A: (Mr. Thompson provides
timeline)

Q: "How were these symptoms affecting her life?" A: (Mr. Thompson explains impact on
daily life)

Q: "After the surgery, did you manage to speak to any of the doctors?" A: (Mr. Thompson
likely mentions phone calls)

Q: "What have you been told about your wife's condition after the surgery?" A: (Mr.
Thompson may mention being told everything was fine, then about being taken back to
theatre)

Q: "Did anyone explain to you why she has been taken back to the theatre?" A: (Mr.
Thompson shares his understanding or lack thereof)

3. Risk Factor Assessment

Focus on bleeding-related factors:

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gk’s notes – part 1

Q: "Does your wife have any long-term medical problems?" A: (Mr. Thompson provides
medical history)

Q: "Has she ever had any bleeding problems?" A: (Mr. Thompson shares any history of
bleeding issues)

Q: "Does she have any liver problems?" A: (Mr. Thompson provides information about
liver health)

Q: "Has she had any previous surgeries?" A: (Mr. Thompson describes any past surgeries)

Q: "Is she on any blood-thinning medications or any other medications?" A: (Mr.

Thompson lists medications)

Q: "Does anyone in your family have any bleeding conditions?" A: (Mr. Thompson shares
family history of bleeding disorders)

Note: Avoid asking about smoking as it's not directly relevant to the current situation.

4. Social History

Q: "Who does your wife live with?" A: (Mr. Thompson describes living situation)

Q: "Do you have any children?" A: (Mr. Thompson provides information about children)

Q: "What does your wife do for a living? Was she working?" A: (Mr. Thompson shares
occupational information)

Q: "Are you the next of kin?" A: (Mr. Thompson confirms or denies)

Note: Don't ask about lasting power of attorney for a 60-year-old patient.

5. Invitation to Share Update

Statement: "I have an important update about Mrs. Thompson that I've been asked to talk
to you about. Can I talk to you about this now? Is there anybody with you? Would you like
to call any other family members before we discuss further?"

6. Delivering the News

• Narrate the events

• Provide a warning shot
• Deliver the bad news clearly and compassionately

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• Use pauses to allow for reaction

Statement: "As we understand, Mrs. Thompson had surgery today. She had a surgery called
aorto-femoral bypass graft. This means she had a problem with circulation in her leg
because of some blockage in the blood vessels. To remove the blockage, she had a bypass
surgery."

"The surgery itself went well. After surgery, we closely monitor patients in a room called the
recovery room. Your wife had a drain, which we check regularly. In the drain, we saw some
blood. Because of this, we had to thoroughly examine her."

Warning shot: "When we examined her, we didn't receive very good news."

Bad news: "I'm really sorry to tell you, we found out that she suffered from a major bleed
after the surgery."

(Pause and wait for reaction)

Important: Be clear about the severity of the situation. The main message is that the
patient has suffered a major bleed after surgery. Don't give false hope, but remain
compassionate.

7. Addressing Concerns and Questions

Q: "I think you have made a mistake. How could this happen?" A: "I understand your
concern. We've been informed that there were no mistakes during the operation.
Unfortunately, this is one of the possible complications of this type of surgery, although it's
not something we anticipated or expected. It's a very unfortunate situation that she
developed this complication."

Q: "If there are complications, why did you do the surgery?" A: "It seems that this level of
complication was not anticipated. It's a very unfortunate situation that she developed this
complication. The surgery was necessary to address the circulation problems in her leg, but
as with any surgery, there are always some risks involved."

Q: "What's going to happen next?" A: "Let me explain what's happening now. We've taken
your wife back for another operation. The surgical team is getting ready. We've given her
six units of blood to help with the blood loss. The surgeons are going to try to find the
source of the bleeding and stop it."

Q: "Is she going to die?" A: "Your wife is in a critical condition at the moment. It's difficult
to say exactly how she will recover. But I want you to know that she's in safe hands. The

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surgeons are very experienced and have done these types of surgeries before. We hope that
she will recover from this."

Note: In post-operative complication scenarios, emphasize the critical nature of the

situation without saying the patient is going to die. Start with acknowledging the difficulty
of the situation, then end on a more hopeful note about the expertise of the surgical team.

Q: "Will I be able to see my wife again?" A: "We hope that she will recover from this and
that you'll be able to see her again. The team is doing everything they can to help her."

Q: "Do you think they will be able to stop the bleeding?" A: "The surgeons are experts in
what they do. They will do everything possible to stop the bleeding. However, it's a serious
situation, and I can't promise anything. We're hopeful that they will be successful."

Q: "I have two sons who live in Australia. Should I tell them?" A: "Yes, it would be better to
inform them that their mother is in a critical condition. We would advise you to tell other
important family members as well. In situations like this, it's important for family to be
informed."

Q: "How long will the operation last?" A: "This type of operation can take about five to six
hours."

Q: "Is six units of blood a lot of blood, doctor?" A: "Unfortunately, yes. Six units of blood is
quite a lot. When we need to transfuse six units of blood, we consider it a major bleeding."

Important Notes and Things to Avoid

1. Be clear and direct about the severity of the situation. The message that the patient
has suffered a major bleed after surgery must be crystal clear.
2. Don't give false hope, but remain compassionate and professional throughout the
conversation.
3. Avoid medical jargon. Explain terms like "aorto-femoral bypass graft" in simple
language.
4. Focus on bleeding-related risk factors in your assessment. Avoid asking irrelevant
questions like those about smoking.
5. Don't ask about lasting power of attorney for a 60-year-old patient.
6. There's no need to use pen and paper to draw or explain anything in this scenario.
7. Be prepared for emotional reactions like anger or crying. Acknowledge and validate
these emotions.
8. If accused of making a mistake, calmly explain that no mistakes were made during
the operation, but this is a possible complication.

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9. When discussing the prognosis, start by acknowledging the difficulty of the

situation, then end on a more hopeful note about the expertise of the surgical team.
10. Emphasize the critical nature of the situation without explicitly saying the patient is
going to die.
11. When asked about informing other family members, advise that it's better to inform
them due to the critical nature of the situation. This is not just about getting
support, but about crossing a boundary where important family members should be
informed.
12. Be honest about the amount of blood transfused if asked, explaining that it
indicates a major bleed.
13. Throughout the conversation, maintain a balance between honesty about the
severity of the situation and compassion for the family member's emotional state.
14. Avoid saying "don't worry" or trying to downplay the seriousness of the situation.
15. Don't focus on irrelevant details or get sidetracked by questions about legality or
hospital policies unless directly asked.
16. Remember to "destroy the patient" in your explanation - not literally, but in the
sense that the severity of the situation must be absolutely clear to the family
member.
17. Avoid using euphemisms. Be direct but compassionate in your language.

Post-Operative Complication Scenario 2 - Stroke

Patient Information

• 80-year-old female patient (Samantha Wilkinson)

• Had brain surgery for a space-occupying lesion (brain tumour)
• In recovery room, noticed unable to move one part of the body
• CT scan showed an ischemic stroke
• Now in intensive care unit, waiting for stroke specialist review

Scenario Background

• Patient had personality and behavioural changes before surgery

• Son (David) lives with the mother
• Son knows mother had brain tumour and surgery
• You are speaking to the son (David)
• This scenario is similar to the previous one but with a different pathology

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Approach to Communication

1. Introduction and Relationship Confirmation

• Greet the patient's son and introduce yourself

• Ask for his name
• Confirm his relationship to the patient and the patient's age

Q: "Hello, I'm Dr. [Your Name], one of the doctors. May I know your name please?" A: "My
name is David."

Q: "David, I understand you're related to Samantha Wilkinson. How are you related to
her?" A: "She's my mother."

Q: "Is it possible to confirm your mother's age as well?" A: "She's 80."

Note: When given a single name, don't ask "Can I call you David?" or "How may I call you?"
This is to check how you deal with different name situations in the exam.

2. Prior Knowledge Assessment

• Paraphrase the situation

• Ask for permission to discuss the current situation
• Inquire about what he's been told so far

Statement: "I understand your mother has been admitted with us. What is your
understanding about your mother being in the hospital?"

Important: Ask about three aspects:

1. Knowledge about the surgery

2. Understanding of what led to the surgery
3. Information received after the surgery

Q: "How much do you know about your mother's surgery?" A: (David explains his
understanding)

Q: "Do you know what sort of surgery she was having?" A: (David shares what he knows
about the brain surgery)

Q: "Did anyone explain to you what sort of surgery it was?" A: (David describes what he was
told about the surgery)

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Q: "Before the surgery, did you have any discussions with the doctors or your mother about
the procedure?" A: (David describes pre-surgery conversations)

Q: "Did anyone explain to you about possible complications of this type of surgery?" A:
(David shares information about complications he was told)

Q: "What made your mother have this surgery in the first place? What symptoms was she
experiencing?" A: (David likely mentions personality and behavioural changes)

Q: "How long had she been experiencing these symptoms?" A: (David provides timeline)

Q: "How were these symptoms affecting her life?" A: (David explains impact on daily life)

Q: "After the surgery today, did anyone explain to you how it went?" A: (David shares what
he was told about the surgery outcome)

Q: "Has anyone given you any information about what happened after the surgery?" A:
(David shares any post-operative information he received)

3. Risk Factor Assessment

Focus on stroke-related factors:

Q: "Does your mother have any medical problems like high blood pressure or high blood
sugar?" A: (David provides medical history)

Q: "Has she ever had a stroke or mini-stroke in the past? Any heart attacks?" A: (David
shares any history of previous strokes or heart problems)

Q: "Is she on any medications? Any blood pressure or cholesterol medications?" A: (David
lists medications)

Q: "Has anyone in your family had a stroke or heart attack?" A: (David provides family
history)

Q: "Does your mother smoke?" A: (David shares smoking history)

Note: Don't ask about bleeding-related factors as they're not relevant to this scenario. Avoid
confusion with the previous bleeding scenario.

4. Social History

Q: "Who does your mother live with?" A: (David likely mentions he lives with her)

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Q: "Where does she live?" A: (David describes living situation)

Q: "Does she have a partner?" A: (David provides information about partner if any)

Q: "Do you have any siblings? Does your mother have any other children?" A: (David shares
information about siblings)

Q: "Who are the important family members in your mother's life?" A: (David lists key
family members)

Q: "Are you the next of kin?" A: (David confirms or denies)

Q: "Has your mother appointed anyone as lasting power of attorney?" A: (David provides
information if available)

5. Invitation to Share Update

Statement: "I have an important update about your mother that I've been asked to talk to
you about. Can I talk to you now? Is there anybody with you? Are you on your own? Would
you like to call somebody before we discuss further?"

6. Delivering the News

• Narrate the events

• Provide a warning shot
• Deliver the bad news clearly and compassionately
• Use pauses to allow for reaction

Statement: "As we understand, your mother had surgery today. The surgery was on her
brain because, unfortunately, she had a brain tumour. I want to let you know that the
surgery itself went very well."

"After any surgery, especially brain surgery, we bring patients to a room called the recovery
room. For patients who've had brain surgery, we regularly perform neurological
examinations. When we did the neurological examination on your mother, we
unfortunately found that she was not able to move one part of her body."

"Because of this finding, we had to do a CT scan."

Warning shot: "Unfortunately, I'm afraid to tell you that we didn't receive very good news
from the CT scan."

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Bad news: "I'm sorry to tell you that the CT scan revealed your mother has suffered a stroke
after the surgery."

(Pause and wait for reaction)

7. Addressing Concerns and Questions

Q: "What are we going to do now? What's the treatment plan?" A: "Let me explain what
we've done and how we're treating her. Your mother has been moved to the intensive care
unit. She's been given treatment for the stroke. We're also waiting for a stroke specialist to
review her condition."

Q: "Is she going to die?" A: "It's difficult to say at this point because your mother is in a
critical condition. Her situation is quite complicated because she had surgery on her brain,
and on top of that, she's developed a stroke in her brain. This means there are multiple
things going on in her brain right now. However, she is receiving treatment, and we hope
that she will benefit from this. We're doing everything we can to help her recover."

Q: "Will she be able to use the right part of her body again?" A: "The recovery depends on
the level of damage caused by the stroke. Some people completely recover, some partially
recover, and unfortunately, some don't recover at all. It depends on the severity of the
stroke and the level of damage. At the moment, I don't have detailed information about
how your mother has been affected. I haven't seen the report and I'm not aware of the full
situation. We're waiting for the specialist to review her. After the specialist's review, we'll be
able to get more information about her potential recovery and how she's been affected."

Q: "Is the stroke a complication of the surgery?" A: "It's difficult to say exactly what has
caused this stroke. Stroke is not a common complication of surgery, even including brain
surgeries. After brain surgery, patients can have some weakness in the body or may not be
able to move, and they can have some bleeding. These are common complications.
However, stroke is more common in elderly people, and your mother is 80 years old. It's
difficult to say what exactly caused the stroke. After the specialist's review, we may be able
to find out more about what caused it. It doesn't look like a typical complication of surgery.
Your mother developed an ischemic stroke, which means there's a clot formation in the
blood vessels. This is quite common in elderly people."

Important Notes and Things to Avoid

1. Be clear about the current situation: the patient had brain surgery and then suffered
a stroke. The message must be crystal clear.
2. Don't use medical jargon. Explain "space-occupying lesion" as "brain tumor".

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3. Focus on stroke-related risk factors. Don't ask about bleeding-related factors as

they're not relevant to this scenario.
4. Don't say the patient is "old." Instead, refer to her age directly: "Your mother is 80
years old."
5. When explaining the stroke, you don't need to specify that it's an "ischemic" stroke
unless asked. Simply saying "stroke" is sufficient for laypeople.
6. Be honest about the critical nature of the situation, but also provide hope where
appropriate.
7. When discussing prognosis, emphasize that it depends on the severity of the stroke
and that you're waiting for the specialist's assessment.
8. If asked about complications, explain that stroke is not a common complication of
brain surgery, but it is more common in elderly people.
9. Don't rush through the explanation. Give the family member time to process
information and ask questions.
10. Be prepared to explain the difference between expected post-surgery symptoms (like
weakness) and the unexpected complication of a stroke.
11. Emphasize that you're waiting for the stroke specialist's review for more detailed
information about the patient's condition and prognosis.
12. Avoid making promises about recovery. Be clear that outcomes can vary widely in
stroke patients.
13. When asked about the cause of the stroke, be honest that it's difficult to determine
at this point. Emphasize that you're waiting for the specialist's review.
14. Don't forget to mention that the initial brain surgery went well before discussing the
post-operative complication.
15. Be prepared for emotional reactions. Acknowledge and validate these emotions if
they occur.
16. Remember to "destroy the patient" in your explanation - not literally, but in the
sense that the severity of the situation must be absolutely clear to the family
member.
17. Avoid using euphemisms. Be direct but compassionate in your language.
18. Don't say "don't worry" or try to downplay the seriousness of the situation.
19. When explaining the neurological examination, make it clear that this is a routine
procedure after brain surgery.
20. If asked about the length of recovery or long-term prognosis, emphasize that it's too
early to say and that you need the specialist's input.

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Osteosarcoma Scenario

Patient Information

• Max Brown, 19 years old (could be male or female)

• X-ray shows lytic lesion, suspected osteosarcoma
• All blood tests were normal

Background

• If male: Pain after playing football, near the knee

• If female: Pain near the knee
• Important: Under 24, if cancer is suspected, it's a same-day referral (admit within
24-48 hours)

Approach to Communication

1. Introduction and Relationship Confirmation

• Greet the patient and introduce yourself

• Confirm the patient's name and age

Example: "Hello, I'm Dr. [Your Name]. Are you Max Brown? Can you confirm your age for
me please?"

2. Prior Knowledge Assessment

Q: "I understand you have come for the test results. Do you know what tests were done
and why?" A: (Patient explains about pain and tests)

3. History Taking (6 key points for osteosarcoma)

1. Pain (SOCRATES) Q: "Can you tell me more about the pain you've been
experiencing?" Q: "Does the pain respond to painkillers?" Q: "Is there anything that
makes it better or worse?" Q: "What about rubbing the area? Does that affect the
pain?" Q: "Do you get pain at any particular time? Any night pain?"
2. Lump Q: "Have you noticed any swelling or lump in the area?"
3. Neuro symptoms Q: "Have you experienced any numbness or abnormal sensations?"
Q: "Any problems with walking or limping?" Q: "Any weakness in the leg?" Q: "Have
you noticed any changes in your mobility?"

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4. Cancer symptoms Q: "Have you noticed any easy bruising?" Q: "Have you been
experiencing any headaches?" Note: Bruising is related to the tumour, headache is
related to calcium levels.
5. Risk factors Q: "Have you ever had chemotherapy as a child?" Q: "Have you ever had
an eye condition called retinoblastoma?" Note: Retinoblastoma has a direct link to
osteosarcoma.
6. ICE (Ideas, Concerns, Expectations) Q: "What do you think could be causing your
symptoms?" Q: "Is there anything specific you're worried about?" Q: "What do you
think the X-ray results might show?" Q: "Did anyone explain to you what they were
looking for when they took the X-ray?"

4. Delivering the News

Statement: "I understand you've come for your X-ray report. I have the results. Is it okay to
discuss them with you today? Is there anybody with you? Would you like to call anyone?"

Narrative: "As we understand, you initially had some pain [mention football if relevant].
You came to the doctors, and they did an X-ray and blood tests. Is that correct?"

Explanation: "Well, the blood tests came back normal. However, unfortunately, we don't
have very good news regarding your X-ray report."

Warning shot: "I'm afraid I don't have good news."

Bad news: "I'm sorry to tell you that the X-ray report shows that doctors suspect this could
be a type of bone cancer called osteosarcoma."

(Pause and wait for reaction)

5. Management Plan

1. Referral: "As you are young, we will try to get you an appointment within 24 hours,
or at most 48 hours, to be admitted for further testing."
2. Department: Orthopaedics
3. Further tests: MRI, CT scan, and biopsy
4. Treatment options:
o Surgery (leg-sparing surgery to protect the leg)
o Chemotherapy
o Radiotherapy
o Possible medication: Mifamurtide

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6. Addressing Concerns and Questions

Q: "Will I be able to play football again?" (if male) A: "Unfortunately, I'm afraid to tell you
that you may not be able to play football. After surgery, you are prone to fractures, so it
wouldn't be safe for you to play contact sports like football."

Q: "Can you please delay my referral? I have an exam." A: "I understand you have an exam,
but it's not advisable to delay your referral. Let me explain why:

1. If we delay treatment, the tumour can grow larger.

2. If the tumour becomes bigger, they may need to remove a larger part of your bone.
3. The cancer could spread, making it more difficult to treat.
4. In some cases, if the tumour becomes too large, it might even require amputation.

While I understand your exam is important, your health is the priority here. We can
provide a letter to your school to postpone your exam, but it's crucial to start treatment as
soon as possible."

Important notes:

• Be clear about the severity of the situation.

• Don't give false hope, but remain compassionate.
• Explain medical terms in simple language.
• Be prepared for emotional reactions.
• Emphasize the importance of prompt treatment.

Social History for Elderly Patients

1. Living Condition

Q: "Where do you live?" Q: "Who do you live with?" Q: "What sort of housing do you
have?" (Especially important for orthopaedic cases) Q: "How are the rooms set up in your
home? Are the living room, main bedroom, and toilets on the same floor?" Q: "Are there
any staircases in your home?" Q: "Do you have a car?"

For orthopaedic cases, ask more detailed questions: Q: "Is your house a two-story building
with staircases or a single-story (bungalow) house?" Q: "How are the rooms arranged? Are
the main living areas and bathroom on the same floor?"

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2. Mobility

Q: "Are you able to walk independently?" Q: "Do you use any walking aids like a Zimmer
frame or crutches?" Q: "Do you have any problems with walking, such as joint pain or
swelling?" Q: "How far can you walk?" Q: "Do you use a wheelchair? Are you wheelchair-
bound?" Q: "Are you bedridden?"

3. Independence

Q: "What sort of day-to-day activities can you do by yourself?" Q: "What activities do you
need help with?" Q: "Do you need help with eating, drinking, going to the toilet, washing
yourself, or changing your clothes?" Q: "Is there anyone who comes to help you with your
daily activities?" Q: "How often does a carer come, if you have one?" Q: "What sort of help
do they offer?" Q: "Who is your main carer?"

Important Notes

• For orthopaedic cases, focus more on the details of the home setup and mobility.
• For conditions like dementia, you may not need as much detail about the home
setup, but still ask about living arrangements and support.
• Always assess the level of independence and support needed for day-to-day activities.
• If the patient has a car, ask who the main driver is.
• These questions can be asked directly to the patient or to their caregiver, depending
on the situation.
• The social history for elderly patients has three main elements: living condition,
mobility, and independence.
• When asking about independence, give specific examples of activities (eating,
toileting, washing, dressing) to get a clear picture of the patient's capabilities.
• For orthopaedic cases, understanding the home setup (e.g., presence of stairs,
location of bathroom) is crucial for discharge planning.

Remember, the goal is to get a comprehensive understanding of the patient's living

situation, mobility, and level of independence. This information is crucial for developing
an appropriate care plan and understanding the patient's support needs.

Things to Avoid:

• Don't assume all elderly people live in care homes or have limited mobility.
• Avoid using judgmental language about a patient's level of independence.
• Don't rush through these questions; they provide valuable information for patient
care.

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• For the osteosarcoma scenario, don't minimize the seriousness of the situation, but
also avoid being overly pessimistic.
• In both scenarios, avoid medical jargon and explain terms clearly.
• Don't forget to offer support and resources, especially in the osteosarcoma scenario
where the news can be overwhelming.

Dementia Scenario and End-of-Life Care Discussion

Patient Information

• 78-year-old female patient (Hope Johnson)

• Admitted due to weight loss
• Suffering from dementia for the last three years
• Stopped eating for last three months
• Started losing weight for last four weeks
• All investigations (ECG, X-ray, ultrasound, CT scan) came back normal
• Nurses gave her a sip of water (important for future feeding discussions)

Scenario Background

• Patient not available to talk

• Speaking with the daughter (Emma White)
• Consultant decided on palliative care
• Further invasive or aggressive treatment not appropriate
• Task: Take relevant history, explain mother's current health status, discuss further
management

Approach to Communication

1. Introduction and Relationship Confirmation

Q: "Hello, I'm Dr. [Your Name], one of the doctors. Are you Emma White?" A: "Yes, I am."

Q: "I understand you're related to Hope Johnson. How are you related to her?" A: "She's my
mother."

Q: "Is it possible to confirm your mother's age?" A: "She's 78."

Paraphrase: "I understand you brought your mother recently and she has been admitted
with us. I've been asked to come and talk to you and explain everything about her current
health status. Is that okay?"

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2. History Taking (4 key elements)

2.1 Weight Loss and Eating Habits

Q: "What made you bring your mother to the hospital this time?" A: (Daughter explains
about stopping eating and weight loss)

Q: "When did she start losing weight? Since when have you noticed this?" A: (Daughter
provides timeline)

Q: "Do you know how much weight she has lost?" A: (Daughter estimates weight loss)

Q: "Has this happened suddenly or gradually?" A: (Daughter describes progression)

Q: "What about her eating habits? Does she eat anything at all now?" A: (Daughter explains
current eating situation)

Q: "Before you brought her to the hospital, how was her eating? What sort of things did
she use to eat?" A: (Daughter describes previous eating habits)

Q: "When did you notice her eating habits change?" A: (Daughter provides timeline of
eating changes)

Q: "Have you tried feeding her with a bottle or spoon?" A: (Daughter explains any feeding
attempts)

Q: "Is she able to take any liquid food, drinks, water, or milk?" A: (Daughter describes what
patient can currently consume)

Q: "How has her feeding changed over the last three years?" A: (Daughter describes
progression of eating difficulties)

2.2 Dementia

Q: "I understand your mother was diagnosed with dementia. When was she diagnosed?" A:
(Daughter provides diagnosis timeline)

Q: "Was she on any treatment for dementia?" A: (Daughter explains treatment)

Q: "Was the treatment helpful?" A: (Daughter describes effectiveness of treatment)

Q: "How has the dementia affected her life?" A: (Daughter describes impact of dementia)

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Q: "How have things changed for her during the last three years because of the dementia?"
A: (Daughter explains progression of dementia)

Q: "Does your mother have any other medical conditions?" A: (Daughter provides
information on other health issues)

2.3 Social History of the Mother

Q: "Where does your mother live?" A: (Daughter describes living situation)

Q: "How is your mother's mobility? Can she walk around?" A: (Daughter explains mobility
status)

Q: "Does she use any walking aids like a Zimmer frame or crutches?" A: (Daughter describes
any mobility aids used)

Q: "How independent is your mother in daily activities?" A: (Daughter describes level of

independence)

Q: "What sort of activities can she do by herself?" A: (Daughter lists activities patient can do
independently)

Q: "What activities does she need help with?" A: (Daughter describes activities requiring
assistance)

Q: "Does she need help with eating, drinking, going to the toilet, washing herself, or
changing clothes?" A: (Daughter explains level of assistance needed)

Q: "Who is her main carer?" A: (Daughter likely mentions herself)

2.4 Social History of the Daughter

Q: "Are you the main carer for your mother?" A: (Daughter confirms)

Q: "What do you do for a living?" A: (Daughter explains occupation)

Q: "Do you have any other responsibilities?" A: (Daughter mentions any other
commitments)

Q: "How are you coping with looking after your mother?" A: (Daughter describes her
experience)

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Q: "Do you need some help? Would any additional support be helpful?" A: (Daughter
expresses needs)

Q: "Have you spoken to your mother's GP about getting some help?" A: (Daughter
mentions any previous attempts to get support)

Q: "Have you spoken to any social services?" A: (Daughter describes any interactions with
social services)

Q: "Has anybody discussed with you about getting help for your mother's care?" A:
(Daughter mentions any previous discussions about support)

Q: "Do you have any financial constraints or need any financial help?" A: (Daughter
discusses financial situation)

3. Explanation and Management Plan

3.1 Explaining Weight Loss

"As we understand, you brought your mother to the hospital because she was losing weight.
We've done several tests, including scans of her abdomen and other investigations. All
these tests came back normal. Our current understanding is that her weight loss is due to
the progression of her dementia."

3.2 Explaining Dementia and Breaking Bad News

Q: "What is your understanding about dementia?" A: (Daughter explains her

understanding)

"Dementia is a condition of the brain that initially affects memory. It's a progressive
condition, meaning it gets worse over time. As it progresses, it can affect various functions
of the body, including appetite and weight. People with dementia go through different
stages."

Warning shot: "Unfortunately, I'm afraid I don't have very good news about your mother's
current health status."

Bad news: "I'm really sorry to tell you, but your mother's dementia has reached the terminal
stages. This means she's not going to show any improvement, and unfortunately, she's not
going to recover from this."

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3.3 Discussing Management Plan (Palliative Care)

"We are going to offer palliative treatment. This is a form of supportive treatment where
the main aim is to take care of symptoms, ensure she's not in pain or distress, and improve
her quality of life for as long as she lives."

Q: "What about her feeding?" A: "The nurses have tried giving her sips of water, which she
tolerated. We can continue with oral feeding, giving her whatever she can tolerate - this
could be water, milk, juice, soup, or smoothies. We'll use a spoon or straw, or give sips,
whatever works best."

Q: "Why don't you feed her through a tube?" A: "Tube feeding wouldn't benefit your
mother at this stage. It won't improve her condition or weight, and it could cause distress,
especially for someone with dementia. There's a risk of confusion, pulling out the tube, or
fluids going into the lungs, which could be dangerous. Our decision not to use tube
feeding is based on what's best for your mother."

Q: "How can you help me look after my mother?" A: "We can offer various types of
support:

1. Care at home: We can arrange for social services, palliative care specialists, nurses,
physiotherapists, and occupational therapists to visit and support you.
2. If care at home becomes too difficult, we can refer your mother to a nursing home.
3. In her final days, care in a hospice is also an option."

Q: "I want to look after my mother. What can I do for her?" A: "There are several things
you can do:

1. Ensure she has a comfortable place to rest.

2. Spend time with her, be around her.
3. Do activities she might enjoy - play music, show photo albums, read to her, or watch
videos together.
4. Simply spending time with her can be very comforting."

Q: "Sometimes my mother yells or screams at me. Why is she behaving like this?" A:
"People with dementia often struggle to communicate. When she yells or screams, it might
be her way of trying to tell you something - she might be in distress or uncomfortable.
Sometimes, it can also be random behaviour due to how dementia affects the brain. It's not
personal, it's unfortunately part of the condition."

Q: "Sometimes she doesn't remember my name or who I am. This upsets me." A: "I'm very
sorry to hear that. It must be difficult. This memory loss is, unfortunately, part of

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dementia. People with this condition often have trouble remembering or recognizing even
close family members. It's not because she doesn't care, it's because of how the disease
affects her brain. This can get worse over time, but it doesn't change the importance of
your relationship."

Q: "Can I take her home?" A: "Yes, you should be able to take her home. However, before
we do that, we need to make sure you're properly supported. We'll refer you to social
services to make necessary arrangements, and organize visits from palliative nurses,
occupational therapists, and physiotherapists. Once everything is properly organized to
ensure both you and your mother are supported, you'll be able to take her home to
continue her care there."

4. End-of-Life Care Discussion (for alternate scenario)

Definition: "End-of-life care is a form of supportive treatment typically given in the last year
of someone's life when all life-prolonging treatments have become ineffective. It focuses on
managing symptoms, reducing distress, and improving quality of life."

Key points:

• Minimally invasive
• Focuses on symptom management (especially pain)
• Aims to improve quality of life and reduce suffering
• Typically involves subcutaneous medications rather than oral or IV
• Does not include life-prolonging treatments

If asked about feeding in end-of-life care: "At the moment, we're not planning to offer any
artificial feeding as it won't improve her condition and could cause distress. However, you
can try oral feeding at home if she can tolerate it. Anything she can take by mouth
shouldn't be a problem."

Important Notes and Things to Avoid

1. Be clear about the terminal nature of the condition, but remain compassionate.
2. Explain medical terms in simple language.
3. Don't rush through the explanation. Give the family member time to process
information and ask questions.
4. Avoid saying the patient is "old." Instead, refer to her age directly: "Your mother is
78 years old."
5. Don't give false hope, but emphasize the focus on comfort and quality of life.
6. Be prepared for emotional reactions. Acknowledge and validate these emotions.
7. Don't forget to offer support resources for the caregiver.

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8. Avoid medical jargon. Explain terms clearly.

9. Don't say "don't worry" or try to downplay the seriousness of the situation.
10. Remember to "destroy the patient" in your explanation - not literally, but in the
sense that the severity of the situation must be absolutely clear to the family
member.
11. Avoid using euphemisms. Be direct but compassionate in your language.
12. Don't forget to ask about the caregiver's wellbeing and need for support.
13. Avoid making promises about specific timelines or outcomes.
14. Don't dismiss the importance of oral feeding if the patient can tolerate it.
15. Remember to explain why certain interventions (like tube feeding) are not
recommended.
16. Don't forget to mention that the initial brain surgery (if applicable) went well before
discussing the post-operative complication.
17. Be prepared for questions about why the condition wasn't noticed earlier. Explain
that dementia is progressive and can accelerate unexpectedly.
18. Avoid comparing the patient's condition to others. Each case of dementia is unique.
19. Don't forget to discuss the importance of advance care planning if it hasn't been
done already.
20. Remember to explain that end-of-life care doesn't mean giving up on the patient,
but rather focusing on comfort and quality of life.

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Nosebleed Scenarios
General Approach to Nosebleed

History Taking

1. Onset Q: "How did the bleeding start?" Q: "Did it start suddenly?" Q: "What were
you doing when it started?" Note: Visualize the scenario and ask everything you
need to know.
2. Duration Q: "How long have you had this bleeding for?"
3. Severity Q: "How much blood did you lose?" Q: "Did you lose a lot of blood?" Q:
"Did you swallow any blood during the bleeding?"
4. Management Q: "How did you stop the bleeding?"
5. Associated Symptoms Q: "While you were bleeding, did you have any symptoms like
dizziness?" Q: "Did you feel your heart racing?" Q: "Did you faint or feel like you
were going to faint?"
6. Potential Causes Q: "Are you taking any blood-thinning medication?" Q: "Were you
picking your nose?" Q: "Do you sniff any substances?" Q: "Have you had a recent
sore throat or cold?" Q: "Have you noticed any growth in your nose?" Q: "Have you
had any recent injuries or trauma to your nose or face?"
7. Medical History Q: "Do you have any blood-related conditions like leukaemia?" Q:
"Have you been feeling unusually tired lately?" (anaemia symptoms) Q: "Have you
noticed any lumps in your neck?" Note: Ask about nasal or oropharyngeal tumours.
8. Family History Q: "Does anyone in your family have bleeding conditions like
haemophilia?"

Examination Findings

• Look for a scar in the Little's area of the nose (high vasculature area)
• Mention: "I would like to examine your nose."

Scenario 1: LGBT-related Transgender Taking Testosterone

(Note: This scenario will be covered in the LGBT section)

Scenario 2: Patient Taking Apixaban

Patient Information

• Taking apixaban for 10 years

• Two episodes of nosebleed: last week and yesterday

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• First episode due to nose picking

Explanation to Patient

"The bleeding you experienced is likely due to a combination of factors. You're taking a
blood-thinning medication (apixaban), which increases your chances of bleeding. When
you pick your nose, it can cause trauma to the delicate blood vessels inside. The
combination of the blood thinner and the trauma from nose picking significantly increases
your risk of nosebleeds. There's a break in the blood vessels in the Little's area of your nose,
which is an area with many blood vessels close to the surface."

Management

1. Advise against nose picking and forceful nose blowing

2. No need for additional testing Explanation: "You've been taking apixaban for 10
years without issues, so we don't need to do any additional tests at this time.
Unnecessary testing would be a waste of resources, which is unethical."
3. Prescribe Naseptin cream
o Explain: "We'll give you a cream called Naseptin. It contains fucidic acid, an
antibiotic to prevent infection and help healing."
o Instructions: "Apply this cream 2-3 times a day to the inside of your nose."

First Aid Advice

Explain to the patient:

1. "If you get a nosebleed, pinch the soft part of your nose."
2. "Lean forward, not backward."
3. "Hold the pinch for 15 minutes."
4. "You can breathe through your mouth while pinching your nose."
5. "Avoid swallowing the blood."
6. "If the bleeding doesn't stop after 15 minutes, go to the nearest hospital."

Hospital Treatment (if needed)

Explain what will happen at the hospital:

1. "They will examine your nose."

2. "They might put a cotton pad in your nose to control the bleeding."
3. "If that doesn't work, they may seal the bleeding spots using heat. This is called
cauterization or diathermy."

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Scenario 3: Spontaneous Nosebleed (No Apixaban, No Nose Picking)

Patient Information

• Two episodes of spontaneous nosebleed: last week and yesterday

• Not taking blood thinners
• Not picking nose

Explanation to Patient

"Your nosebleeds are likely due to changes in temperature. When the temperature changes,
the lining of your nose can become dry. This dry lining can easily crack and cause bleeding.
The blood vessels in your nose are very close to the surface, which is why even small cracks
can lead to noticeable bleeding."

Management

(Same as Scenario 2)

1. Prescribe Naseptin cream

2. Provide first aid advice
3. Explain potential hospital treatment if bleeding persists

Additional Advice

• Consider using a humidifier to keep the air moist, especially during sleep
• Drink plenty of water to stay hydrated
• Avoid excessive heat or air conditioning that can dry out nasal passages

Important Notes and Things to Avoid

1. Don't perform unnecessary tests, especially if the patient has been on stable
medication for years without issues.
2. Avoid wasting resources with unnecessary medications or procedures. This is
unethical and will negatively impact your assessment.
3. Be thorough in your explanation, even for seemingly obvious points (like breathing
through the mouth when pinching the nose). This shows you're not ignorant and
are careful about small points.
4. Don't ignore small details - they show attentiveness and care.
5. Explain all steps of potential treatment, including what might happen at the
hospital.
6. Be clear and concise in your explanations of causes and management.

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7. Tailor your explanation to the specific scenario (blood thinners, nose picking, or
temperature changes).
8. Don't forget to provide first aid advice for future episodes.
9. Remember to address the patient's concerns and answer any questions they might
have.
10. Avoid medical jargon - explain terms in simple language.
11. Don't rush through the explanation. Give the patient time to process and ask
questions.
12. Avoid making assumptions about the patient's knowledge or experience with
nosebleeds.
13. Don't forget to mention the importance of following up if nosebleeds become
frequent or severe.
14. Remember to explain why you're not ordering tests in scenarios where they're not
necessary.
15. Don't overlook the potential psychological impact of recurrent nosebleeds,
especially in the spontaneous bleeding scenario.

Teenage Pregnancy Scenario

Patient Information

• 15-year-old girl
• Brought to A&E with parents
• Presenting complaint: Acute vomiting (started today, 2-3 episodes)

Important Considerations

• Patients under 16 cannot be seen alone, except for contraception

• Anyone of childbearing age should be considered pregnant until proven otherwise
• Confidentiality is crucial when discussing sensitive topics with teenagers

Approach to Assessment

1. Vomiting Assessment

Q: "When did the vomiting start?" A: (Patient may say it started today)

Q: "How many times have you vomited?" A: (Patient may say 2-3 times)

Q: "What does the vomit look like? Any blood in it?" A: (Patient describes vomit content)

Q: "How much do you vomit each time?" A: (Patient describes amount)

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Q: "Is there anything that makes the vomiting better or worse?" A: (Patient describes any
factors affecting vomiting)

2. Potential Causes Assessment

Central Nervous System

Q: "Do you have any headaches or dizziness with the vomiting?" Q: "Have you noticed any
changes in your vision or balance?"

Ear Conditions

Q: "Do you have any ear pain or ringing in your ears?"

Gastrointestinal Causes

Q: "Do you have any abdominal pain?" Q: "Have you had any diarrhoea?" Q: "Any changes
in your bowel habits?"

Genitourinary Causes

Q: "Do you have any pain when urinating?" Q: "Have you noticed any changes in your
urine colour or smell?"

Reproductive Causes

Q: "When was your last menstrual period?" A: (Patient may say it was six weeks ago)

Q: "Is there any possibility you could be pregnant?" A: (Patient may express uncertainty or
say "I don't know")

Q: "Are you sexually active?" Note: At this point, the patient may look concerned about
confidentiality.

Statement: "I want to assure you that whatever we discuss here will be confidential."

Q: "Do you have a boyfriend?" A: (Patient may confirm)

Q: "Are you sexually active with your boyfriend?" A: (Patient may confirm)

Q: "What contraception do you use?" A: (Patient may say "We don't use contraception" or
"We use the withdrawal method")

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3. Relationship Assessment

Q: "Who is your boyfriend? How old is he?" A: (Patient provides age of boyfriend)

Q: "How long have you been in this relationship?" A: (Patient describes length of
relationship)

Q: "Do your parents know about your relationship?" A: (Patient may say parents know
about the boyfriend)

Q: "Do your parents know about your sexual relationship?" A: (Patient may express fear,
saying something like "If my mom knows, she will kill me")

Q: "How is your relationship? Is it supportive?" A: (Patient describes nature of relationship)

Q: "Has your partner ever been aggressive or abusive towards you?" A: (Patient responds
about nature of relationship)

4. Pregnancy Test

Statement: "I would like to do a pregnancy test along with other observations."

Management Plan

If Pregnancy Test is Positive

Statement: "The pregnancy test is positive. You are pregnant, and this is likely the reason
for your vomiting."

1. Symptomatic Management "We will give you some medications to help with the
vomiting."
2. Referral and Advice "For your pregnancy, we advise you to speak to your GP. You
can also contact NUPAS (National Unplanned Pregnancy Advisory Service) for
confidential advice."
3. Safety Netting "Your vomiting might become more severe, a condition called
hyperemesis gravidarum. If it starts to interfere with your eating, drinking, or daily
activities, please seek medical help immediately."

Important Notes and Things to Avoid

1. Do not congratulate the patient on the pregnancy.

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2. Do not express that the pregnancy is unfortunate.

3. Do not initiate discussion about termination.
4. Maintain confidentiality throughout the conversation.
5. Do not involve parents in the management without the patient's consent.
6. Remember that a 15-year-old can make decisions if they demonstrate understanding
(Gillick competence).
7. Be careful and sensitive in your approach and language.
8. Focus on providing information and resources rather than making decisions for the
patient.
9. Always assess the nature of the relationship for any signs of abuse or coercion.
10. Be prepared to provide information about confidential services like NUPAS.
11. Remember to address the immediate health concern (vomiting) while also
addressing the underlying cause (pregnancy).
12. Be aware of the legal and ethical considerations when dealing with minors.
13. Don't rush through the explanation. Give the patient time to process and ask
questions.
14. Avoid making assumptions about the patient's knowledge or experience with sexual
health.
15. Don't forget to explain why you're asking sensitive questions about sexual activity
and relationships.
16. Remember to "destroy the patient" in your explanation - not literally, but in the
sense that the severity of the situation must be absolutely clear to the patient.
17. Avoid using euphemisms. Be direct but compassionate in your language.
18. Don't overlook the potential psychological impact of an unplanned pregnancy on a
teenager.
19. Remember to explain that the GP or NUPAS can provide further information
about all options available, including continuing the pregnancy, adoption, or
termination, without pushing the patient towards any specific option.

Nursing Home Scenario - Elderly Patient with Confusion

Patient Information

• Name: Leslie Brown

• Age: 83 years old
• Location: Brought to hospital from nursing home
• Presenting complaint: Confused, unable to give history
• Observations: Suggest sepsis/pneumonia
o Temperature: 38°C (high)
o Respiratory rate: High
o Blood pressure: Low

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o Heart rate: High

o Oxygen saturation: Low on air

Scenario Background

• Patient is currently in the hospital

• Nursing home staff felt she was unwell and confused
• You need to call the nursing home for information
• You may need to discuss management with examiner or carer

Approach to Communication

1. Telephone Call to Nursing Home

Doctor: "Hello, is this Westfield Nursing Home?" Staff: "Yes, it is."

Doctor: "Hello, I'm Dr. [Your Name], one of the doctors calling from Manchester Hospital.
The reason I'm calling you today is to discuss one of your residents." Staff: "Okay, how can
I help you?"

Doctor: "May I know your name, please?" Staff: "My name is Anna."

Doctor: "Thank you, Anna. What is your role there? Do you work at the nursing home?"
Anna: "Yes, I'm one of the carers here."

Doctor: "Excellent, Anna. The reason I'm calling you today is about one of your residents
called Leslie Brown. She's with us at the moment and is not able to speak. We're not able
to collect some information about her. Do you look after Leslie Brown?" Anna: "Yes, I
sometimes look after her, but I wasn't here last night when she was taken to the hospital."

Doctor: "I see. Is there anybody I can speak to who can give me some information about
what happened yesterday?" Anna: "I'm afraid there's nobody available right now who was
here yesterday, but we have some notes I can read from."

Doctor: "That would be very helpful, thank you. Before we proceed, let me confirm the
right details. I just want to double-check that we have the same information and are talking
about the same person. Can you confirm Leslie Brown's hospital number?" Anna:
"Certainly, let me check our records. Yes, her hospital number is [number]."

Doctor: "Thank you. Now, could you please tell me what information you have about why
she was brought to the hospital?"

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2. History Taking

Anna: "According to our notes, Mrs. Brown was brought to the hospital because she
seemed unwell and was more confused than usual."

Doctor: "I see. Was she unwell recently before being brought to the hospital?" Anna: "Yes,
the notes mention she had been a bit off-colour for a few days."

Doctor: "Can you tell me more about that? Has she had any specific symptoms?" Anna:
"The notes say she was a little bit chesty."

Doctor: "What do you mean by 'chesty'? Has she had any cough?" Anna: "Yes, it mentions
she had a cough and seemed short of breath at times."

Doctor: "I see. Has she had any fever?" Anna: "Yes, the night staff recorded a temperature
of 37.8°C the night before she was sent in."

Doctor: "Any wheezing or other breathing problems?" Anna: "The notes don't mention
wheezing, but they do say she seemed to be breathing faster than usual."

Doctor: "Thank you. Now, has she had any urinary symptoms? Any changes in her urine or
pain when passing urine?" Anna: "There's no mention of urinary symptoms in the notes,
I'm afraid."

Doctor: "Alright. Has she become more forgetful lately? Any change in her memory or
behaviour recently?" Anna: "Mrs. Brown has dementia, so she's often confused, but the
notes say she seemed more confused than usual in the last few days."

Doctor: "Has she had any falls recently? Any head injuries?" Anna: "No falls or injuries are
recorded in her recent notes."

Doctor: "Has she been eating and drinking normally? Any changes in her appetite or fluid
intake?" Anna: "The notes mention she's been eating and drinking less than usual over the
past few days."

Doctor: "Thank you. Now, about her medical history. Does Leslie have any ongoing
medical conditions apart from the dementia you mentioned?" Anna: "Yes, according to our
records, she has hypertension as well as dementia."

Doctor: "What medications does she take?" Anna: "She's on amlodipine for her blood
pressure and donepezil for her dementia."

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Doctor: "Does she have any allergies?" Anna: "Yes, it's clearly marked in her file that she's
allergic to penicillin."

Doctor: "That's very important information, thank you. Now, about her social situation.
Who are her family members?" Anna: "She has a daughter named Sarah who visits
regularly."

Doctor: "Is Sarah her next of kin?" Anna: "Yes, Sarah is listed as her next of kin."

Doctor: "Does Mrs. Brown have a lasting power of attorney?" Anna: "Yes, Sarah has lasting
power of attorney for health and welfare decisions."

Doctor: "Is there any advance directive for her treatment?" Anna: "I don't see any advance
directive in her file."

Doctor: "Is there any DNR (Do Not Resuscitate) or ADRT (Advance Decision to Refuse
Treatment) order?" Anna: "No, there's no DNR or ADRT order in her file."

Doctor: "Who is her GP?" Anna: "Her GP is Dr. Thompson at the Greenwood Surgery."

Doctor: "Thank you very much for all this information, Anna. It's been very helpful. Could
you please scan and send all this information to the hospital?" Anna: "Of course, I'll do that
right away."

Doctor: "Thank you for your help. Goodbye." Anna: "You're welcome. Goodbye."

Management Discussion

If discussing with Examiner:

Doctor: "Today, I assessed Mrs. Leslie Brown, an 83-year-old lady brought in from a
nursing home, confused. My provisional diagnosis is pneumonia complicated by sepsis."

Examiner: "Please outline your management plan."

Doctor: "Certainly. First, I will take care of ABC - Airway, Breathing, and Circulation. For
investigations, I'll order blood tests including FBC, U&E, ESR, and CRP. I'll also activate
the sepsis 6 protocol, which includes taking blood cultures, checking lactate, and
monitoring urine output. I'll order a chest X-ray as well.

For treatment, given her penicillin allergy, I'll start empirical antibiotic therapy with
clarithromycin. We'll also give IV fluids and oxygen as needed.

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Further actions include informing seniors about this case, speaking to her GP for collateral
history, and informing her family, particularly her daughter Sarah who has lasting power of
attorney."

Examiner: "Good. How would you explain this to the patient's daughter?"

Doctor: "I would use less medical language but still cover the key points. I'd say something
like this:

'Mrs. Brown seems to have a chest infection that has spread throughout her body. We call
this sepsis. We're going to run some tests, including blood tests and a chest X-ray. We'll
start her on antibiotics - not penicillin due to her allergy - and give her fluids to help her
body fight the infection. We're also going to closely monitor her condition. Given her
confusion and dementia, we'll need to make decisions in her best interests, and as you have
lasting power of attorney, we'll keep you informed and involved in these decisions.'"

Important Notes and Things to Avoid

1. Always confirm patient details to ensure you're discussing the correct patient.
2. Be thorough in history taking, considering all potential causes of confusion in the
elderly.
3. Don't forget to ask about allergies - the penicillin allergy is crucial information.
4. If given a choice between discussing with examiner or carer, choose the examiner.
5. Adjust your language based on who you're speaking to (medical terms for examiner,
simpler terms for carer).
6. Don't forget to mention informing seniors, GP, and family as part of the
management plan.
7. Be prepared to explain medical terms if discussing with a carer.
8. Don't assume the nursing home staff member you're speaking to has all the
information - they may need to refer to notes.
9. Remember to ask about advance directives and DNR orders - these are important
for treatment decisions.
10. Don't forget to request that the nursing home send all relevant information to the
hospital.
11. When calling the nursing home, introduce yourself and state your reason for calling
before asking for information.
12. Don't use medical jargon when speaking with nursing home staff unless you're sure
they'll understand it.
13. Be prepared for the possibility that the staff member you're speaking to may not
have all the information - they might need to refer to notes.
14. When discussing management with the examiner, use the term "empirical
treatment" rather than "broad-spectrum" when talking about antibiotics.

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15. Remember that empirical treatment targets the most common causative agent for
the particular condition, not necessarily the broadest spectrum of organisms.
16. Don't forget to consider UTI as a possible cause of sepsis in elderly patients, even if
chest symptoms are present.
17. Be aware that the scenario may sometimes change to focus on UTI rather than
pneumonia - be prepared to adapt your approach.
18. When discussing with the examiner, remember to mention activating the sepsis 6
protocol.
19. Don't forget to mention monitoring urine output as part of the sepsis management.
20. Remember that the language used with a carer should be somewhere between
layman's terms and medical terminology - not completely simplified, but not fully
medical either.

Nursing Home Scenario - Elderly Patient with Confusion (No Infection)

Patient Information

• Age: 80 years old

• Gender: Female
• Location: Brought to hospital from nursing home
• Presenting complaint: Confused
• Observations:
o Temperature: Normal
o Respiratory rate: Normal
o Blood pressure: Normal
o Heart rate: Normal
o Oxygen saturation: Normal
o GCS: 13 out of 15

Scenario Background

• Patient brought to hospital by nursing home staff due to confusion

• Patient is not able to give a history
• All vital signs are normal except for decreased GCS
• This scenario differs from previous ones in key aspects

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Approach to Communication

1. Telephone Call to Nursing Home

Doctor: "Hello, is this Sunnyside Nursing Home?" Staff: "Yes, it is."

Doctor: "Hello, I'm Dr. Smith calling from City Hospital. I'm calling about one of your
residents who was brought in today due to confusion. May I know your name and role?"
Staff: "I'm Jane, one of the carers. I've been looking after this lady regularly."

Doctor: "Thank you, Jane. Can you confirm the patient's name and details for me?" Jane:
"Yes, it's Mrs. Elizabeth Johnson, born on 15th May 1943."

Doctor: "Thank you. Now, can you tell me more about the confusion you've noticed in
Mrs. Johnson?" Jane: "She's been acting strangely, not like her usual self. She seems
disoriented and is having trouble recognizing some of the staff."

2. History Taking

Doctor: "What specific things have you noticed about her behaviour?" Jane: "She's been
forgetting where her room is, mixing up staff members' names, and yesterday she tried to
leave the home saying she needed to pick up her children from school."

Doctor: "I see. When did you first notice these changes? Has it been getting better or
worse?" Jane: "We first noticed about three days ago. It seemed to come on suddenly and
has been getting gradually worse."

Doctor: "How is Mrs. Johnson's memory usually? Has she been diagnosed with dementia?"
Jane: "No, she's usually quite sharp. She's never been diagnosed with dementia. She usually
manages her own medications and remembers all her grandchildren's birthdays."

Doctor: "Has she had any recent infections? Any fever, cough, or urinary symptoms?" Jane:
"No, she hasn't shown any signs of infection. Her temperature has been normal and she
hasn't complained of any pain or discomfort."

Doctor: "Has Mrs. Johnson had any falls recently?" Jane: "Yes, now that you mention it, she
fell three days ago when getting up from a chair."

Doctor: "Can you tell me more about this fall? What happened just before, during, and
after?" Jane: "She was sitting in the lounge and tried to stand up quickly when her daughter
arrived. She lost her balance and fell backwards. She didn't hit her head on anything, but
she did land quite heavily on her bottom."

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Doctor: "After the fall, did she have any immediate confusion, vomiting, memory
problems, balance issues, or weakness in any part of her body?" Jane: "No, she seemed fine
immediately after. She was a bit shaken up, but she was talking normally and walked back
to her room without any problems. But over the next few days, she slowly started becoming
confused."

Doctor: "Has she had any headaches, nausea, or visual disturbances since the fall?" Jane:
"She did mention a headache yesterday, but we didn't think much of it at the time. She
hasn't complained of nausea or any vision problems."

Doctor: "What medications is Mrs. Johnson currently taking?" Jane: "She's on amlodipine
for high blood pressure and simvastatin for cholesterol. She also takes a daily
multivitamin."

Doctor: "Does she have any allergies?" Jane: "Yes, she's allergic to penicillin."

Doctor: "Who are her next of kin? Does she have any advance directives or DNR orders?"
Jane: "Her daughter, Sarah, is her next of kin. I don't believe there are any advance
directives or DNR orders, but I'd have to check her file to be certain."

Management Plan

Based on the history and presentation, the likely diagnosis is a chronic subdural
hematoma.

Doctor: "Thank you for all this information, Jane. Based on what you've told me, especially
about the fall a few days ago, we suspect that Mrs. Johnson may have developed a slow
bleed in her brain. This is called a chronic subdural hematoma. We're going to do a CT
scan to confirm this. If confirmed, she may need a small surgery to remove the blood clot."

Jane: "Oh, I see. Is it our fault this happened?"

Doctor: "It's difficult to say whether this is related to her care. Falls can happen despite best
precautions, especially in older adults. What's important now is to focus on her treatment.
I can assure you that before we discharge her, we'll refer her to social services for a safety
assessment to help prevent future falls."

Jane: "Thank you, doctor. What should we do now?"

Doctor: "For now, please send over any additional medical records you have for Mrs.
Johnson. We'll keep you updated on her condition and treatment plan. If her family

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contacts you, please let them know we're taking care of her and that they can call the
hospital for more information."

Jane: "Of course, I'll do that right away."

Doctor: "Thank you, Jane. If you think of any other information that might be relevant,
please don't hesitate to call back."

Detailed Management Plan

1. Investigations:
o Urgent CT scan of the head
2. Treatment:
o If CT confirms subdural hematoma:
§ Refer to neurosurgeons
§ Potential treatments include burr hole surgery or craniotomy to
evacuate the clot
3. Further actions:
o Inform the patient's next of kin (daughter Sarah)
o Refer to social services for safety assessment before discharge
o Review and potentially adjust current medications
o Arrange follow-up care and rehabilitation if surgery is performed

Important Notes and Things to Avoid

1. This scenario differs from previous ones:

o All vital signs are normal (no signs of infection/sepsis)
o The carer is familiar with the patient (unlike previous scenarios)
o The patient does not have a history of dementia
o Recent fall is a key factor in the history
2. Focus on analysing the confusion:
o Ask for specific examples of confused behaviour
o Determine onset and progression
o Don't assume it's due to dementia or delirium from infection
3. Pay close attention to the fall history:
o Ask about immediate and delayed symptoms after the fall
o Consider chronic subdural hematoma even if there were no immediate
symptoms
o Remember that elderly patients may develop subdural hematomas from
seemingly minor falls
4. When discussing fault or responsibility with the nursing home staff:
o Be diplomatic and non-judgmental

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o Focus on current treatment and future prevention rather than assigning

blame
o Reassure them that falls can happen despite best precautions
5. Remember to mention the need for social services assessment before discharge to
prevent future falls.
6. Be prepared to explain medical terms like "chronic subdural hematoma" in simple
language. Example: "It's a slow bleed between the brain and its outer covering,
which can put pressure on the brain and cause confusion."
7. Don't forget to ask about medications, allergies, next of kin, and advance directives.
8. When ordering CT scan, be clear about the suspected diagnosis to ensure
appropriate urgency.
9. Be prepared to explain the potential need for neurosurgical intervention if the CT
confirms a subdural hematoma.
10. Avoid jumping to conclusions about infection or dementia based on previous
scenarios. Each case should be approached individually.
11. Don't dismiss the importance of the fall just because there were no immediate
symptoms. Chronic subdural hematomas can develop slowly over days.
12. Avoid using medical jargon when speaking with nursing home staff. Explain things
in clear, simple terms.
13. Don't forget to follow up with the nursing home after the diagnosis and treatment
plan are confirmed.

Obstructive Sleep Apnea

Patient Overview and Scenario Background

• 40-45 year old man

• Presenting to GP with sleeping problems
• BMI likely in obesity category
• Has visited GP in the past but no testing done previously
• Two scenarios to be aware of:
1. Patient presenting with sleeping problems (primary focus of these notes)
2. Diabetic follow-up scenario (to be studied separately)

I. Approach to Communication

Initial Greeting and Open-Ended Question

Doctor: "Hello, Mr. Johnson. How may I help you today?" Patient: "I've been having some
sleeping problems lately."

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Explore the Nature of the Sleeping Problem

Doctor: "I see. Can you tell me more about what kind of sleeping problems you're
experiencing?" Patient: "Well, I snore a lot. My wife has been complaining about it."

Doctor: "Thank you for sharing that. Snoring can certainly be disruptive, both for you and
your wife. Let's explore this further to understand what might be going on."

II. History Taking

Sleep Patterns

Doctor: "Can you tell me more about your sleep patterns?" Patient: "What do you mean
exactly?" Doctor: "Well, there are three main things we look at when it comes to sleep
problems:

1. Do you find it difficult to fall asleep?

2. Do you fall asleep easily but wake up in the middle of the night, perhaps gasping for
air?
3. Do you feel sleepy all the time, even during the day? Additionally, some people wake
up very early in the morning. Which of these, if any, do you experience?"

Patient: [Provides answer]

Doctor: "I see. And what time do you usually go to bed? How long does it take you to fall
asleep? How many hours do you typically sleep?"

Patient: [Provides answer]

Snoring

Doctor: "You mentioned snoring. How did you first become aware of your snoring?"
Patient: "My wife told me about it."

Doctor: "I see. And since when have you been snoring? Has it been getting better or worse
over time?" Patient: [Provides answer]

Doctor: "Is there anything you've noticed that makes the snoring better or worse?" Patient:
"What do you mean?" Doctor: "For example, some people find their snoring is worse after
drinking alcohol, when they're very tired, or in certain sleeping positions. Some find it
improves with exercise. Have you noticed any patterns like that?"

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Patient: [Provides answer]

Symptoms of Obstructive Sleep Apnea

Doctor: "I'd like to ask you about some other symptoms that sometimes go along with
snoring. Do you ever wake up at night gasping for air?"

Patient: [Provides answer]

Doctor: "How about during the day - do you experience any of the following:

• Tiredness?
• Recent weight gain?
• Feeling sleepy while doing other activities? Have you ever fallen asleep while doing
other activities?"

Patient: "Like what?"

Doctor: "For example:

• While watching TV
• While reading a book
• Taking a rest after lunch
• While sitting and talking to somebody
• Sitting in a car or vehicle as a passenger Have you experienced falling asleep in any
of these situations?"

Patient: [Provides answer]

Doctor: "Do you drive?" Patient: [Provides answer]

If yes: "Have you ever fallen asleep or felt very drowsy while driving?"

Patient: [Provides answer]

Other Potential Causes

Doctor: "I'd like to ask about a few other things that can sometimes affect sleep or cause
snoring:

• Have you had any surgeries on your nose or throat?

• Any accidents or injuries, particularly to your face or neck?
• Do you smoke?

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• How about alcohol consumption?

• Have you had any recent weight gain?"

Patient: [Provides answers to each question]

III. PMAFTOSA (Medical, Allergies, Past Medical History, Travel, Occupation, Social
History, Alcohol)

Doctor: "Now, I'd like to ask you some general questions about your health and lifestyle."

Medical

Doctor: "Are you currently taking any medications?"

Patient: [Provides answer]

Allergies

Doctor: "Do you have any allergies to medications or anything else?"

Patient: [Provides answer]

Past Medical History

Doctor: "Have you had any significant medical conditions or surgeries in the past?"

Patient: [Provides answer]

Travel

Doctor: "Have you travelled anywhere recently?"

Patient: [Provides answer]

Occupation

Doctor: "What is your occupation?"

Patient: [Provides answer]

Note: Pay special attention if the patient's occupation involves driving (e.g., taxi driver,
delivery driver, ambulance driver, bus driver, lorry driver).

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Social History

Doctor: "Can you tell me a bit about your living situation? Who do you live with?"

Patient: [Provides answer]

Alcohol

Doctor: "How much alcohol do you typically drink in a week?"

Patient: [Provides answer]

IV. Examination

Doctor: "I'd like to check your height and weight to calculate your BMI, if that's alright
with you."

[Perform BMI calculation]

Note: In obstructive sleep apnea, BMI is typically in the obesity category.

V. Diagnosis and Explanation

Doctor: "Thank you for providing all this information, Mr. Johnson. Based on what you've
told me, there's a possibility that you might have a condition called obstructive sleep apnea.
Have you heard of this before?"

Patient: "No, I haven't. What is it?"

Doctor: "Obstructive sleep apnea is a condition that affects your airway during sleep. When
we sleep, the muscles in our throat relax. In some people, these muscles relax too much,
which can cause the airway to close temporarily. This can wake you up briefly, often with a
gasping sensation, although you might not always remember it. It can happen multiple
times during the night, which can disrupt your sleep and lead to daytime tiredness and
other symptoms."

Patient: "That sounds serious. Is that what's causing my snoring?"

Doctor: "Snoring is often a symptom of obstructive sleep apnea, but not everyone who
snores has sleep apnea. We'll need to do some further tests to confirm the diagnosis."

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VI. Management Plan

Doctor: "Here's what I suggest we do next:

1. Referral: I'm going to refer you to a sleep specialist. They'll be able to conduct a
sleep study, which will measure your brain activity and oxygen levels during sleep.
This will help confirm whether you have obstructive sleep apnea.
2. Urgent Referral: Given your symptoms [and occupation if relevant, e.g., "and your
job as a taxi driver"], I'm going to make this an urgent referral. This means you
should be seen relatively soon, but it may still take about 4-6 weeks.
3. Sleep Study: The sleep specialist will conduct sleep studies. They'll study your brain
activity during sleep and measure your oxygen levels. This will help confirm the
diagnosis.
4. Treatment: If the sleep study confirms obstructive sleep apnea, the main treatment
is usually a device called CPAP (Continuous Positive Airway Pressure). It's a mask-
like device connected to a small motor that you wear while sleeping. It keeps your
airway open, preventing the episodes of blocked breathing. It might feel a bit
uncomfortable at first, but most people get used to it over time.
5. Lifestyle Changes: In the meantime, there are some lifestyle changes that can help:
o Try to lose some weight if you're overweight
o Regular exercise can help
o Cut down on stimulant products like coffee and alcohol, especially close to
bedtime
o Try to maintain a regular sleep schedule
6. Driving: Until we have a definitive diagnosis, I'd advise you to be very cautious
about driving, especially if you're feeling tired. If the diagnosis is confirmed, we may
need to inform the DVLA.
7. Follow-up: I'd like to see you again in [appropriate timeframe] to check on your
progress and discuss the results of your sleep study when they're available.

Do you have any questions about this plan?"

Patient: [Asks questions if any]

Doctor: "One last thing - obstructive sleep apnea, if left untreated, can increase your risk of
developing heart-related conditions like heart attacks or strokes. That's why it's important
we investigate this thoroughly and get you the right treatment if needed."

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VII. Important Notes and Things to Avoid

1. Two Scenarios: Be aware that obstructive sleep apnea can present in two main
scenarios: a) A patient coming in with sleeping problems (as in this case) b) As part
of a diabetic follow-up (to be studied separately)
2. Differentiation: Be sure to differentiate between obstructive sleep apnea and
insomnia.
o People with sleep apnea are often sleepy during the day and fall asleep easily
but may wake up gasping for air.
o Those with insomnia have trouble falling asleep.
3. BMI: Always check or calculate BMI for patients with suspected obstructive sleep
apnea. It's often in the obesity category.
4. Occupation: Pay special attention to the patient's occupation, especially if it involves
driving. This affects the urgency of the referral and potential safety concerns.
5. Urgent Referral:
o For sleep apnea, an urgent referral typically means 4-6 weeks, not the 2-week
cancer pathway.
o Don't specify the exact timeframe to the patient unless asked.
o If asked, you can say it usually takes about 4-6 weeks.
o The urgency is higher for patients whose occupation involves driving.
6. Referral Details:
o Sleep clinic referral
o Patient will be seen by a sleep specialist (usually a neurologist)
o They will conduct sleep studies, measuring brain activity and oxygen levels
during sleep
7. CPAP Explanation: When explaining CPAP, mention that it might be
uncomfortable at first but patients usually adapt over time.
8. Lifestyle Advice: Always include advice on weight loss, regular exercise, and
reducing stimulants like caffeine and alcohol.
9. Driving Advice: Always advise caution with driving for patients with suspected sleep
apnea, especially if their job involves driving.
10. DVLA: Remember to mention that the DVLA may need to be informed if sleep
apnea is confirmed, especially for professional drivers.
11. Follow-up: Always arrange a follow-up appointment to discuss the results of the
sleep study and any ongoing management.
12. Avoid Dismissing Snoring: While not all snoring indicates sleep apnea, take all
reports of snoring seriously, especially when accompanied by daytime sleepiness or
observed apneas.
13. Spouse Involvement: If the spouse is present or mentioned (as in this case with the
wife complaining about snoring), you can suggest they buy earplugs from the
pharmacy as a temporary measure.

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14. Comprehensive History: Ensure you cover all aspects of the patient's history,
including recent weight gain, alcohol consumption, smoking, and any previous
surgeries or injuries to the nose or throat.
15. Epworth Sleepiness Scale: While not mentioned explicitly in the consultation, be
aware of the Epworth Sleepiness Scale. This is a questionnaire used to measure
daytime sleepiness and can be helpful in assessing the severity of sleep apnea.
16. Heart-related Risks: Always mention the increased risk of heart-related conditions
like heart attacks or strokes if sleep apnea is left untreated. This helps emphasize the
importance of diagnosis and treatment.
17. Patient Education: Take time to explain the condition, its potential causes, and the
importance of treatment. This can improve patient compliance with the
management plan.
18. Avoid Guarantees: While CPAP is often effective, avoid guaranteeing that it will
solve all the patient's problems. Every patient responds differently to treatment.

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TIA, Stroke, and Bell's Palsy

Overview

This guide covers four important scenarios that can cause confusion due to similar
presenting symptoms:

1. TIA in GP setting
2. TIA in A&E setting
3. Stroke (telephone call scenario)
4. Bell's palsy

It's crucial to identify and treat each correctly, as management differs significantly.

I. Initial Approach

When a patient presents with neurological symptoms:

Doctor: "Hello, how may I help you today?"

Patient: "Doctor, I developed some symptoms."

Doctor: "I see. What sort of symptoms did you experience?"

Patient: "I developed some weakness, and my face was going to one side."

II. Key Diagnostic Question

The critical question to differentiate between TIA/Stroke and ongoing symptoms:

Doctor: "Do you have any symptoms at the moment as we talk?"

Scenario 1: No Current Symptoms (Potential TIA)

Patient: "No, I don't have any symptoms right now."

Doctor: "I see. When did you develop these symptoms?"

Patient: "I developed them last night."

Doctor: "How long did the symptoms last?"

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Patient: "They lasted for about 20 minutes."

Scenario 2: Ongoing Symptoms (Potential Stroke)

Patient: "Yes, doctor. I still have some numbness and weakness."

Note: Any symptoms lasting more than 24 hours are also considered a stroke.

III. FAST-3 Assessment

Use the FAST-3 approach to assess symptoms:

T - Time (3 questions)

1. Do you have any symptoms at the moment as we talk?

2. When did you develop these symptoms?
3. How long did the symptoms last? (or "How long have you had these symptoms?" if
ongoing)

F - Face

Doctor: "Have you had any symptoms on your face? Such as weakness, drooping on one
side, or numbness?"

Patient: [Provides answer]

Doctor: "Any problem with your vision? Have you had any loss of vision? How is your
vision? Any blurry vision?"

Patient: [Provides answer]

A - Arm (and other limbs)

Doctor: "Have you experienced any arm weakness, numbness, or difficulty moving your
arm? What about your leg? Any numbness, weakness, or difficulty moving? Have you had
any falls or problems with walking? Any limping?"

Patient: [Provides answer]

S - Speech and Swallowing

Doctor: "Have you had any problems with your speech? Any difficulties with swallowing?"

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Patient: [Provides answer]

IV. Differential Diagnosis

Consider other conditions that may present with similar symptoms:

Bell's Palsy

• Symptoms only on one side of the face

• Only affects facial muscles

Doctor: "Are your symptoms limited to just one side of your face?"

Patient: [Provides answer]

Doctor: "Have you noticed any rash along with these symptoms?" (to rule out Ramsay Hunt
syndrome)

Patient: [Provides answer]

Guillain-Barré Syndrome

Doctor: "Have you had any recent infections, such as diarrhoea or a respiratory infection?"

Patient: [Provides answer]

Doctor: "Did your symptoms start from your legs and move upwards?"

Patient: [Provides answer]

Myasthenia Gravis

Doctor: "Do your symptoms occur at a certain time of day, particularly in the evenings?
Have they happened multiple times?"

Patient: [Provides answer]

Doctor: "Have you ever experienced any drooping of your eyelids or 'lazy eye'?"

Patient: [Provides answer]

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Brain Tumor

Doctor: "Have you experienced any persistent, focal neurological symptoms?"

Patient: [Provides answer]

V. PMAFTOSA Assessment

Complete a thorough assessment, focusing on:

Medical History

Doctor: "Do you have any pre-existing medical conditions, such as high blood pressure,
diabetes, or high cholesterol?"

Patient: [Provides answer]

Allergies

Doctor: "Do you have any allergies to medications?"

Patient: [Provides answer]

Past Medical History

Doctor: "Have you ever had a stroke or mini-stroke before?"

Patient: [Provides answer]

Travel

Doctor: "Have you travelled recently?"

Patient: [Provides answer]

Occupation

Doctor: "What is your occupation?"

Patient: [Provides answer]

Social History

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Focus on modifiable and non-modifiable risk factors:

Non-modifiable risk factors:

• Family history
• Previous stroke or TIA
• Age
• Gender

Modifiable risk factors (DATES):

• Diet
• Alcohol
• Tobacco
• Exercise
• Stress

Doctor: "I'd like to ask you about some lifestyle factors. First, can you tell me about your
diet?"

Patient: [Provides answer]

Doctor: "How much alcohol do you typically consume?"

Patient: [Provides answer]

Doctor: "Do you smoke or use any tobacco products?"

Patient: [Provides answer]

Doctor: "How often do you exercise?"

Patient: [Provides answer]

Doctor: "How would you describe your stress levels?"

Patient: [Provides answer]

VI. Examination

For TIA diagnosis in a scenario, the examination should be normal:

Doctor: "I'm going to perform a brief examination now."

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[Perform examination]

Doctor: "Your examination appears normal at the moment."

For Bell's palsy, there will be findings related to the facial nerve:

Doctor: "I've noticed some weakness in the muscles on one side of your face, which is
consistent with involvement of the facial nerve."

VII. Diagnosis and Management

For TIA:

Doctor: "Based on your symptoms that have now resolved and the normal examination, I
suspect you may have experienced a Transient Ischemic Attack, or TIA. This is sometimes
called a 'mini-stroke'. We need to take this seriously as it can be a warning sign for a future
stroke."

Management:

1. Immediate aspirin (if not contraindicated)

2. Urgent referral to a TIA clinic (usually seen within 24 hours)
3. Address modifiable risk factors

For Stroke:

If symptoms are ongoing or lasted more than 24 hours:

Doctor: "Your ongoing symptoms suggest you may be experiencing a stroke. This requires
immediate emergency treatment."

Management:

1. Call for emergency ambulance

2. Do not give aspirin until a CT scan has been performed
3. Prepare for urgent hospital admission

For Bell's Palsy:

Doctor: "The weakness on one side of your face, without other neurological symptoms,
suggests a condition called Bell's palsy. This is caused by inflammation of the facial nerve."

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Management:

1. Consider oral steroids if within 72 hours of symptom onset

2. Eye protection advice
3. Possible antiviral treatment if Ramsay Hunt syndrome is suspected

VIII. Important Notes and Things to Avoid

1. Always ask about current symptoms to differentiate between TIA and stroke.
2. For chest pain, use a similar approach to differentiate between MI, unstable angina,
and stable angina:
o Ask: "Do you have chest pain at the moment as we talk?"
o If yes: Consider MI
o If no: Ask about the circumstances when pain occurred
§ If at rest: Consider unstable angina
§ If only during exertion: Consider stable angina
3. Don't forget to assess all aspects of FAST-3, including vision problems.
4. Consider other neurological conditions in your differential diagnosis.
5. Focus on both modifiable and non-modifiable risk factors in your assessment.
6. Remember the DATES mnemonic for lifestyle factors: Diet, Alcohol, Tobacco,
Exercise, Stress.
7. For TIA, give aspirin immediately if not contraindicated.
8. For suspected stroke, do not give aspirin until a CT scan has been performed.
9. Be prepared to arrange urgent referrals or emergency services as needed.
10. Provide clear explanations to patients about their condition and the reasons for
your management plan.
11. Always consider the impact of the patient's occupation, especially for conditions
that may affect their ability to work safely (e.g., driving occupations).
12. Don't rely solely on classic textbook descriptions. Be prepared for variations in
presentation and atypical cases.
13. Remember that the urgency of referral for TIA depends on the patient's occupation,
especially if it involves driving.
14. For urgent referrals, don't specify an exact timeframe to the patient unless asked. If
asked, you can say it usually takes about 4-6 weeks.
15. Be aware that a 2-week urgent referral is typically reserved for suspected cancer
pathways.
16. When explaining CPAP for sleep apnea, mention that it might be uncomfortable at
first but patients usually adapt over time.
17. Always mention the increased risk of heart-related conditions like heart attacks or
strokes if conditions like sleep apnea or TIA are left untreated.

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18. Avoid dismissing symptoms even if they seem minor. Take all reports seriously,
especially when accompanied by other concerning symptoms.
19. If a spouse or family member is mentioned as noticing symptoms, involve them in
the discussion if present, or suggest they accompany the patient to future
appointments.
20. Be thorough in your history taking. Don't forget to ask about recent weight changes,
alcohol consumption, smoking, and any previous surgeries or injuries that might be
relevant.
21. When discussing lifestyle changes, be specific and realistic. Offer concrete
suggestions for improvement rather than general advice.
22. Remember to arrange follow-up appointments to discuss test results and monitor
progress, even for conditions that may seem less urgent.

Transient Ischemic Attack (TIA) in GP Setting

I. Patient Scenario

• 60-65 year old man

• Made an appointment at GP's request of his wife
• Only significant history: patient smokes and drives regularly
• No other past medical history mentioned

II. Initial Consultation

Doctor: "Hello, how may I help you today?"

Patient: "My wife asked me to see you."

Doctor: "I see. Can you tell me more about why your wife wanted you to come in?"

Patient: "Well, last night I was brushing my teeth, and my face went to one side. My wife
saw it first and asked me to check in the mirror. I did, and I could see it was going to one
side. This morning, she insisted I come to see you about it."

III. Critical Thinking Point

Note: The patient has not clearly stated whether the symptoms are still present or have
resolved. This is a crucial point that requires clarification and demonstrates the importance
of critical thinking in diagnosis.

Doctor: "Thank you for sharing that. Before we continue, I have an important question:
Do you have any symptoms at the moment as we speak?"

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Patient: "No, everything seems normal now."

Doctor: "I see. And when exactly did the symptoms start last night, and how long did they
last?"

Patient: [Provides timing details]

IV. FAST Assessment

F - Face

Doctor: "You mentioned your face went to one side. Can you describe that in more detail?
Did you notice any numbness or weakness on one side of your face?"

Patient: [Provides details]

A - Arm

Doctor: "Did you experience any weakness or numbness in your arms or legs during this
episode?"

Patient: [Provides answer]

S - Speech

Doctor: "Did you notice any changes in your speech? Any difficulty speaking or
understanding others?"

Patient: [Provides answer]

T - Time

Doctor: "You've already mentioned when it started. Can you confirm again exactly when
the symptoms began and how long they lasted?"

Patient: [Confirms timing]

V. Risk Factor Assessment (PMAFTOSA)

Medical History

Doctor: "Do you have any pre-existing medical conditions, such as high blood pressure,
diabetes, or high cholesterol?"

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Patient: [Provides answer]

Allergies

Doctor: "Do you have any allergies to medications?"

Patient: [Provides answer]

Past Medical History

Doctor: "Have you ever experienced anything like this before? Any history of stroke or
heart problems in your family?"

Patient: [Provides answer]

Travel

Doctor: "Have you travelled recently?"

Patient: [Provides answer]

Occupation

Doctor: "You mentioned you drive regularly. Is driving a part of your occupation?"

Patient: [Provides answer]

Social History (DATES)

• Diet
• Alcohol
• Tobacco: Patient is known to smoke
• Exercise
• Stress

Doctor: "I'd like to ask about some lifestyle factors. Can you tell me about your typical diet?
How much alcohol do you consume? I know you smoke, but how much and for how long?
What about exercise and stress levels?"

Patient: [Provides answers for each category]

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VI. Examination

Doctor: "I'd like to perform a neurological examination now, focusing on your face, arms,
and legs. I'll also check the nerves in your head and neck."

[Perform examination]

Doctor: "Your examination appears normal at the moment."

VII. Diagnosis and Explanation

Doctor: "From the information I've gathered, it seems you may have experienced what we
call a Transient Ischemic Attack, or TIA. This is sometimes referred to as a 'mini-stroke'.
Have you heard of this before?"

Patient: "No, I haven't. What exactly is it?"

Doctor: "A TIA, or Transient Ischemic Attack, is a condition that affects the brain. It
occurs when there's a temporary interruption to the blood supply of brain cells, causing the
symptoms you experienced. The key word here is 'temporary' - the symptoms come and go,
which is why we use the term 'transient'."

Patient: "I see. Is it serious?"

Doctor: "Unfortunately, a TIA is potentially dangerous. While the symptoms have resolved,
it can be a warning sign for a future stroke. That's why we need to take it seriously and act
quickly."

VIII. Management Plan

1. Immediate Aspirin Doctor: "First, I'm going to prescribe you a high dose of aspirin,
300mg, to take immediately. This is a blood-thinning medication that can help
prevent further issues." Note: If aspirin is not available in the surgery, write a
prescription for the patient to buy and take immediately.
2. Urgent Referral Doctor: "I'm also going to arrange an emergency appointment for
you at the TIA clinic. Given that your symptoms occurred within the last week, you
should be seen by a stroke specialist within 24 hours." Note on referral urgency:
o Symptoms within last 7 days: Seen within 24 hours
o Symptoms more than 7 days ago: Seen within a week
3. TIA Clinic Visit Explanation Doctor: "At the TIA clinic, you'll be seen by a stroke
specialist. They may perform several tests, including:
o A CT scan of your brain

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o Blood tests
o A scan of the blood vessels in your neck, called a Doppler scan These tests
will help confirm the diagnosis and determine the best treatment plan."
4. Ongoing Medication Doctor: "The specialist will likely change your blood-thinning
medication to one called clopidogrel, which you'll need to take for at least two years.
They may also prescribe cholesterol-lowering medication if your levels are high
(specifically, if it's more than 3.5 mg), and possibly a type of blood pressure
medication called an ACE inhibitor."
5. Interim Instructions Doctor: "If there's any delay in seeing the specialist, continue
taking the 300mg aspirin every 24 hours until your appointment."
6. Driving Advice Doctor: "I must advise you not to drive for the next four weeks. This
is a precautionary measure to ensure your safety and the safety of others on the
road. You don't need to inform the DVLA at this stage."
7. Lifestyle Changes Doctor: "Making some changes to your lifestyle can significantly
reduce your risk of future events. This includes:
o Quitting smoking
o Reducing alcohol intake
o Improving your diet
o Increasing physical activity
o Managing stress We can discuss these in more detail and I can provide
resources to help you make these changes."

IX. Follow-up and Closing

Doctor: "Do you have any questions about what we've discussed or the plan moving
forward?"

Patient: "Is this a big deal, doctor?"

Doctor: "I understand your concern. While I wouldn't use the term 'big deal', I would say
that a TIA is potentially dangerous. It significantly increases your risk of having a full
stroke in the near future, which is why we're taking these precautions and acting quickly.
With proper treatment and lifestyle changes, we can greatly reduce this risk."

Patient: [Asks any additional questions]

Doctor: "I'll be arranging your TIA clinic appointment right away. They will contact you
with the details. Remember to take the aspirin I've prescribed immediately, and don't
hesitate to contact us or seek emergency care if you experience any new or worsening
symptoms. I'd also like to see you for a follow-up appointment in [appropriate timeframe]
to check on your progress and discuss any results or recommendations from the TIA
clinic."

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X. Important Notes and Things to Avoid

1. Always clarify whether symptoms are ongoing or have resolved. This is crucial for
differentiating between TIA and stroke.
2. Don't assume all facial symptoms are Bell's palsy. Always consider TIA, especially
with rapid onset and resolution.
3. Be thorough in risk factor assessment, including occupational factors like regular
driving.
4. Use professional language. Avoid colloquial terms like "big deal" when discussing
the seriousness of the condition. Instead, use terms like "potentially dangerous" or
explain the increased risk of stroke.
5. Provide clear, specific advice about medication dosage (300mg aspirin) and duration
(clopidogrel for two years).
6. Remember the timeframes for TIA clinic referrals:
o Symptoms within last 7 days: Seen within 24 hours
o Symptoms more than 7 days ago: Seen within a week
7. Don't forget to advise against driving for 4 weeks.
8. Avoid medical jargon without explanation. Always provide clear definitions and
explanations for medical terms.
9. Don't overlook the importance of lifestyle modifications in preventing future events.
10. Remember to arrange a follow-up appointment to ensure continuity of care.
11. Be prepared to explain why you're not ordering immediate tests in the GP setting.
The focus is on urgent referral to the TIA clinic.
12. Don't rush through the explanation of TIA. Ensure the patient understands the
concept of a "mini-stroke" and why it's a warning sign.
13. Avoid creating unnecessary alarm, but also don't downplay the seriousness of a TIA.
Strike a balance in your communication.
14. Don't forget to mention the possibility of cholesterol and blood pressure
medications, even if you're not prescribing them immediately.
15. Be clear about the long-term nature of some treatments (e.g., clopidogrel for two
years) to set appropriate expectations.
16. Remember to involve the patient's wife in the discussion if present, as she was the
one who noticed the symptoms and insisted on the GP visit.
17. Avoid using abbreviations without explanation. Always provide the full term (e.g.,
Transient Ischemic Attack) before using the abbreviation (TIA).
18. Don't neglect to emphasize the urgency of the situation and the importance of
attending the TIA clinic appointment.
19. Be prepared to repeat key information, as patients may be anxious and may not
absorb all details in one go.
20. Remember to document the consultation thoroughly, including the patient's
account of symptoms, your examination findings, and the management plan.

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TIA Discharge Scenario (A&E Setting)

I. Scenario Overview

• 69-year-old female patient brought to A&E by her husband

• Patient developed symptoms including weakness, slurred speech, dropping of the
angle of the mouth, and difficulty swallowing
• Symptoms lasted for 2 hours and occurred 3 hours ago
• CT scan normal, neurological examination normal
• Blood pressure is high
• Blood tests have been done and results are pending
• Patient will be seen in the TIA clinic
• Patient is too upset to talk, so you need to speak with the husband

II. General Approach

1. Do not repeat tests or procedures that have already been done ("do not toast bread
that has already been toasted").
2. Be oriented to the current situation and the information provided.
3. Address the husband's concerns and potential nervousness.
4. Be empathetic and professional throughout the interaction.
5. Remember this is one of three common discharge scenarios (others being epilepsy
discharge in a 13-year-old girl and iron deficiency anaemia with suspected colonic
cancer).

III. Initial Interaction

Doctor: "Hello, I'm Dr. [Your Name], one of the doctors here. May I know your name,
please?"

Husband: "I'm Peter."

Doctor: "Peter, I understand that you're related to Mrs. Hunter Jones. Could you confirm
your relationship and her age?"

Husband: "She's my wife, and she's 69."

Doctor: "Thank you. I understand she's been brought in today, and I've been asked to
discuss her condition with you. Could you tell me what happened?"

Note: Do not mention that the patient is too upset to talk. This information is provided
for context but should not be explicitly stated to the husband.

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IV. History Taking

Use the FAST-3 approach and inquire about risk factors:

1. Time (T3 questions) Doctor: "When exactly did your wife's symptoms start?"
Husband: [Provides answer] Doctor: "And how long did these symptoms last?"
Husband: "They lasted for about two hours." Doctor: "Are there any ongoing
symptoms now?" Husband: "No, she seems to be better now."
2. Face Doctor: "Did you notice any changes in your wife's face, such as drooping on
one side?" Husband: "Yes, I noticed the angle of her mouth was drooping."
3. Arms Doctor: "Did your wife experience any weakness or numbness in her arms or
legs?" Husband: "She mentioned some weakness, but I'm not sure where exactly."
4. Speech Doctor: "Was there any change in your wife's speech?" Husband: "Yes, her
speech was slurred, and she had difficulty swallowing."
5. Risk Factors (MAP-TOSA) Doctor: "I'd like to ask about some factors that might
affect your wife's health. Does she have any existing medical conditions, such as
high blood pressure, diabetes, or high cholesterol?" Husband: [Provides answer]
Doctor: "Does she have any allergies to medications?" Husband: [Provides answer]
Doctor: "Has she ever experienced anything like this before? Any history of stroke or
heart problems in your family?" Husband: [Provides answer] Doctor: "Have you
traveled recently?" Husband: [Provides answer] Doctor: "Are you both retired, or is
your wife still working?" Husband: "We're both retired." Doctor: "I'd like to ask
about some lifestyle factors. Can you tell me about your wife's typical diet?"
Husband: "We eat out a lot, mostly fast food." Doctor: "How much alcohol does
your wife typically consume?" Husband: "She drinks two glasses of wine on
weekends." Doctor: "Does your wife smoke?" Husband: "Yes, she does." Doctor:
"How often does your wife exercise?" Husband: "She doesn't like doing exercise."
Doctor: "How would you describe your wife's stress levels?" Husband: [Provides
answer]

Note: During this conversation, you may notice the husband is nervous (e.g., rubbing the
floor with his foot). Don't comment on this immediately, but address it naturally during
the conversation.

V. Addressing Nervousness (if observed)

Doctor: "Peter, I can see that you're a bit nervous. Is it because of your wife's condition?"

Husband: [Responds]

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Doctor: "It's completely understandable to feel this way when a loved one experiences such
symptoms. I want to reassure you that your wife is in safe hands now, and we're doing
everything we can to help her. It's good that she was brought to the hospital quickly."

VI. Explaining Test Results and Diagnosis

Doctor: "After your wife was brought in, we performed several tests. We did a neurological
examination, which came back normal. We also did a CT scan of her brain, which was also
normal. We've taken some blood tests, and we're waiting for those results.

We've also checked her blood pressure, which is unfortunately on the higher side at 150,
which is considered high.

Based on the information we've gathered, it appears that your wife may have experienced
what we call a Transient Ischemic Attack, or TIA. This is sometimes referred to as a 'mini-
stroke'. Have you heard of this before?"

Husband: [Responds]

Doctor: "A TIA is a condition that affects the brain. It occurs when there's a temporary
interruption to the blood supply of brain cells, causing the symptoms your wife
experienced. The key word here is 'temporary' - the symptoms come and go, which is why
we use the term 'transient'. Unfortunately, a TIA can be a warning sign for a potential
future stroke, which is why we take it very seriously."

VII. Treatment Plan

Doctor: "Now, let me explain our treatment plan:

1. Aspirin: We typically give a high dose of aspirin (300mg) immediately when we

suspect a TIA. This is a blood-thinning medication that helps prevent further issues.
[Note: If aspirin has already been given, mention this. If not, explain that it will be
given.]
2. TIA Clinic Appointment: Your wife will need to come to the TIA clinic tomorrow.
There, she'll be seen by a stroke specialist who will:
o Review all her test results, including the blood tests we're waiting for
o Likely change her blood-thinning medication to one called clopidogrel,
which she'll need to take for at least two years
o Possibly start her on blood pressure medication, likely a type called a thiazide
o May also prescribe cholesterol-lowering medication if needed
3. Driving Advice: We advise your wife not to drive for the next four weeks as a
precautionary measure.

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4. Lifestyle Changes: Making some changes to your wife's lifestyle can significantly
reduce her risk of future events. This includes:
o Quitting smoking
o Reducing alcohol intake
o Improving diet
o Increasing physical activity
o Managing stress

Do you have any questions about this plan?"

VIII. Addressing Common Questions

1. "Can this happen again?" Husband: "Doctor, can this happen again?" Doctor:
"Unfortunately, yes, this can happen again. The risk is higher in the next few weeks,
which is why we're taking these precautions and acting quickly."
2. "How can we prevent this?" Husband: "How can we prevent this from happening
again?" Doctor: "Prevention involves both medical management and lifestyle
changes. Doctors can help by prescribing preventive medications like blood
thinners, cholesterol-lowering drugs, and blood pressure medications. You can help
by supporting your wife in making lifestyle changes like regular exercise, healthy
eating, reducing alcohol intake, and quitting smoking."
3. "My wife drinks two glasses of wine on weekends. Is she an alcoholic?" Husband:
"My wife drinks two glasses of wine on weekends. Is she an alcoholic?" Doctor: "We
don't refer to anyone as an alcoholic, Mr. Johnson. Current health guidelines
recommend consuming less than 14 units of alcohol per week. Two glasses of wine
per week is within this limit. However, it's important to note that there's no
completely safe level of alcohol consumption. While your wife's intake is moderate,
further reduction is always beneficial for overall health, especially after a TIA."

IX. Closing the Conversation

Doctor: "Do you have any other questions or concerns, Peter?"

[Address any final questions]

Doctor: "Thank you for your time today. Remember, your wife will need to come to the
TIA clinic tomorrow. The clinic will contact you with the exact time. If you notice any new
or worsening symptoms before then, please don't hesitate to seek immediate medical
attention. Take care, and we'll see you both tomorrow."

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X. Important Notes and Things to Avoid

1. Don't repeat tests or procedures already done. Be oriented to the current situation.
2. Address the husband's nervousness if observed, but do so naturally during the
conversation, not immediately upon meeting.
3. Be empathetic and professional throughout. The husband may be grumpy or
anxious, so maintain a calm and understanding demeanour.
4. Don't use the term "good news" when describing normal test results. Simply state
the results without qualification.
5. Avoid using medical jargon without explanation. Always provide clear definitions
and explanations for medical terms.
6. Don't tell the husband to "bring" his wife to the appointment. Phrase it as "she
needs to come" to avoid sounding patronizing.
7. Be clear about the seriousness of a TIA without causing undue alarm.
8. Avoid using terms like "alcoholic." Instead, discuss recommended alcohol limits and
health implications.
9. Don't dismiss the patient's current alcohol consumption, even if it's within
guidelines. Emphasize that less is always better, especially after a TIA.
10. Remember to mention driving restrictions.
11. Be prepared to repeat key information, as the husband may be anxious and may not
absorb all details in one go.
12. Avoid making assumptions about the patient's lifestyle or the husband's
understanding of medical terms.
13. Don't rush through the explanation. Ensure the husband understands each part of
the diagnosis and treatment plan.
14. Remember to document the conversation thoroughly after its conclusion.
15. Don't calculate any scores for TIA or PE scenarios, as this is not required.
16. Be aware that this is a common discharge scenario and approach it accordingly.
17. Don't mention that the patient is too upset to talk; this information is for your
context only.
18. Be prepared for the husband to be grumpy or nervous, and handle the situation
with patience and empathy.
19. Avoid using colloquial terms like "big deal" when discussing the seriousness of the
condition.
20. Remember to address lifestyle factors comprehensively, including diet, alcohol
consumption, smoking, exercise, and stress.

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Stroke Call Scenario (Telephone Consultation)

I. Scenario Overview

• 59-year-old man calling the GP

• Patient has a history of high blood pressure for 10 years, controlled with amlodipine
• Patient fell down while making breakfast this morning
• Currently experiencing numbness and weakness in his arm
• This is a telephone consultation (F2 in GP setting)

II. General Approach

1. Remember this is a telephone consultation, so examination will be limited.

2. The goal is to quickly assess the situation and provide appropriate guidance.
3. Be prepared to advise calling an ambulance if stroke is suspected.
4. Explain the condition and treatment process, even in an emergency situation (for
exam purposes).
5. Avoid imaginary examinations in telephone scenarios.

III. Initial Interaction

Doctor: "Hello, this is Dr. [Your Name]. How may I help you today?"

Patient: "I fell down while making breakfast this morning."

Doctor: "I'm sorry to hear that. Can you tell me more about what happened?"

Patient: "I'm not sure how I fell, but since then I've been having some numbness and
weakness in my arm."

IV. History Taking

Use the FAST approach and inquire about risk factors:

1. Face Doctor: "Have you noticed any changes in your face? For example, is one side
drooping or numb?" Patient: [Provides answer]
2. Arms Doctor: "You mentioned numbness and weakness in your arm. Is this in one
arm or both? Can you move both arms equally?" Patient: [Provides answer]
3. Speech Doctor: "Have you noticed any changes in your speech? Are you having any
difficulty speaking or understanding others?" Patient: [Provides answer]
4. Time Doctor: "When exactly did you fall this morning? How long have you been
experiencing these symptoms?" Patient: [Provides answer]

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5. Additional Symptoms Doctor: "Are you experiencing any other symptoms? Any
headache, vision changes, dizziness, or difficulty with balance?" Patient: [Provides
answer] Doctor: "Do you have any symptoms right now as we speak?" Patient: "Yes, I
still have numbness and weakness in my arm."
6. Risk Factors (MAP-TOSA) Doctor: "I see from your records that you have a history
of high blood pressure for the last 10 years and you're taking amlodipine. Is your
blood pressure generally well-controlled with this medication?" Patient: [Provides
answer] Doctor: "Are you taking any other medications?" Patient: [Provides answer]
Doctor: "Do you have any other medical conditions?" Patient: [Provides answer]
Doctor: "Do you smoke or drink alcohol?" Patient: [Provides answer] Doctor: "Can
you tell me about your diet and exercise habits?" Patient: [Provides answer]

V. Limited Telephone Assessment

Note: Do not perform an "imaginary" examination. Instead, ask the patient to perform
simple tasks if appropriate.

Doctor: "Can you try to smile for me? Does it feel even on both sides?" Patient: [Provides
answer]

Doctor: "Can you raise both arms in front of you? Are they even, or is one dropping?"
Patient: [Provides answer]

Doctor: "Can you repeat this phrase: 'The sky is blue in Cincinnati'? Any difficulty?"
Patient: [Provides answer]

VI. Diagnosis and Explanation

Doctor: "Based on the information you've provided, I'm concerned that you might be
experiencing a stroke. Have you heard of stroke before?"

Patient: [Provides answer]

Doctor: "Let me explain what a stroke is. A stroke is a serious condition that affects the
brain. It occurs when there's an obstruction or interruption of blood supply to the brain
cells, which causes the symptoms you're experiencing. This can be caused by a blood clot
forming in the blood vessels or by a blockage in the blood supply to the brain.
Unfortunately, high blood pressure, which you have a history of, is a risk factor for stroke."

Patient: "Is it serious?"

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Doctor: "Yes, a stroke is a very serious condition. It requires immediate medical attention,
which is why we need to act quickly."

VII. Management Plan

Doctor: "Here's what we need to do:

1. Call an Ambulance: I strongly advise you to call an ambulance immediately. This is

the fastest and safest way to get you the care you need.
2. Prepare for Ambulance Arrival: After you hang up with me, please do the following:
o Call the ambulance (999 or your local emergency number)
o Go to your front door and leave it open if you can do so safely
o Stay near the open door and wait for the ambulance
3. Hospital Treatment: When you get to the hospital, they will likely do the following:
o Perform a CT scan or possibly an MRI to confirm the stroke
o If confirmed, you'll be given clot-busting treatment. This is the main
treatment for stroke.
o They may offer blood-thinning medication like aspirin, but this will be
decided by the hospital doctors.
o If you reach the hospital within a certain number of hours from when your
symptoms started, they might give you a special clot-dissolving medication
called tPA (tissue plasminogen activator).
o In some cases, they might consider surgical treatment. This involves inserting
a wire through the blood vessels to reach the brain and remove the clot. This
is more suitable for clots in the front part of the brain.
4. Do Not Take Aspirin: I want to emphasize that you should not take any aspirin or
other medication before the ambulance arrives. The doctors need to determine the
type of stroke before giving any medication.

Do you understand this plan? Do you have any questions?"

Patient: [Asks questions if any]

Doctor: "Remember, time is crucial in stroke treatment. Please call the ambulance as soon
as we hang up. I can call you back in about 5 minutes to check on you if you'd like, but the
most important thing is to get emergency help right away."

VIII. Closing the Call

Doctor: "Do you have any other questions before you call the ambulance?"

[Address any final questions]

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Doctor: "Alright, please call the ambulance now. Remember to leave your front door open
if you can do so safely, and wait near it. The emergency services may give you further
instructions over the phone. Take care, and I hope you get the help you need quickly."

IX. Important Notes and Things to Avoid

1. Always treat a suspected stroke as an emergency. Advise calling an ambulance

immediately.
2. Do not advise the patient to take aspirin or any other medication before emergency
services arrive.
3. Avoid performing an "imaginary" examination. Stick to what the patient can tell you
over the phone.
4. Don't forget to ask about the timing of symptom onset, as this is crucial for
treatment decisions.
5. Remember to explain the condition and potential treatments, even in an emergency
situation (for exam purposes).
6. Avoid medical jargon without explanation. Always provide clear definitions and
explanations for medical terms.
7. Don't rush through the explanation. Ensure the patient understands the seriousness
of the situation and the need for immediate action.
8. Remember to advise the patient to leave the front door open for the ambulance if
they can do so safely.
9. Avoid making definitive diagnoses over the phone. Use phrases like "I'm concerned
you might be experiencing a stroke" rather than "You are having a stroke."
10. Don't forget to offer a follow-up call if appropriate, but emphasize that calling the
ambulance is the priority.
11. Be prepared to repeat key information, as the patient may be anxious and may not
absorb all details in one go.
12. Avoid downplaying the seriousness of the situation, but also try not to panic the
patient.
13. Remember to document the call thoroughly after its conclusion.
14. In telephone scenarios, don't suggest examinations that can't be performed over the
phone. Stick to what the patient can report or do themselves.
15. Always confirm if the patient is still experiencing symptoms at the time of the call.
16. Be clear about the role of the ambulance service - they can provide immediate advice
and treatment en route to the hospital.
17. Don't forget to mention the possibility of surgical treatment for certain types of
strokes.
18. Avoid suggesting that the patient should come to the GP practice instead of calling
an ambulance.

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19. Remember to emphasize the importance of quick action due to the time-sensitive
nature of stroke treatment.
20. Don't neglect to ask about the patient's ability to call an ambulance themselves. If
they can't, be prepared to call on their behalf.

Bell's Palsy Scenario (GP Setting)

I. Scenario Overview

• Female patient in GP setting (F2)

• Presenting with weakness in the face
• Patient had childbirth two weeks ago (postpartum patient)
• Symptoms developed yesterday
• Symptoms are ongoing and limited to the face
• Scenario may be labelled as "postpartum patient" in results sheet

II. Initial Approach

1. The scenario may be labelled as "postpartum patient" rather than explicitly stating
Bell's Palsy.
2. Be aware that pregnancy and recent childbirth are risk factors for Bell's Palsy.
3. Focus on detailed facial symptoms and rule out other neurological conditions.
4. Be prepared for the possibility of a picture being presented at the start of the
consultation.

III. Initial Interaction

Doctor: "Hello, I'm Dr. [Your Name]. How can I help you today?"

Patient: "I've developed some weakness in my face since yesterday."

Doctor: "I'm sorry to hear that. Can you tell me more about these symptoms?"

Patient: "It's only affecting my face, and I'm still experiencing it now."

Doctor: "I understand you recently had a baby. Congratulations! When exactly did you give
birth?"

Patient: "Thank you. I had my baby two weeks ago."

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IV. Detailed History Taking

1. Facial Symptoms Doctor: "Let's go through your facial symptoms in detail. Have you
noticed:
o Any weakness on your face?
o Any numbness or abnormal sensations?
o Are you able to frown or raise your eyebrows?
o Can you close your eyes completely?
o Are you able to blow out your cheeks?
o Can you smile or show your teeth?"

Patient: [Provides answers to each question]

2. Other Cranial Nerve Symptoms Doctor: "I'd like to ask about some other possible
symptoms:
o Any numbness in other parts of your face? (Trigeminal nerve)
o Any changes in your vision?
o Any changes in your hearing?
o Any difficulties with speech or swallowing?
o Can you move your neck from side to side without problems? (Accessory
nerve)"

Patient: [Provides answers]

3. Other Neurological Symptoms Doctor: "Have you experienced any symptoms in

your arms or legs?" Patient: [Answers]
4. Additional Symptoms Doctor: "Have you noticed:
o Any rash, particularly around your ear? (to rule out Ramsay Hunt syndrome)
o Any fever or flu-like symptoms?
o Any headaches or vomiting? (to rule out brain tumour)
o Any balance problems?"

Patient: [Provides answers]

5. Eye Symptoms Doctor: "Have you experienced any symptoms related to your eyes?
Any irritation or dryness?" Patient: "Yes, I have some irritation in my eye."
6. Pregnancy and Childbirth Doctor: "Let's talk a bit about your recent pregnancy and
childbirth:
o How was your pregnancy overall?
o Was it a full-term delivery?
o How was the delivery?
o How is your baby doing?

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o Are you breastfeeding?"

Patient: [Provides information]

7. PMAFTOSA Assessment Complete a thorough assessment, including:

o Medical history
o Allergies
o Past medical history
o Travel history
o Occupation
o Social history

V. Examination

Doctor: "I'd like to examine you now, particularly focusing on the nerves in your head and
neck. Is that okay?"

Patient: "Yes, that's fine."

[Perform examination based on findings provided on paper]

Doctor: "Thank you for allowing me to examine you. Based on the examination, I can see
that [describe findings, e.g., 'you're unable to frown on the left side, can't close your left eye
completely, and can't blow out your left cheek']."

Note: If a picture is provided, interpret it correctly:

• The side that's not moving is the affected side

• The face deviates towards the normal side
• Example: "Based on this picture, it appears that your right side is affected as it's not
moving. The face is deviating towards the left side, which is the normal side."

VI. Diagnosis and Explanation

Doctor: "Based on your symptoms and the examination, I believe you may have a condition
called Bell's Palsy. Have you heard of this before?"

Patient: "No, I haven't. What is it?"

Doctor: "Bell's Palsy is a condition affecting the facial nerve. There's a nerve called the
facial nerve in our face, and when it becomes paralyzed, it causes weakness of the muscles

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on one side of the face. Most of the time, the exact cause is unknown, but pregnancy and
recent childbirth can be risk factors, which may be relevant in your case."

VII. Treatment Plan

Doctor: "Here's how we typically treat Bell's Palsy:

1. Medication: We'll start you on a high dose of a steroid medication called

prednisone. You'll need to take this for 10 days.
2. Follow-up: If there's no improvement within two weeks, we'll refer you to a
neurologist. However, most people start to see some improvement within two
weeks, and many have a complete recovery within six months.
3. Eye Care: You mentioned some irritation in your eye. I'd like you to go to the eye
casualty department immediately. It's a walk-in centre, so you don't need an
appointment. They'll check your eye to ensure there's no damage.
4. Eye Protection: During the day, wear sunglasses to protect your eye. At night, cover
your eye when you sleep since you can't close it completely.
5. Eating and Drinking: You might find it difficult to eat and drink normally. Try
using liquid foods like smoothies and juices. You can use a straw or spoon to help.
6. Emotional Support: Sometimes, this condition can cause distress. If you feel you
need support, we can arrange some talking therapy.

Do you have any questions about this plan?"

Patient: [Asks any questions]

VIII. Closing the Consultation

Doctor: "Do you have any other concerns or questions?"

[Address any final questions]

Doctor: "Please remember to go to the eye casualty department today. If you notice any
new symptoms or if things aren't improving after two weeks, please come back to see us.
Take care, and I hope you start feeling better soon."

IX. Important Notes and Things to Avoid

1. Don't miss the postpartum context - it's a key risk factor for Bell's Palsy.
2. Avoid confusing the affected side - remember, the side that's not moving is the
affected side. The face deviates towards the normal side.
3. Don't forget to ask about eye symptoms - they're crucial for management.

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4. Avoid medical jargon without explanation. Always provide clear definitions and
explanations for medical terms.
5. Don't rush through the explanation. Ensure the patient understands the condition
and treatment plan.
6. Remember to advise about eye protection both day and night.
7. Don't forget to mention the possibility of talking therapy if the patient is distressed.
8. Avoid making definitive prognoses, but do offer hope - most people improve within
weeks to months.
9. Don't neglect to ask about the baby and breastfeeding - these are important
contextual factors.
10. Remember to document the consultation thoroughly after its conclusion.
11. Be prepared for the possibility of a picture being presented at the start of the
consultation or during the examination.
12. Don't forget to differentiate Bell's Palsy from stroke by noting that symptoms are
limited to the face and don't affect arms or legs.
13. Avoid suggesting that the condition is not serious - while often self-limiting, it can
be distressing for patients.
14. Remember to emphasize the importance of immediate eye casualty visit if there are
any eye symptoms.
15. Don't forget to mention that Bell's Palsy is always unilateral.
16. Avoid calculating any scores or mentioning them in this scenario.
17. Remember that the initial treatment (steroids) is typically managed by the GP, not
requiring immediate specialist referral unless there's no improvement after two
weeks.
18. Don't forget to ask about all cranial nerve symptoms, including trigeminal and
accessory nerves.
19. Be sure to inquire about possible signs of Ramsay Hunt syndrome (rash around the
ear) and brain tumour symptoms (persistent headache, vomiting).
20. Remember to ask about the patient's ability to eat and drink, as this can be affected
by facial weakness.

Encephalitis vs Meningitis Scenario (A&E Setting)

I. Scenario Overview

• F2 doctor in A&E
• 15-year-old boy brought by ambulance following fits
• Father accompanied the patient
• Task: Speak to the father, take focused history, interpret findings, make provisional
diagnosis, explain findings, and discuss management

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• This is a data interpretation scenario with lumbar puncture results

• Scenario may alternate between encephalitis and meningitis based on the findings
provided

II. Initial Approach

1. Findings will be provided on an A4 sheet on the table from the beginning

2. Read the task and study the findings before interacting with the patient's father
3. Be prepared for the father to be nervous and potentially grumpy
4. Do not repeat tests or procedures that have already been done
5. Remember this is a data interpretation scenario - plan and prepare accordingly

III. Initial Interaction

Doctor: "Hello, I'm Dr. [Your Name]. I understand you brought your son in today. Can
you tell me what happened?"

Father: "We were watching football, then suddenly he was saying some random words. I
thought he might be hallucinating. After that, he developed fits, so I called an ambulance."

Doctor: "I'm sorry to hear that. That must have been a very difficult experience for you.
Can you tell me more about the fits?"

IV. Detailed History Taking

1. Fits Details Doctor: "Were the fits in part of his body or the full body?" Father: "It
was his full body." Doctor: "How severe were the jerky movements? How long did
they last?" Father: [Provides answer] Doctor: "During the fits, did you notice any
injuries, biting of the tongue, frothing at the mouth, or loss of bladder or bowel
control?" Father: [Provides answer]
2. Pre-fit Symptoms Doctor: "Just before developing the fits, was your son unwell? Did
he mention any symptoms or warnings like hearing things, seeing things, smelling
things, or seeing zigzag lines?" Father: "He was a little unwell." Doctor: "Did you
notice any confusion or disorientation before the fits?" Father: [Provides answer]
3. Post-fit Symptoms Doctor: "After the fits, did your son experience any vomiting,
confusion, loss of consciousness, or weakness in the body?" Father: [Provides
answer]
4. Encephalitis Symptoms Doctor: "Has your son complained of:
o Drowsiness or difficulty speaking?
o Loss of sensation in any part of the body?
o Problems with vision or moving his eyes?

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o Any behavioural or personality changes, or feeling agitated?" Father:

[Provides answers]
5. Infection Symptoms Doctor: "Has your son had:
o High temperature?
o Any rash or swelling of the glands?
o Feeling sick, muscle aches, or joint pains?" Father: [Provides answers]
6. Meningitis Symptoms Doctor: "Has your son mentioned:
o Being sensitive to light?
o Any neck pain or stiffness?
o Difficulty moving his body?" Father: [Provides answers]
7. PMAFTOSA Assessment Complete a thorough assessment, focusing on:
o Recent infections (fever, flu-like symptoms)
o General lymphadenopathy
o Neurological symptoms
o Drug use (ask carefully, as the patient is 15)

Doctor: "Has your son had any recent illnesses, like fever or flu-like symptoms?" Father:
[Provides answer] Doctor: "Has he mentioned any swelling in the glands of his neck or
elsewhere?" Father: [Provides answer] Doctor: "Is your son on any medications?" Father:
[Provides answer] Doctor: "I know this might be a sensitive topic, but do you know if your
son has ever experimented with any recreational drugs?" Father: "He's got some friends, but
I'm not sure if he takes any drugs." Note: Avoid asking the father about the son's sexual
history

V. Interpreting and Explaining Findings

Doctor: "I'd like to explain the findings from our tests and examinations. Is that okay?"

Father: "Yes, please tell me what's going on."

Doctor: "Based on our observations:

1. Your son is running a temperature of 38.1°C, which means he has a fever.

2. His heart is beating a bit faster than normal.
3. Unfortunately, he's a little confused and drowsy at the moment.
4. We've done a CT scan of his brain, which came back normal.
5. We've noticed some swelling in the glands throughout his body.
6. We've also performed a procedure called a lumbar puncture. This involves taking
some fluid from around the spine and examining it under a microscope.
Unfortunately, this shows there's some infection around his brain."

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[If rash is mentioned in findings] "We've also noticed some rash on his body."

[For encephalitis] "In the lumbar puncture, we found a high number of cells called
lymphocytes, which suggests a specific type of infection."

[For meningitis] "In the lumbar puncture, we found a high number of cells called
neutrophils or polymorphs, which suggests a different type of infection."

Note: Do not read out all numbers. Interpret and summarize the important points.

VI. Diagnosis and Explanation

[For Encephalitis] Doctor: "Based on these findings, I believe your son may have a
condition called encephalitis. Have you heard of this before?"

Father: "No, what is it?"

Doctor: "Encephalitis is an inflammation of the brain cells, usually caused by a viral

infection. The high number of lymphocytes we found in the spinal fluid suggests this type
of infection."

[For Meningitis] Doctor: "Based on these findings, I believe your son may have a condition
called meningitis. Have you heard of this before?"

Father: "I've heard of it, but I'm not sure what it means."

Doctor: "Meningitis is an inflammation of the membranes surrounding the brain, usually

caused by a bacterial infection. The high number of neutrophils or polymorphs we found
in the spinal fluid suggests this type of infection."

VII. Treatment Plan

Doctor: "Here's how we plan to treat your son:

1. Admission: We'll need to admit him to the hospital under the care of our medical
team.
2. Isolation: He'll be placed in isolation to prevent any potential spread of infection.
3. Medication: [For Encephalitis] We'll start him on an antiviral medication called
acyclovir. This treatment usually lasts for 2-3 weeks. [For Meningitis] We'll start him
on strong antibiotics, likely including benzylpenicillin.
4. Supportive Care: We'll also provide:
o Steroid medications to reduce inflammation

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oPain relief, including strong painkillers like morphine if needed

o Medication like paracetamol to reduce fever
5. Monitoring: We'll closely monitor his condition throughout his stay.

Do you have any questions about this plan?"

VIII. Addressing Specific Concerns

[For Encephalitis] Father: "Will he develop any long-term complications?"

Doctor: "Unfortunately, there is a possibility of long-term complications. These could

include speech problems, weakness in the body (sometimes even paralysis in severe cases),
and memory problems. He might lose some previous memories or experience ongoing
memory issues. However, the severity can vary greatly between individuals."

Father: "Is there any vaccination for this?"

Doctor: "For this particular infection, there isn't a specific vaccination available at the
moment."

[For Meningitis] Father: "Am I safe? Could I get this infection?"

Doctor: "Since you live with your son, there's a possibility you might have been exposed to
the infection. I'd advise you to speak with your GP about getting a preventive medication
called ciprofloxacin. It's an antibiotic given as a single dose to prevent meningococcal
infection in close contacts."

IX. Important Notes and Things to Avoid

1. Don't repeat tests or procedures that have already been done. Be oriented to the
current situation.
2. Avoid using medical jargon without explanation. Always provide clear definitions.
3. Don't read out all the numbers from the findings. Interpret and summarize the
important points.
4. Avoid using terms like "good news" when describing normal results.
5. Don't use phrases like "caring father" or "caring son" - these can sound artificial and
forced.
6. Be prepared to leave out some information that isn't relevant to the patient (e.g.,
reflex findings).
7. Remember to explain what a lumbar puncture is in simple terms.
8. Don't forget to mention that both conditions require isolation.

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9. Avoid making definitive prognoses, but do offer honest information about potential
complications.
10. Remember that the key difference in diagnosis is often in the lumbar puncture
results: lymphocytes for encephalitis, neutrophils/polymorphs for meningitis.
11. Don't forget to mention that neither condition is notifiable.
12. Be prepared for different questions depending on the diagnosis (long-term
complications for encephalitis, risk of transmission for meningitis).
13. Remember to document the conversation thoroughly after its conclusion.
14. Don't calculate any scores for this scenario.
15. Avoid suggesting coming to the GP practice - this is an emergency situation
requiring hospital admission.
16. Be cautious when asking about drug use, given the patient's age.
17. Don't neglect to address the father's potential nervousness or grumpiness with
empathy.
18. Avoid rushing through the explanation. Ensure the father understands each part of
the diagnosis and treatment plan.
19. Remember that the scenario may alternate between encephalitis and meningitis -
pay close attention to the lumbar puncture results to make the correct diagnosis.
20. Don't forget to mention the possibility of rash, but remember that it may be present
in both conditions and might not be diagnostic on its own.

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Breast Lump Scenarios

I. Overview of Breast Lump Scenarios

There are eight main breast lump scenarios to be aware of:

1. Suspected breast cancer (no mannequin, examination findings given)

2. Suspected breast cancer (with mannequin)
3. Reassurance (no lump, no family history, nothing needs to be done)
4. Patient requesting mammogram (age >50, do not give mammogram)
5. Patient requesting mammogram (age ~32, do not give mammogram)
6. Breast engorgement (with breast pain)
7. Mastitis (with mannequin)
8. Mastitis (no mannequin)

Note: There are no current scenarios for fibroadenoma, cyclic mastalgia, or ductal ectasia.
These were old scenarios from before the pandemic.

Important: Breast lump is one of three important lump scenarios in PLAB 2, along with
neck lump (nasal oropharyngeal tumour) and testicular lump.

II. General Approach to Breast Lump Complaints

1. Initial Question Doctor: "How may I help you today?" Patient: "Doctor, I found a
lump in my breast." Doctor: "I see. How did you find out about the lump?" Patient:
[Explains how they discovered the lump, e.g., "I felt it while showering" or "I found
it during self-examination"]
2. Confirmation Doctor: "Did you examine yourself and feel the lump?" Patient: "Yes, I
did examine and I think I have a lump."
3. Detailed Assessment using Morphology, Evolution, Symptoms (MES) approach

Morphology

• Location: "Which breast is affected? Left or right?"

• Position: "Which part of the breast? Is it in the outer aspect, inner aspect, or on
top?"
• Size: "How big is the lump? Would you say it's the size of a grape, or smaller like a
pea, or somewhere in between?"
• Consistency: "How does it feel? Is it a hard lump, like a hard nodule, or is it soft?"
• Texture: "Does it feel smooth, or are the edges irregular?"
• Shape: "Does it have a regular, round shape?"

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• Mobility: "When you feel it, does the lump move freely, or does it seem attached to
the skin or underlying tissue?"

Evolution

• Onset: "When did you first notice this lump?"

• Changes: "Since you've noticed it, has it been changing? Is it growing, becoming
smaller, or staying the same size?"
• Variability: "Have you noticed if it changes size when you lie down? Or does it
become more obvious when you lean forward?"

Symptoms

• Pain: "Is the lump painful?"

• Skin changes: "Have you noticed any redness or skin changes around the lump?"
• Sensation: "Is there any numbness or abnormal sensation in the area?"
• Nipple changes: "Have you noticed any changes in your nipple? Any changes in
colour, size, or shape?"
• Discharge: "Is there any fluid or blood leaking from the nipple?"
• Skin dimpling: "Have you noticed any dimpling or puckering of the skin on your
breast?"
• Secondary symptoms: "Have you noticed any lumps elsewhere, like in your armpit
or neck?"
• General symptoms: "Have you experienced any unexplained weight loss, general
pain, or unusual tiredness?"

III. Risk Factor Assessment (PMAFTOSA)

• Medical history: Doctor: "Do you have any previous breast conditions?" Patient:
[Provides answer] Doctor: "Are you on any medications, particularly any hormonal
treatments or contraceptives?" Patient: [Provides answer]
• Allergies: Doctor: "Do you have any allergies we should be aware of?" Patient:
[Provides answer]
• Past medical history: Doctor: "Have you had any significant medical conditions in
the past?" Patient: [Provides answer]
• Travel history: Doctor: "Have you travelled anywhere recently?" Patient: [Provides
answer]
• Occupation: Doctor: "What is your occupation?" Patient: [Provides answer]
• Social history: Doctor: "Is there any history of breast or ovarian cancer in your
family?" Patient: [Provides answer] Doctor: "Do you have any children? If so, at what
age did you have your first child?" Patient: [Provides answer] Doctor: "Did you
breastfeed your children?" Patient: [Provides answer] Doctor: "At what age did you

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start your periods?" Patient: [Provides answer] Doctor: "Are you menopausal? If so,
at what age did you go through menopause?" Patient: [Provides answer] Doctor: "Do
you smoke?" Patient: [Provides answer] Doctor: "How would you describe your
weight? Have you had any recent weight changes?" Patient: [Provides answer]
Doctor: "How much alcohol do you typically consume?" Patient: [Provides answer]

IV. Examination

Note: The need for physical examination may not be explicitly stated. Look for clues:

• Presence of a couch in the room (95% confirmatory for physical examination)

• Patient's attire (e.g., wearing a scarf or large shirt that could be covering a
mannequin)

If examination is required: Doctor: "I would like to examine your breast now. Is that okay
with you?" Patient: "Yes, that's fine."

[Perform examination based on the scenario]

V. Scenario-Specific Approaches

1 & 2. Suspected Breast Cancer (with or without mannequin)

• Focus on thorough history and examination

• Explain findings and need for referral

3. Reassurance Scenario

• Emphasize normal findings

• Educate on breast self-examination and when to seek medical attention

4 & 5. Mammogram Request (different age groups)

• Explain why mammogram is not recommended in these cases

• Discuss appropriate screening methods based on age and risk factors

6. Breast Engorgement

• Focus on breastfeeding history

• Discuss management strategies for engorgement

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7 & 8. Mastitis (with or without mannequin)

• Assess for signs of infection

• Discuss treatment options, including antibiotics if necessary

VI. General Management Principles

1. For suspected cancer:

o Urgent referral to breast clinic
o Explain the two-week wait pathway
2. For benign conditions:
o Provide reassurance
o Educate on breast awareness and self-examination
3. For infections (mastitis):
o Prescribe appropriate antibiotics
o Advise on supportive measures

VII. Important Notes and Things to Avoid

1. Don't miss asking about key symptoms like nipple changes or discharge.
2. Don't rush through the history-taking process. Each detail can be crucial for
diagnosis.
3. Remember to address the patient's concerns and anxiety, especially in cases of
suspected cancer.
4. Don't promise that a lump is benign without proper investigation.
5. Remember to discuss breast awareness and self-examination in all scenarios.
6. Don't forget to ask about family history of breast and ovarian cancer.
7. Pay attention to subtle clues about whether physical examination is required
(presence of couch, patient attire).
8. Remember that breast issues can be sensitive - always ensure patient comfort and
privacy.
9. Don't forget that breast lump scenarios are one of three important lump scenarios
in PLAB 2, along with neck lump and testicular lump.
10. Avoid calculating any scores or mentioning them in these scenarios.
11. Don't forget to consider the patient's age when discussing mammogram requests.
12. Be prepared for the possibility of a mannequin being present but concealed under
the patient's clothing.
13. Always consider patient age and risk factors when assessing breast lumps.
14. Any breast lump in a woman over 40 should be treated as a potential cancer
pathway.
15. Be familiar with genetic counselling and BRCA gene testing concepts.

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16. When examining a mannequin, mention checking axillary lymph nodes but don't
actually examine the patient's armpit.
17. Every breast lump is a referral, but the urgency and pathway depend on the patient's
age and risk factors.
18. Don't offer mammograms unnecessarily, especially when recent ones have been
done or for younger patients.
19. Remember that the key to success in these scenarios is recognizing the type of
scenario quickly and adapting your approach accordingly.
20. Always provide clear explanations to patients about why certain tests or referrals are
or aren't recommended.
21. There are three scenarios related to breast pain in postpartum women: breast
engorgement, mastitis with mannequin, and mastitis without mannequin.
22. Always ask about recent childbirth in breast pain scenarios.
23. Be prepared for variations in how the information is presented (mannequin vs.
paper findings vs. picture).
24. Understand the difference between engorgement (blocked ducts) and mastitis
(infection).
25. Remember that breast abscess is not a scenario in PLAB 2.

Scenario 1: Suspected Breast Cancer (No Mannequin)

Patient Profile

• 50+ year old lady

• Found a lump 2-3 weeks ago
• Family history of breast cancer (mother and sister had breast cancer)

Key Points

• No couch in the room (indicator that it's not a physical examination scenario)
• Findings will be given on paper after mentioning examination

Approach

Doctor: "Hello, I'm Dr. [Your Name]. How can I help you today?"

Patient: "I found a lump in my breast about two or three weeks ago."

Doctor: "I see. Can you tell me more about how you discovered this lump?"

Patient: [Provides details]

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Doctor: "I understand this must be concerning for you. Do you have any family history of
breast cancer?"

Patient: "Yes, my mother and sister both had breast cancer."

[Continue with detailed history taking using MES approach]

Doctor: "I'd like to examine your breast now. Is that okay with you?"

Patient: "Yes, that's fine."

[Examiner provides findings on paper]

Management

Doctor: "Based on the examination and your family history, I think it's important we refer
you to a breast clinic for further assessment. They will likely perform a mammogram,
ultrasound, and possibly a biopsy. If a cancer is confirmed, treatment options may include
surgery, chemotherapy, and radiotherapy. Do you have any questions about this?"

Scenario 2: Suspected Breast Cancer (With Mannequin)

Patient Profile

• Lady with breast lump

• Family history of breast/ovarian cancer

Key Points

• Mannequin present for examination

• Visible breast lump on mannequin

Approach

[Similar to Scenario 1, but include physical examination]

Doctor: "I'm going to examine your breast now. I'll also need to check your armpit area for
any lymph nodes."

[Perform examination on mannequin, but don't actually examine armpit]

Examiner: "There are no palpable axillary lymph nodes."

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Management

[Same as Scenario 1]

Scenario 3: Reassurance (No Lump, No Family History)

Patient Profile

• Lady who thinks she found a lump

• No clear age specified

Key Points

• Patient unsure about all questions regarding the lump

• No family history of breast cancer
• No lump found on examination

Approach

Doctor: "Can you tell me more about this lump you think you've found?"

Patient: "I'm not sure... I think I felt something, but I'm not certain."

[Continue with detailed questions, patient likely to answer "I'm not sure" to most]

Doctor: "Is there any history of breast cancer in your family?"

Patient: "No, not that I'm aware of."

[Perform thorough examination]

Doctor: "I've examined your breast thoroughly, and I haven't found any lumps. It's actually
quite common for women to worry about breast cancer, and many experience this fear at
some point in their lives. However, based on my examination and the information you've
provided, there's nothing to be concerned about at the moment."

[If patient is over 50] Doctor: "As you're over 50, you're eligible for routine mammogram
screening every three years. This is a good way to keep an eye on your breast health."

[Educate on breast awareness and self-examination]

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Scenario 4: Mammogram Request (Age ~50)

Patient Profile

• ~50 year old lady

• Thinks she found a lump
• Family history of cancer (e.g., maternal cousin with breast cancer)

Key Points

• Mannequin present
• Patient will ask for mammogram during examination

Approach

[Take detailed history as in previous scenarios]

Doctor: "You mentioned some cancers in your family. Can you tell me more about that?
Who in your family had cancer, and what type was it?"

Patient: "My maternal cousin had breast cancer. There have been other cancers in the
family too."

Doctor: "I see. Was your cousin a first-degree relative (like a sister) or a second-degree
relative?"

Patient: [Provides answer]

[During examination]

Patient: "Doctor, can I have a mammogram?"

Doctor: "Have you had any recent mammograms?"

Patient: "Yes, I had one about six months ago."

Doctor: "I understand your concern, but having another mammogram so soon wouldn't be
beneficial. The changes in your breast tissue over just six months wouldn't be significant
enough to show up, and it would expose you to unnecessary radiation. Instead, given your
family history, I think it would be more appropriate to refer you for genetic counselling.
They can assess your risk more thoroughly and, if necessary, recommend genetic testing for

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genes like BRCA1 and BRCA2. This test can be expensive, around £1000, and is only
offered to suitable candidates. Would you like me to arrange this referral for you?"

Scenario 5: Mammogram Request (Age ~32)

Approach and Management

[Similar to Scenario 4, but emphasize that mammograms are not typically recommended
for women under 40]

Important Notes on Referrals for Family History

Refer to breast cancer assessment unit only if:

• First-degree relative diagnosed with breast cancer under 40

• First-degree relative diagnosed with bilateral breast cancer under 50
• Two first-degree relatives diagnosed with breast cancer at any age
• One first-degree and one second-degree relative diagnosed with breast cancer at any
age

Scenario 6: Breast Engorgement

Patient Profile

• Recently gave birth (usually about 3 weeks ago, but can be up to 2 months)
• Presenting with breast pain

Key Points

• Usually bilateral in reality, but may be presented as unilateral in the exam

• No fever
• Caused by blockage of milk ducts

Approach

Doctor: "Hello, I'm Dr. [Your Name]. How can I help you today?"

Patient: "I've been having pain in my breast."

Doctor: "I'm sorry to hear that. Can you tell me more about this pain? When did it start?"

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Patient: "It started a few days ago. It's a constant ache and my breast feels very full and
tight."

Doctor: "I see. Have you recently given birth?"

Patient: "Yes, about three weeks ago."

Doctor: "Congratulations on your new baby. Is the pain in one breast or both?"

Patient: "It's mainly in my [left/right] breast." [Note: In reality, it's usually both, but the
exam may present it as unilateral]

Doctor: "Have you noticed any fever or other symptoms like redness or warmth in the
breast?"

Patient: "No, just the pain and fullness."

Doctor: "How has breastfeeding been going? Have you noticed any difficulties?"

Patient: "It's been a bit challenging. My breast feels so full that it's hard for the baby to latch
sometimes."

[Continue with detailed history, asking about all causes of breast pain]

Examination

Doctor: "I'd like to examine your breast now. Is that okay?"

Patient: "Yes, that's fine."

[Perform examination - breast will be painful]

Doctor: "Thank you for allowing me to examine you. Your breast does feel quite firm and
full, which is consistent with engorgement."

Management

Doctor: "Based on your symptoms and the examination, it seems you're experiencing breast
engorgement. This is common in new mothers and is caused by a blockage in the milk
ducts. Here are some things that can help:

1. Continue breastfeeding or expressing milk regularly. This is crucial to prevent

further blockage.

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2. Before feeding, use warm compresses on your breast for about 5-10 minutes. This
can help stimulate milk flow.
3. Gently massage the breast while feeding or expressing, moving from the chest wall
towards the nipple.
4. After feeding, use cold compresses for about 15 minutes to reduce swelling and
discomfort.
5. Wear a well-fitting, supportive bra, but make sure it's not too tight.
6. Vary your breastfeeding positions to help drain all areas of the breast.

If these measures don't help or if you develop a fever or notice redness in your breast,
please come back to see us immediately as this could indicate an infection."

Scenario 7: Mastitis (with mannequin)

Patient Profile

• Recently gave birth

• Presenting with breast pain and fever

Key Points

• Similar symptoms to engorgement but with fever

• Requires antibiotics
• Mannequin present for examination

Approach

[Similar initial questions to Scenario 6]

Doctor: "Have you noticed any fever or chills?"

Patient: "Yes, I've been running a fever for the past day or so."

Doctor: "Have you noticed any redness or a warm area on your breast?"

Patient: "Yes, there's a red, sore area on my [left/right] breast."

Examination

Doctor: "I need to examine your breast now. Is that alright?"

Patient: "Yes, go ahead."

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[Perform examination on mannequin]

Doctor: "Thank you. I can feel a tender, firm area in your breast, which is consistent with
mastitis."

Management

Doctor: "Based on your symptoms and the examination, you have a condition called
mastitis. This is an infection in the breast tissue. Here's how we'll treat it:

1. I'll prescribe an antibiotic called flucloxacillin. It's safe to take while breastfeeding.
Take it for the full course, even if you start feeling better.
2. For pain relief, you can take paracetamol. Avoid aspirin as it's not recommended
while breastfeeding.
3. Continue to empty the breast by feeding or expressing milk. This is important for
your recovery.
4. Use warm compresses before feeding and cold compresses after to help with
discomfort.
5. Rest as much as possible and stay well-hydrated.
6. If possible, start feeds on the affected breast to ensure it's emptied effectively.

If your symptoms don't improve after a couple of days on the antibiotics, or if they get
worse, please come back to see us immediately."

Scenario 8: Mastitis (no mannequin)

Patient Profile

• Gave birth about two months ago

• Presenting with breast pain
• No fever mentioned initially

Key Points

• Unilateral pain
• No couch in the room (no physical examination)
• Findings will be given on paper or as a picture

Approach

[Similar initial questions to previous scenarios]

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Doctor: "I'd like to examine your breast. Is that okay?"

Patient: "Yes, that's fine."

[Examiner provides findings on paper or as a picture]

Doctor: "The examination shows a wedge-shaped swelling in your breast. This is

characteristic of a condition called mastitis."

Management

Doctor: "Even though you haven't mentioned a fever, the wedge-shaped swelling indicates a
condition called mastitis. This is an infection in the breast tissue. We'll treat it with
antibiotics, specifically flucloxacillin. Here's the plan:

[Continue with management plan as in Scenario 7]

Important Notes

1. Key differences:
o Engorgement: No fever, bilateral (though may be presented as unilateral in
exam)
o Mastitis: Fever or wedge-shaped swelling, unilateral
2. Antibiotic for mastitis: Flucloxacillin (remember as "milk flu")
3. Pain relief: Paracetamol is safe, avoid aspirin in breastfeeding mothers
4. In the exam, breast engorgement is usually presented about 3 weeks postpartum,
while mastitis can occur up to 2 months postpartum
5. Be prepared for the possibility of a picture being presented, especially in the no-
mannequin mastitis scenario
6. A wedge-shaped swelling is diagnostic of mastitis, even in the absence of fever
7. Always provide clear explanations and instructions to the patient
8. Encourage continuation of breastfeeding or milk expression in both conditions
9. Advise patients to return if symptoms worsen or don't improve with treatment

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Irritable Bowel Syndrome (IBS) Scenario

I. Scenario Overview

• F2 doctor in GP setting
• 65-year-old man, follow-up appointment
• Patient had normal stool sample 3 months ago
• Symptoms: tummy pain, changed bowel habits (diarrhoea), bloating, flatulence
• Symptoms present since patient's 20s
• Patient is a PhD student or professor
• Symptoms worsen during stress (e.g., exam times)
• Buscopan (hyoscine butylbromide) no longer effective

II. Key Points to Remember

1. Only IBS scenarios in PLAB 2, not IBD (Inflammatory Bowel Disease)

2. No cancer symptoms in this scenario
3. Changed bowel habits alone are not suspicious for cancer in this context

III. Handling Mistakes

If you accidentally say IBD instead of IBS:

Doctor: "I'm sorry, Mrs. Johnson. That was a slip of the tongue. What I meant to say is that
this could be a condition called IBS. Have you heard of IBS before?"

Patient: "No, I don't know anything about it."

Doctor: "IBS stands for Irritable Bowel Syndrome. It's a condition that affects the bowel
system..."

[Continue explanation, using the term IBS multiple times to reinforce the correct
diagnosis]

IV. Initial Approach

Doctor: "Hello, I understand you're here for a follow-up. How have you been feeling since
your last visit?"

Patient: "Well, I'm still having those tummy problems. The Buscopan I was using doesn't
seem to be working anymore."

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Doctor: "I'm sorry to hear that. Can you tell me more about your symptoms?"

V. Detailed History Taking

1. GI Symptoms Doctor: "Can you describe your tummy pain? How often do you
experience it?" Patient: "I get this dull ache in my belly, sometimes it's crampy. It
comes and goes, but I'd say I have it most days." Doctor: "You mentioned changed
bowel habits. Can you elaborate on that?" Patient: "I've been having more diarrhoea
lately. My bowel movements are more frequent and loose." Doctor: "Are you
experiencing any bloating or excessive gas?" Patient: "Yes, both of those. The
bloating can be really uncomfortable, and I'm passing gas more often than usual."
2. Duration and Pattern Doctor: "How long have you been experiencing these
symptoms?" Patient: "I've had these issues on and off since my 20s, but they've
gotten worse recently."
3. Aggravating and Alleviating Factors Doctor: "Have you noticed anything that makes
your symptoms better or worse?" Patient: "They definitely get worse when I'm
stressed, like during exam times or deadlines for my research. I think dairy products
might make it worse too. Exercise seems to help a bit."
4. Diet Doctor: "Have you noticed any specific foods that trigger your symptoms?"
Patient: "As I mentioned, dairy seems to be a problem. Sometimes spicy foods or
too much caffeine can set it off too."
5. Cancer Symptoms (to rule out) Doctor: "Have you noticed any blood in your stool?"
Patient: "No, I haven't seen anything like that." Doctor: "Have you experienced any
unintended weight loss or unusual fatigue?" Patient: "No, my weight has been stable,
and I'm not more tired than usual."
6. Previous Treatments Doctor: "You mentioned Buscopan isn't working anymore.
How long have you been taking it?" Patient: "I've been using it on and off for years. I
could buy it from the pharmacy, but lately it doesn't seem to help much." Doctor:
"Have you tried any other treatments or remedies?" Patient: "I've tried peppermint
tea and avoiding certain foods, but nothing seems to help consistently."
7. Impact on Daily Life Doctor: "How are these symptoms affecting your daily life and
work?" Patient: "It's really interfering with my studies and research work. Sometimes
I have to rush to the bathroom during lectures or meetings, which is embarrassing."

VI. PMAFTOSA Assessment

Complete a thorough assessment, including:

• Medical history
• Allergies
• Past medical history
• Travel history

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• Occupation (PhD student/professor)

• Social history

VII. Examination

Doctor: "I'd like to perform a brief examination of your abdomen. Is that okay?"

[Mention examination for the sake of completeness, even if not physically performed in
this scenario]

VIII. Diagnosis and Explanation

Doctor: "Based on your symptoms and our previous tests, I believe you could be
experiencing a condition called Irritable Bowel Syndrome, or IBS. Have you heard of IBS
before?"

Patient: "I'm not sure. What exactly is IBS?"

Doctor: "IBS is a condition that affects the bowel system. It's what we call a functional
condition, which means there's no structural abnormality in your bowels. The current
understanding is that the neurons, or nerve cells, around your bowel become
hypersensitive and overactive. This oversensitivity can cause symptoms when food particles
pass through your bowels too quickly or too slowly."

IX. Management Plan

Doctor: "Here's how we're going to manage your IBS:

1. Medication: I'm going to prescribe a medication called amitriptyline to help control

your symptoms. This works differently from Buscopan and can be more effective for
long-term management of IBS.
2. Further Testing:
o We'll repeat your stool sample test, as it's been more than three months since
the last one.
o We'll also arrange a routine colonoscopy. This isn't urgent as we're not
suspecting cancer, but given your age and changed bowel habits, it's a good
precaution.
3. Symptom Diary: I'd like you to keep a diary of your symptoms and the foods you
eat. This will help you identify triggers. As an educated person, you'll be able to
analyse this and figure out which foods to avoid.
4. Dietary Advice:
o Try to avoid foods that are difficult to digest like cabbage, beans, and onions.

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o If dairy seems to worsen your symptoms, consider avoiding it.

o Pay attention to your reaction to spicy foods and caffeine, as you mentioned
these might be triggers.
5. Lifestyle Changes:
o Regular exercise can help improve symptoms. You mentioned it helps, so try
to incorporate more of it into your routine.
o Stress management techniques might be beneficial, especially around exam
times or research deadlines. Consider relaxation techniques or mindfulness
practices.

Do you have any questions about this plan?"

X. Safety Netting

Doctor: "While we're not suspecting anything more serious, it's important to come back if
you notice any new symptoms like blood in your stool, unexplained weight loss, or unusual
fatigue."

XI. Important Notes and Things to Avoid

1. Don't confuse IBS with IBD (Inflammatory Bowel Disease). If you accidentally say
IBD, correct yourself immediately and reinforce the correct term (IBS) multiple
times.
2. Remember that changed bowel habits alone, especially in a patient with long-
standing symptoms, are not necessarily suspicious for cancer.
3. Always consider the patient's lifestyle (stress from studies) and long-standing nature
of symptoms in IBS.
4. Don't dismiss the impact of IBS on quality of life, especially for a student or
professional.
5. Avoid promising a cure, but emphasize that symptoms can be managed effectively.
6. Remember to discuss the role of stress and diet in IBS management.
7. Don't forget to mention the need for routine colonoscopy given the patient's age,
even if cancer is not suspected.
8. Be prepared to explain IBS in simple terms, focusing on the concept of oversensitive
bowel neurons.
9. Always provide clear explanations for any tests or treatments you recommend.
10. Remember to address the patient's concern about their previous medication
(Buscopan) no longer working.
11. Don't calculate any scores or mention them in this scenario.
12. Remember that the patient has had symptoms since their 20s, which is
characteristic of IBS.

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13. Be aware that the scenario might include a detail to potentially confuse you, such as
mentioning dairy products as a trigger.

Colonic Cancer Scenarios

There are three main colonic cancer scenarios:

1. "Skin to Skin" scenario

2. Elderly woman with bloody diarrhoea
3. Iron deficiency anaemia patient brought to A&E with collapse and changed bowel
habits

"Skin to Skin" Colonic Cancer Scenario

Patient Profile

• Approximately 50 years old

• Presenting in GP setting
• Main complaint: Bloating

Key Points

• Requires real physical examination on a real person ("skin to skin")

• Presence of a couch in the room indicates real examination is required
• Patient is an actor, not actually ill

Approach

1. Initial Interaction

Doctor: "Hello, I'm Dr. [Your Name]. What brings you in today?"

Patient: "I've been feeling really bloated lately."

Doctor: "I'm sorry to hear that. Can you tell me more about this bloating?"

2. Detailed History Taking

a) GI Symptoms

Doctor: "Have you noticed any changes in your bowel habits?" Patient: "Yes, I've been going
to the toilet more frequently these days."

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Doctor: "Have you experienced any abdominal pain?" Patient: "Yes, I've had some pain on
the left side of my tummy."

Doctor: "Is the pain relieved by passing stool?" Patient: "No, it doesn't seem to make a
difference."

Doctor: "Have you noticed any blood in your stool?" Patient: [Provides answer]

b) Weight Loss

Doctor: "Have you noticed any changes in your weight recently?" Patient: "Actually, yes. I've
lost about half a stone in the last two months."

c) Appetite

Doctor: "How's your appetite been?" Patient: "It's not great. I often leave food on my plate,
which is unusual for me."

d) Pancreatic Cancer Symptoms (to rule out)

Doctor: "Have you been feeling more thirsty than usual or urinating more frequently?"
Patient: [Provides answer]

Doctor: "Have you noticed any yellowing of your skin or eyes?" Patient: [Provides answer]

e) Risk Factors

Doctor: "Is there any history of bowel problems or polyps in your family?" Patient: [Provides
answer]

Doctor: "Do you smoke?" Patient: [Provides answer]

Doctor: "How much red meat do you typically eat?" Patient: [Provides answer]

Doctor: "Do you drink alcohol?" Patient: "No, I don't drink alcohol."

3. MAP-TOSA Assessment

Complete a thorough MAP-TOSA assessment, including:

• Medical history
• Allergies
• Past medical history

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• Travel history
• Occupation
• Social history

4. Physical Examination

Doctor: "I'd like to examine your abdomen now. Is that okay?"

Patient: "Yes, that's fine."

[Perform gentle abdominal examination]

Note: Be gentle during examination. The patient will have some tenderness, especially on
the left side.

5. Diagnosis and Explanation

Doctor: "Based on your symptoms and the examination, I'm concerned that this could be
something more serious, possibly affecting your colon. We need to investigate this further."

6. Management Plan

Doctor: "Here's what we need to do:

1. I'm going to refer you urgently to a gastroenterologist. This will be on what we call a
two-week cancer pathway. This doesn't mean you have cancer, but it ensures you're
seen quickly.
2. The specialist will likely arrange for you to have a colonoscopy. This is a procedure
where they look inside your colon with a camera.
3. We'll also do some blood tests today to check your overall health.

Do you have any questions about this plan?"

7. Safety Netting

Doctor: "If you notice any new symptoms or if your current symptoms worsen before your
appointment, please don't hesitate to come back or seek urgent medical attention."

Important Notes and Things to Avoid

1. Remember this is a "skin to skin" scenario - real examination on a real person is

required.

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2. The presence of a couch in the room is a key indicator that real examination is
required.
3. Be gentle during the abdominal examination. The patient is an actor and doesn't
actually have a lump or serious condition.
4. If you examine too aggressively, the examiner may stop you by saying "examination
over." This is to protect the actor from discomfort.
5. Don't forget to ask about pancreatic cancer symptoms (diabetes symptoms, jaundice)
to rule it out.
6. Always consider the patient's age and risk factors when assessing for colonic cancer.
7. Remember the key symptoms: bloating, weight loss (half a stone in two months),
change in bowel habits, abdominal pain (left side).
8. Don't dismiss subtle signs like the patient mentioning leaving food on their plate
(indicating loss of appetite).
9. Be prepared to explain the two-week cancer pathway without alarming the patient
unnecessarily.
10. Remember that smoking is a very important risk factor for colonic cancer.
11. Don't forget to ask about family history of bowel problems or polyps.
12. Be aware that this scenario doesn't involve alcohol use by the patient.
13. The abdominal pain is included in the scenario partly to protect the actor from
overly aggressive examination.
14. Remember that the pain is not relieved by defecation, which helps differentiate it
from conditions like diverticulitis.
15. The patient's symptoms have been present for about two months.
16. There are only two bloating scenarios in PLAB 2 - this one and an ovarian cancer
scenario with an abdominal mannequin.
17. Don't try to find an actual lump during examination - remember the patient is an
actor.

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Palpitations
Overview of Scenarios

• Four distinct scenarios for palpitations:

o Two scenarios involve middle-aged people (50+ or 70+)
o Two scenarios involve young people (less than 30, specifically mentioned 30
and 19)
• Key differences in approach:
o Middle-aged scenarios: No ECG provided, focus on investigative approach
o Young people scenarios: ECG provided, requirement for definite diagnosis

Detailed Approach to Palpitations

Patient Description and Initial Conversation

When a patient presents with palpitations, they might describe it as:

• "I have some thumping sensation in my chest."

• "I have some fluttering feeling in my chest."
• "My heart is beating in a weird way."

Follow-up question: "Would you say that your heart is beating irregularly?" Expected
patient response: "Yes, it is beating irregularly."

Comprehensive History Taking (DOPRA Approach)

1. Duration
o "Since when have you been experiencing these symptoms?"
o "Is it continuous or does it come and goes?"
o If intermittent: "Each time when you get this, how long does it last for?"
o "How many episodes have you had so far?"
2. Onset
o "How did these symptoms start? Was it sudden or gradual?"
3. Precipitating/Alleviating Factors
o "Is there anything that makes it better?"
o "Is there anything that makes it worse?"
o "What about stress? Does it affect your symptoms?"
o "How about exercise? Does it have any impact?"
4. Red Flags (Associated Symptoms)

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o "When you have these irregular heartbeats, have you experienced any of the
following simultaneously?"
§ "Any dizziness?"
§ "Any chest pain?"
§ "Any shortness of breath?"
§ "Have you had any fainting spells or lost consciousness?"
5. Associated Factors

a. Heart-related history:

o "Do you have any previous heart problems?"

o "Have you ever been diagnosed with high blood pressure?"
o "Have you ever had a heart attack?"
o "Have you undergone any heart surgeries?"
o "Did you have any heart conditions during childhood?"

b. Other medical conditions:

o "Do you have any thyroid-related issues?"

o "Are you aware of any hormone-related conditions?"

c. Medications:

o "Are you currently taking any medications?"

o Specific questions about:
§ Asthma medications
§ Thyroid medications (e.g., "Are you taking levothyroxine?")

d. Psychiatric conditions:

o "Do you sometimes feel anxious?"

o "Have you been diagnosed with or experienced depression?"
o "Have you ever had panic attacks?"

e. Substance use:

o "Do you drink alcohol? If so, how much and how often?"
o "Do you smoke?"
o "How much caffeine do you consume daily? Do you drink more than three
cups of coffee a day?"
o "Do you consume energy drinks?"

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f. Stress levels:

o "How would you describe your current stress levels?"

o "Are there any significant stressors in your life right now?"

Physical Examination

• Mention to the patient: "I would like to perform a physical examination."

• Note: In exam scenarios, physical examination details are typically not provided.

ECG Interpretation (When Provided)

• For young patients, an ECG will be provided and must be interpreted.

• Key areas to examine:
o Lead II for quick assessment
o Look for extra beats or abnormal wave patterns

Scenario 1: Middle-Aged Man (50 years old)

Patient Profile

• 50-year-old man
• No medical problems
• No past medical history
• No blood pressure issues
• No family history of heart problems
• No significant caffeine or alcohol consumption
• No apparent risk factors

Symptoms

• Four episodes of palpitations in the last four months

• Each episode lasted only for a few seconds

Approach and Management

1. Explain possible diagnoses: "Based on your symptoms and age, there are two
possible causes we need to consider:
o Atrial fibrillation, which is common for your age group
o Supraventricular tachycardia, another type of irregular heartbeat"
2. Investigations: "To better understand what's happening, we need to run some tests:

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o We'll do a complete blood workup, including thyroid function, blood sugar

levels, and electrolyte balance.
o We'll perform a 12-lead ECG to get a snapshot of your heart's electrical
activity.
o We'll also set you up with a 24-hour heart monitoring device. This isn't a
Holter monitor, but a device you'll wear that will record your heart's activity,
especially when you feel the irregular beats."
3. Referral: "I'm going to refer you to a cardiologist for a more specialized evaluation.
This will be a routine referral, not an urgent one."
4. Safety netting: "While we're investigating this, if you experience these irregular
heartbeats and feel unwell in any way - such as severe dizziness, chest pain, or
shortness of breath - please call an ambulance immediately."

Scenario 2: Older Man (70 years old)

Patient Profile

• 70-year-old man
• Has high blood pressure
• Takes medication (e.g., amlodipine)
• Family history of heart attack (father had one)
• Occasionally drinks coffee

Approach and Management

• Similar to Scenario 1, but with crucial differences: "Given your age, existing high
blood pressure, family history, and symptoms, we need to take a more cautious
approach:
o We'll run the same tests as mentioned before: blood work, ECG, and 24-
hour monitoring.
o However, I'm going to make an urgent referral to cardiology. This means you
should be seen within 4-6 weeks, rather than waiting for a routine
appointment."

Scenario 3: Young Man (30 years old)

Patient Profile

• 30-year-old man
• Initially came for travel vaccines
• Mentioned irregular heartbeat to nurses

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• Experiencing work-related stress

• Drinks lots of coffee and alcohol

Symptoms

• Thought he was having a heart attack

• Irregular heartbeat

ECG Findings

• Ventricular ectopic beats

• Normal QRS complex followed by an extra, wider QRS complex

Approach and Management

1. Explain diagnosis: "I've looked at your ECG, and what we're seeing are called
ventricular ectopic beats. Let me explain what that means:
o These are extra heartbeats originating from the lower chambers of your
heart.
o They're causing the irregular rhythm you're feeling.
o The good news is that these are generally benign, meaning they're not
harmful.
o They're often caused by lifestyle factors like stress, caffeine, and alcohol
consumption."
2. Treatment: "The main treatment for this is lifestyle modification:
o Try to reduce your coffee and alcohol intake.
o We need to work on managing your stress levels. Have you considered stress-
reduction techniques like meditation or yoga?
o Regular exercise can actually help improve these symptoms. Aim for at least
150 minutes of moderate exercise per week."
3. Safety netting: "While these ectopic beats are generally harmless, if you experience
severe symptoms like chest pain, severe shortness of breath, or fainting, please seek
immediate medical attention."

Scenario 4: Young Person (19 years old)

Patient Profile

• 19-year-old
• If male: law student
• If female: medical student
• Experiencing stress due to studies

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• High coffee consumption

• Alcohol consumption (mentioned for law student)

Symptoms

• Fluttering feeling or thumping sensation in chest

• Symptoms improve with exercise

ECG Findings

• Atrial ectopic beats

• Inverted P waves (especially noticeable in lead II)

Approach and Management

1. Explain diagnosis: "I've reviewed your ECG, and what we're seeing are called atrial
ectopic beats. Let me break that down for you:
o These are extra heartbeats originating from the upper chambers of your
heart.
o They're causing the fluttering or thumping sensation you're feeling.
o Like the ventricular ectopics we discussed earlier, these are also benign -
meaning they're not harmful.
o They're often triggered by factors like stress, lack of sleep, and high caffeine
intake, which are common in students like yourself."
2. Treatment: "The primary treatment here is lifestyle modification:
o Try to cut back on the coffee. I know it's tough during exam time, but
excessive caffeine can trigger these symptoms.
o For the law student: "Also, try to moderate your alcohol intake."
o Stress management is crucial. Are there any resources at your university for
stress reduction or counseling?
o Regular exercise is beneficial, and it's great that you've noticed improvement
with activity. Try to maintain a consistent exercise routine."
3. Safety netting: "While these ectopic beats are not dangerous, if you experience any
severe symptoms or feel very unwell, don't hesitate to seek medical attention."

Important Notes for Exam Scenarios

1. Differential approach based on age:

o For middle-aged patients (50+ or 70+):
§ No ECG provided
§ Focus on probable causes (atrial fibrillation or supraventricular
tachycardia)

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§Emphasize the investigative nature of the scenario

o For young patients (30 or younger):
§ ECG always provided
§ Specific diagnosis required (ventricular or atrial ectopic beats)
2. ECG Interpretation:
o Always examine lead II for a quick assessment
o Ventricular ectopics: Look for extra, wider QRS complex
o Atrial ectopics: Look for inverted P waves, especially in lead II
o Note: V1 can sometimes show opposite P wave polarity, so focus on lead II
3. Diagnosis Communication:
o Always mention the exact type of ectopic beat (ventricular or atrial)
o Emphasize that ectopic beats are benign and not harmful
o Explain the connection between lifestyle factors and symptoms
4. Treatment Approach:
o Lifestyle modifications are the primary treatment for ectopic beats
o Be specific about recommendations: reduce caffeine/alcohol, manage stress,
exercise regularly
5. Safety Netting:
o Always include safety netting advice
o Instruct patients when to seek immediate medical attention
6. Referrals:
o For middle-aged patients with no risk factors: Routine cardiology referral
o For older patients or those with risk factors: Urgent cardiology referral (4-6
weeks)
7. Investigations:
o For middle-aged patients: Emphasize the need for blood tests, ECG, and 24-
hour monitoring
o Explain the purpose of each test to the patient

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Side Effects Scenarios

There are five key scenarios related to medication side effects:

1. Oxybutynin
2. Citalopram
3. Lithium
4. Steroid
5. Carbimazole

General approach for scenarios 1, 2, 4, and 5:

• When the patient is already on the medication:

1. Check for other side effects
2. Investigate reasons for developing side effects
3. Assess how the treatment was working
• Principle: Do no harm - stop the medication immediately (except for steroids)

For steroids: Treat the side effects rather than stopping the medication

For Lithium: Different approach

For scenarios where the course is almost complete (e.g., dog bite treatment): Patient can
complete the course if only one day left

Oxybutynin Side Effects Scenario

Patient Profile

• Male patient (important to note, not female)

• Given Oxybutynin for prostate problem (urinary frequency)
• Initially prescribed 5 mg, advised to increase to 10 mg if symptoms not controlled

Consultation Approach

1. Opening
o "I understand you've come for a follow-up. How have you been?"

Note: Patient may be very talkative. Allow them to speak without interruption. This is one
of three scenarios where patients talk excessively:

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Oxybutynin scenario
§
§ Breast cancer patient scenario
§ Liver enzyme-related scenarios
2. Potential Presenting Complaints (varies by scenario)
o a. Funny turns b. Dry mouth c. Diarrhea
3. Explore Presenting Complaint Example for "Funny Turns":
o "What do you mean by funny turns?"
o Patient may describe:
§ "I went on holiday. While at the hotel reception, I couldn't get back
to my room. My wife said I looked confused."
§ "Another day, I went to play golf. After changing, my friend said I
acted confused."
§ "I went to play poker with my friends. I usually play very well, but I
was losing. My friend said I couldn't play properly."
4. Inquire about Other Side Effects Remember "Dry, Dry, Dry" + GIT + Neuro
symptoms

a. Dry symptoms:

o "Have you experienced any dryness in your mouth or eyes?"

o "Any difficulties urinating or pain while urinating?"
o "Have you had any constipation?"
o "Any problems fully emptying your bladder?"

b. GIT symptoms:

o "Have you felt nauseous or had any vomiting?"

o "Any diarrhea, tummy pain, or increased gas?"
o "Any problems with excessive farting or burping?"

c. Neuro symptoms:

o"Have you had any headaches?"

o "Any blurred vision?"
o "Have you felt unusually warm or had a high temperature?"
o "Any difficulty swallowing?"
o "Have you experienced any fainting or confusion?"
5. Medication History
o "Are you taking your medication regularly?"
o "Did you increase the dose as advised? From 5 mg to 10 mg?"
o "Are you still taking the medication or have you stopped?"
o "For how long were you on this treatment?"

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"Were your urinary frequency symptoms controlled when you were on the
o
medication?"
o "Have the symptoms returned since stopping the medication?"
o "Do you remember why you were initially prescribed this medication?"
6. Memory Assessment (if patient asks about dementia)
o "How has your memory been lately?"
o "Have you been forgetting things more often?"
o "Any difficulties with household activities?"
o "Do you ever forget names of people close to you?"
o "Have you had trouble recognizing faces of family members?"
o "Do you forget important dates?"
o "Have you ever gotten lost on a familiar street?"
o "How's your driving? Any difficulties?"
7. Complete PMAFTOSA

Management

1. Explain side effects are due to medication

2. Advise to temporarily stop Oxybutynin
3. Wait for 2-3 weeks before reassessing
4. Suggest lifestyle changes:
o Reduce fluid intake (ensure not dehydrated)
o Avoid stimulants (caffeine, alcohol, smoking)
o Regular exercise
o Improve sleep habits
5. If no improvement, consider alternative medication (e.g., alpha-blockers like
tamsulosin)

Things to Avoid

• Don't interrupt the patient, even if they're very talkative

• Don't dismiss memory concerns; assess thoroughly
• Don't continue Oxybutynin if side effects are severe
• Don't forget to provide safety netting advice
• Don't rush the patient or show signs of impatience
• Don't neglect to explore all potential side effects

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Vaginal Discharge Scenarios

General Approach: Morphology, Evolution, Symptoms (MES)

1. Morphology of Discharge
o "What sort of discharge is it? Watery, creamy, thick, or thin?"
o "How much discharge is there? Is it a large amount?"
o "What color is the discharge?"
o "How would you describe its appearance?"
2. Evolution of Symptoms
o "When did you first notice the discharge?"
o "Is it constant or does it come and go?"
o "Is it getting better or worse?"
o "Is there anything that makes it better or worse?"
o "Do you notice it more at any particular time?"
3. Associated Symptoms
o "Does the discharge have any smell?"
o "Is there any itching?"
o "Do you have any pain or discomfort?"
o "Any soreness in the vaginal area?"
o "Have you noticed any rashes?"
o "Any pain during sexual intercourse?"
o "Do you have any abdominal pain?"
o "Any burning sensation when you urinate?"
o "Have you noticed any swelling around your genital area?"
o "Any lumps or bumps in the genital region?"
o "Is there any redness in the area?"
4. Risk Factors

a. Bacterial Vaginosis Risk Factors:

o "Do you use any lotions or douches in the vaginal area?"

o "Have you changed your underwear type recently?"
o "Do you use soap or bubble bath products in your genital area?"
o "Have you been using any new hygiene products?"

b. STI Risk Factors (if applicable):

o "Do you always practice safe sex?"

o "Have you changed sexual partners recently?"
o "Are you on any form of contraception?"

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o"When was your last sexual health check-up?"

5. Complete PMAFTOSA
6. Examination
o Mention: "I would like to perform an examination if that's okay with you."
o Observe for any visible signs
o Check temperature
o Perform speculum examination (if indicated)
o Perform bimanual examination (if indicated)

Candida Infection

Patient Profile:

• Female, around 40 years old

• Presenting with vaginal discharge

Key Features:

• White discharge
• No smell
• Itchy
• Possible cottage cheese appearance
• Symptoms typically present within one week due to itchiness

Questions to Ask:

• "What color is the discharge?"

• "Does the discharge have any smell?"
• "Is there any itching? How severe is it?"
• "Would you describe the discharge as having a cottage cheese-like appearance?"
• "How long have you had these symptoms?"
• "Have you had any similar episodes in the past?"
• "Have you tried any over-the-counter treatments?"

Diagnosis: Candida (yeast) infection

Treatment:

• First-line treatment: Fluconazole (oral capsule, single dose)

• Explain: "The most effective treatment for this type of infection is a medication
called Fluconazole. It's a single oral capsule that you take once."

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Things to Avoid in Vaginal Discharge Scenarios

• Don't assume STI without proper risk assessment

• Don't neglect to ask about all associated symptoms
• Don't forget to offer examination
• Don't prescribe treatment without clear diagnosis
• Don't use alternatives to first-line treatments without justification
• Don't rush through the MES approach
• Don't forget to provide lifestyle advice to prevent recurrence

IV. Important Notes for Exam Scenarios

1. Clarity of Scenarios:
o Each scenario is designed with a clear diagnosis or direction
o There are no "not really sure" or multiple cause scenarios
o Exception: Palpitations, which require investigation
2. Patient Responses:
o In STI-related scenarios, patients will clearly indicate safe or unsafe sexual
practices
o There's no ambiguity in patient responses regarding risk factors
3. Diagnosis Approach:
o Focus on the most probable diagnosis based on given information
o Avoid suggesting multiple causes or expressing uncertainty unless explicitly
stated in the scenario
4. Talkative Patients:
o In scenarios with very talkative patients, allow them to speak without
interruption
o Listening attentively is part of data gathering
o Reflect on what they say in your management plan
5. Time Management:
o In talkative patient scenarios, the patient may talk for up to six minutes
o After this, they will typically allow you to take control of the consultation
6. Scenario Variations:
o Be prepared for the same scenario to present differently on different days
o Example: Oxybutynin scenario may focus on funny turns, dry mouth, or
diarrhea
7. First-Line Treatments:
o Always recommend the established first-line treatment
o Example: For Candida, prescribe Fluconazole, not other antifungals
8. Exam Structure:
o Scenarios are created based on specific topics

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o There are no scenarios where the diagnosis is uncertain

9. Listening Skills:
o In talkative patient scenarios, listening is a crucial part of data gathering
o Reflecting on what the patient says in your management plan is important
10. Vaginal Discharge Scenarios:
o There are many scenarios related to vaginal discharge (6-8 mentioned)
o Always use the MES approach (Morphology, Evolution, Symptoms)
11. Risk Factor Assessment:
o For bacterial vaginosis, focus on hygiene practices
o For STIs, focus on sexual history
o Scenarios will clearly indicate which direction to pursue

Bacterial Vaginosis

Scenario Overview

This scenario presents a potentially new or challenging case that may be difficult to
diagnose on the first encounter without clear data gathering. It's important to note that
this scenario is considered relatively new and may not have been encountered frequently
before.

Patient Profile

• Female patient
• Married for 10-15 years
• In a stable relationship

Presenting Complaint

Patient's initial statement: "I have some vaginal discharge, a lot of discharge, and that
smells."

Key Features

1. Large amount of discharge

2. Smelly discharge
3. Not itchy

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Detailed History Taking

Opening Question

Doctor: "Can you tell me more about this discharge you're experiencing?"

Exploring the Discharge (MES Approach)

Morphology

Doctor: "How would you describe the discharge? Is it watery, creamy, or thick?" Patient:
[Wait for response]

Doctor: "And how much discharge are you noticing? You mentioned it's a lot?" Patient:
"Yes, it's quite a large amount."

Doctor: "What color is the discharge?" Patient: [Wait for response]

Evolution

Doctor: "When did you first notice this discharge?" Patient: [Wait for response]

Doctor: "Has it been constant, or does it come and go?" Patient: [Wait for response]

Doctor: "Have you noticed any changes in the amount or appearance over time?" Patient:
[Wait for response]

Symptoms

Doctor: "You mentioned the discharge smells. Can you describe the odor?" Patient: "It has
a strong, unpleasant smell."

Doctor: "Is there any itching or irritation in the vaginal area?" Patient: "No, it's not itchy."

Doctor: "Have you experienced any pain or discomfort in the area?" Patient: [Wait for
response]

Doctor: "Any pain during urination or sexual intercourse?" Patient: [Wait for response]

Sexual History

Doctor: "I understand this might be a sensitive topic, but it's important for your health.
Are you currently sexually active?" Patient: "Yes, I'm married."

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Doctor: "How long have you been married?" Patient: "For about [10-15] years."

Doctor: "Do you and your husband use any form of protection during intercourse?"
Patient: "No, we don't. We've been married for so long."

Doctor: "Have there been any recent changes in your sexual activity or partners?" Patient:
"No, just my husband."

Risk Factors

Doctor: "Have you recently changed any of your hygiene practices?" Patient: [Wait for
response]

Doctor: "Do you use any lotions, douches, or special soaps in the vaginal area?" Patient: "I
am putting a lot of lotions."

Doctor: "Can you tell me more about these lotions? How often do you use them?" Patient:
[Wait for response]

Doctor: "Do you use bubble baths or any scented products in that area?" Patient: [Wait for
response]

Medical History

Doctor: "Have you had any similar episodes in the past?" Patient: [Wait for response]

Doctor: "Are you currently taking any medications?" Patient: [Wait for response]

Doctor: "Any recent illnesses or changes in your health?" Patient: [Wait for response]

Examination

Doctor: "Based on what you've told me, I would like to perform an examination if that's
okay with you. This will help us determine the cause of your symptoms."

[At this point, the examiner will provide a picture showing the cervix with a large amount
of discharge]

Doctor: "I've completed the examination. I can see that there is indeed a significant
amount of discharge present."

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Diagnosis Discussion

Doctor: "Based on your symptoms and the examination, this could be a condition called
bacterial vaginosis. It's a common vaginal infection that occurs when there's an imbalance
in the normal bacteria in the vagina."

Management Plan

Doctor: "Here's what I suggest we do:

1. First, we'll take a swab to test the discharge. This will help confirm the diagnosis.
2. Given your symptoms, I think it's best to start treatment right away. I'm going to
prescribe an antibiotic called metronidazole. You'll need to take it for seven days.
3. Is it also okay if we test for some common sexually transmitted infections like
gonorrhea and chlamydia? This is just to be thorough, even though your risk seems
low.
4. The test results will take about 48 hours. If they show a different infection, we
might need to change the antibiotics.
5. In the meantime, I'd suggest avoiding the use of lotions in the vaginal area, as these
can sometimes upset the natural balance of bacteria."

Follow-up

Doctor: "I'd like you to come back in about a week to see how you're doing. If your
symptoms don't improve with the treatment, or if you have any concerns before then,
please don't hesitate to come back sooner."

Important Notes for the Scenario

1. This scenario presents bacterial vaginosis as the most likely diagnosis, but it's crucial
to keep an open mind.
2. The use of lotions is a key piece of information that supports the bacterial vaginosis
diagnosis.
3. Despite the stable relationship, it's still important to offer STI testing.
4. The large amount of discharge and the smell are key symptoms, while the absence of
itching is also noteworthy.
5. Always perform an examination when offered the opportunity.
6. Be prepared for potential variations or additional information in this scenario, as
it's described as relatively new.

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Things to Avoid

1. Don't assume it's an STI without evidence, especially given the stable relationship.
2. Don't forget to ask about hygiene practices, particularly the use of lotions and
bubble baths.
3. Don't skip the examination or swab testing.
4. Don't neglect to offer STI testing, even in seemingly low-risk situations.
5. Don't jump to conclusions based solely on the discharge; consider all symptoms and
risk factors.
6. Don't forget to provide lifestyle advice (e.g., avoiding lotions) along with medical
treatment.

ECG Teaching Scenario

Scenario Overview

You are an F2 (Foundation Year 2 doctor) in the emergency department. A nursing

student approaches you, wanting to learn about how to read an ECG.

Initial Encounter

Nursing Student: [Approaches with an ECG, possibly in a friendly, enthusiastic manner]

"Doctor, I want to learn about this ECG!"

Note: The student may appear overly friendly or "dancing" with the ECG. This is an
attempt to break the ice and be friendly.

Professional Behavior

1. Maintain Professional Boundaries

o Be friendly but not overly casual
o Don't cross professional boundaries
o Be "professionally friendly" - warm on the outside, cool on the inside
o Avoid phrases like:
§ "Hi mate!"
§ "Don't worry, it's very simple."
§ "I'm so cool/nice."
o Don't laugh excessively or act too casually
o Remember: Your behavior is being assessed, even if not explicitly mentioned

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2. Introduction
o Introduce yourself by your first name
o Mention your role (F2)
o Don't use "Doctor" title with colleagues
o Example: "Hi, I'm [Your Name]. I'm one of the F2s here. I understand you're
[Student's Name], a nursing student, and you'd like to learn about ECGs. I'd
be happy to teach you."
3. Creating a Learning Environment
o Be welcoming and friendly, but maintain professionalism
o Create a friendly environment conducive to learning
o Don't be overly formal or distant

Teaching Approach

1. Avoid Theoretical Questions

o Don't ask: "Can you tell me how to calculate the rate?"
o Don't ask: "Do you know what muscles are here?"
o Don't ask: "How many regions are in the abdomen?"
o Reason: Modern teaching methods (for Gen Z) focus on "show and tell"
2. Don't Ask Students to Repeat
o Avoid asking them to repeat what you've taught
o Instead, invite general questions: "Do you have any questions at this point?"
3. Focus on the Task
o Don't ask about ECG source or patient consent
o Don't teach ethics or clinical management
o Stick to teaching how to read an ECG
4. Use Visual Aids
o Use pen and paper
o Draw a large, clear ECG diagram (not a small one in the corner)
o Say: "Let me draw a diagram to explain the basics of an ECG."
5. Content to Cover
o Basic ECG waves: P, Q, R, S, T
o Explain what each wave represents
o How to calculate heart rate
o What sinus rhythm means
o How to calculate rate in irregular rhythms
o Some basic pathologies
6. Time Management
o Invite questions at the 6-minute mark: "Do you have any questions so far
about what we've covered?"
o Focus on quality over quantity

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o Don't rush to finish all content

ECG Teaching Content

1. Drawing the ECG

o Draw a large, clear diagram
o Say: "This is a basic ECG tracing. Let's go through each wave."
o Label P wave (first upward wave): "This first upward deflection is the P wave.
It represents atrial depolarization."
o Q wave (small downward): "This small downward deflection is the Q wave."
o R wave (largest upward, always bigger than S): "The large upward spike is the
R wave. It's usually the most prominent part of the QRS complex."
o S wave: "Following the R wave, we have this downward deflection called the
S wave."
o T wave: "Finally, we have the T wave, which represents ventricular
repolarization."
2. Explain Wave Meanings
o P wave: "The P wave represents atrial depolarization, which is when the atria
contract."
o QRS complex: "The QRS complex represents ventricular depolarization, or
the contraction of the ventricles."
o T wave: "The T wave represents ventricular repolarization, when the
ventricles relax and prepare for the next beat."
3. Basic Concepts
o How to calculate heart rate: "To estimate the heart rate, we can use the 300
method. Count the number of large squares between R waves and divide 300
by that number."
o Definition of sinus rhythm: "Sinus rhythm is the normal rhythm of the
heart. It's characterized by regular P waves followed by regular QRS
complexes."
o Identifying non-sinus rhythms: "Any rhythm that doesn't follow this pattern
is considered non-sinus."
o Calculating rate in irregular rhythms: "For irregular rhythms, we count the
number of QRS complexes in a 6-second strip and multiply by 10."
4. Pathologies to Mention
o ST elevation: "ST elevation, particularly in certain leads, can indicate
myocardial infarction."
o Hyperkalemia: "In hyperkalemia, we often see tall, peaked T waves."
5. ECG Interpretation
o Practice with sample ECGs: "Let's look at this ECG. What do you notice
about the ST segments in leads I, aVL, and V4-V6?"

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o Identify ST elevation in leads I, aVL, V4-V6: "The elevation in these leads

suggests an anterolateral MI."
o Recognize hyperkalemia patterns: "See these tall, peaked T waves? This
pattern is typical of hyperkalemia."

Things to Avoid

1. Don't discuss ethics or ECG source

o Avoid asking: "Where did you get this ECG?" or "Did you get consent from
the patient?"
2. Avoid teaching clinical management of conditions
o Don't say: "If you see an MI, you need to call the seniors immediately."
3. Don't ask theoretical questions
o Avoid: "Can you tell me how to calculate the rate?"
4. Avoid asking students to repeat information
o Don't say: "Now, can you repeat back to me what I just explained?"
5. Don't clean tables or arrange papers (not part of teaching)
6. Don't worry about categorizing actions into data gathering, interpersonal skills, or
management domains

Important Notes

1. ECG knowledge is crucial and enduring in medicine

o "ECG has been around for 100 years and will likely be used for centuries to
come."
2. Focus on teaching basics clearly and effectively
3. Quality of teaching is more important than quantity of information covered
o "It's better to explain a few concepts well than to rush through everything."
4. Be prepared to interpret common ECG patterns (e.g., anterolateral MI,
hyperkalemia)
5. Your factual information must be correct to avoid losing marks
o Example of a mistake to avoid: Saying "300 divided by small boxes" instead of
"large boxes" when calculating heart rate

Resource Suggestions

• Website: "Life in the Fast Lane" for ECG learning

• YouTube videos for basic ECG concepts

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Closing the Teaching Session

• Summarize key points: "To recap, we've covered the basic waves of an ECG, how to
calculate heart rate, and looked at a couple of common abnormalities."
• Invite final questions: "Do you have any final questions about what we've discussed?"
• Encourage further learning: "ECG interpretation is a skill that improves with
practice. Keep looking at ECGs whenever you get the chance."
• Thank the student: "Thank you for your interest in learning about ECGs. I hope
this has been helpful."

Four Box System for Medical Consultations

Introduction to the Four Box System

The "four box system" is a method for structuring medical consultations, created to solve
many problems in patient interactions. It's important to note that this system has a specific
creator who emphasizes its uniqueness and importance.

When to Use the Four Box System

The four-box system is used in specific scenarios where a patient makes an appointment
and asks for something specific. It's crucial to understand the correct application of this
system.

Examples of patient requests that warrant the use of the four-box system:

1. Asking for a referral Patient: "Can you refer me to a specialist for my knee pain?"
2. Seeking information Patient: "I want to know more about the flu vaccine."
3. Discussing worries Patient: "I'm worried I might have diabetes. Can we talk about
it?"
4. Inquiring about other people's information (confidentiality issues) Patient: "Can you
tell me about my daughter's test results?"
5. Asking about medication Patient: "I've heard about a new blood pressure
medication. Can you prescribe it for me?"
6. Questioning medical decisions Patient: "Why did you do a DNR for my father?"

It's important to note that not every consultation requires the four-box system. It's
specifically for situations where patients are actively seeking something from you.

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Structure of the Four Box System

The system consists of four conceptual "boxes":

• Boxes 1 and 2: Used to collect information from the patient

• Boxes 3 and 4: Used to give information to the patient

Box 1: General Questions

Theme: Why and How based questions Focus: Patient's concerns, ideas, or expectations

Example questions:

• "What do you understand about [topic]?"

• "Why do you think [procedure] is necessary?"
• "How much do you know about [subject]?"

It's crucial to ask these questions even if patients respond with "no" or seem reluctant. This
is often a cultural factor, and persistence (with politeness) is key.

Doctor: "What do you know about vaccines?" Patient: "Not much, really." Doctor: "That's
okay. Can you tell me why you think we give vaccines?" Patient: "I guess to prevent
diseases?" Doctor: "Exactly. And do you have any idea how they work?"

Box 2: Risk Factors and General Health

Focus: Patient's general health and specific risk factors

Example questions:

• "Do you have any existing medical conditions?"

• "Is there a family history of [relevant condition]?"
• "Can you tell me about your lifestyle, such as diet and exercise?"

Doctor: "Before we discuss the PSA test further, can you tell me about your general health?"
Patient: "I'm generally healthy, but my father had prostate cancer." Doctor: "I see. And have
you noticed any urinary symptoms recently?"

Box 3: General Explanation

Purpose: Explain the subject matter discussed in Box 1 Content: Provide general
information about the topic

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Example (for vaccines): Doctor: "Let me explain what vaccines are and how they work.
Vaccines contain weakened or inactive parts of a particular organism that triggers an
immune response within the body. This helps our immune system to recognize and fight
that organism in the future..."

Box 4: Patient-Specific Information

Purpose: Relate the general information to the patient's specific case Content: Provide
recommendations or decisions based on the patient's situation

Example: Doctor: "Based on what we've discussed about vaccines and considering your
child's health, I would recommend proceeding with the 8-week vaccines. They're important
for protecting your child against several serious diseases..."

Detailed Example Scenarios

1. 8-week vaccine information

Box 1: Doctor: "What do you know about the 8-week vaccines?" Patient: "Not much, just
that they're supposed to protect my baby."

Box 2: Doctor: "How has your baby's health been since birth?" Patient: "Generally good, but
there was a bit of jaundice in the first week."

Box 3: Doctor: "The 8-week vaccines protect against several diseases including diphtheria,
tetanus, pertussis, polio, and Hib. They work by..."

Box 4: Doctor: "For your baby, given their good health, I recommend proceeding with the
vaccines as scheduled..."

2. Surgical abortion information

Box 1: Doctor: "What's your understanding of surgical abortion?" Patient: "I know it ends a
pregnancy, but I'm not sure how it's done."

Box 2: Doctor: "Can you tell me about your general health and any previous pregnancies?"
Patient: "This is my first pregnancy. I'm generally healthy but I smoke occasionally."

Box 3: Doctor: "A surgical abortion is a procedure that uses suction to remove the
pregnancy from the uterus. It's typically done under local anesthetic..."

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Box 4: Doctor: "In your case, given that you're in good health and it's an early pregnancy, a
surgical abortion would be a safe option if that's what you decide..."

3. Questioning a referral ("Why did you refer me?")

Box 1: Doctor: "Can you tell me what you understand about why you've been referred?"
Patient: "Not really. I just got this letter saying I need to see a specialist."

Box 2: Doctor: "Let's review your recent visits. You came in with chest pain last month,
correct?" Patient: "Yes, that's right."

Box 3: Doctor: "Referrals are made when we feel a specialist's expertise would be beneficial.
In cases of chest pain, we often refer to cardiologists to..."

Box 4: Doctor: "In your specific case, given your symptoms and family history, I felt it was
important to have a cardiologist evaluate you to ensure we're not missing anything
serious..."

4. Pap smear information and referral

Box 1: Doctor: "What do you know about pap smears?" Patient: "I know they're for women,
but I'm not sure what they check for."

Box 2: Doctor: "Have you ever had a pap smear before? And is there any history of cervical
cancer in your family?" Patient: "No, this would be my first. And no family history that I
know of."

Box 3: Doctor: "A pap smear is a screening test for cervical cancer. It involves collecting
cells from the cervix to check for any abnormalities..."

Box 4: Doctor: "For you, as a [age] woman with no previous pap smears, I would strongly
recommend having one. It's an important preventive measure..."

5. Vasectomy referral request

Box 1: Doctor: "What do you understand about vasectomy?" Patient: "I know it's a way for
men to prevent pregnancy, but I'm not sure how it works."

Box 2: Doctor: "Can you tell me about your general health? Any issues with bleeding or
previous surgeries?" Patient: "I'm healthy overall. No surgeries, but I do take aspirin daily
for my heart."

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Box 3: Doctor: "A vasectomy is a surgical procedure that prevents sperm from leaving the
body. It involves cutting and sealing the tubes that carry sperm..."

Box 4: Doctor: "In your case, given your overall good health, a vasectomy could be a
suitable option. However, we'd need to discuss managing your aspirin use before the
procedure..."

6. DNR (Do Not Resuscitate) explanation

Box 1: Doctor: "Can you tell me what you understand about the DNR order for your
father?" Patient: "I'm not sure. Does it mean you're giving up on him?"

Box 2: Doctor: "Let's talk about your father's current condition. What have the doctors told
you about his prognosis?" Patient: "They said his heart is very weak and he's unlikely to
recover."

Box 3: Doctor: "A DNR, or Do Not Resuscitate order, is a medical order that instructs
healthcare providers not to perform cardiopulmonary resuscitation (CPR) if a patient's
heart stops beating or if they stop breathing..."

Box 4: Doctor: "In your father's case, given his severe heart condition and overall health,
CPR would be unlikely to be successful and could cause additional suffering..."

7. Confidentiality issues (e.g., "Can you tell me about my daughter's test results?")

Box 1: Doctor: "What do you understand about medical confidentiality?" Patient: "I
thought as a parent, I had the right to know everything about my child's health."

Box 2: Doctor: "Can you tell me how old your daughter is? And has she discussed her
medical information with you before?" Patient: "She's 17. We usually discuss her health,
but she's been more private lately."

Box 3: Doctor: "Medical confidentiality is a fundamental principle in healthcare. It means

that healthcare providers must keep a patient's medical information private unless the
patient gives permission to share it..."

Box 4: Doctor: "In your daughter's case, as she's 17, she has the right to privacy regarding
her medical information. I can't disclose her test results without her permission..."

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8. Patient worries (e.g., prostate cancer, vascular dementia, stroke)

Box 1: Doctor: "You mentioned you're worried about prostate cancer. Can you tell me why
you're concerned?" Patient: "My brother was just diagnosed, and I'm wondering if I should
be checked."

Box 2: Doctor: "I see. Can you tell me about any symptoms you've been experiencing? And
how old are you?" Patient: "I'm 55. No real symptoms, just worried because of my brother."

Box 3: Doctor: "Prostate cancer is indeed more common as men age, and family history can
increase risk. Screening typically involves a blood test called PSA and sometimes a physical
exam..."

Box 4: Doctor: "Given your age and family history, it would be reasonable to discuss
prostate cancer screening. However, it's important to understand the pros and cons of
screening..."

9. Test requests (e.g., PSA test)

Box 1: Doctor: "What do you know about the PSA test?" Patient: "I've heard it can detect
prostate cancer early, but I'm not sure how it works."

Box 2: Doctor: "Before we discuss the test, can you tell me about your general health and
any urinary symptoms you might be having?" Patient: "I'm in good health overall. No real
urinary problems, just getting up once at night sometimes."

Box 3: Doctor: "The PSA test measures the level of Prostate-Specific Antigen in your blood.
It can be elevated in prostate cancer, but also in non-cancerous conditions..."

Box 4: Doctor: "In your case, given your age and lack of symptoms, we should discuss the
potential benefits and drawbacks of PSA testing before deciding..."

10. Medication prescription requests

Box 1: Doctor: "You've asked about a new blood pressure medication. What do you know
about it?" Patient: "I saw an ad that said it's better than other medications. I thought it
might be good for me."

Box 2: Doctor: "I see. Let's review your current blood pressure control and any side effects
you're experiencing with your current medication." Patient: "My BP is okay, around
135/85. No real side effects, but I thought newer might be better."

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Box 3: Doctor: "New medications aren't always better for everyone. Each person responds
differently to medications. The best medication is one that effectively controls your blood
pressure with minimal side effects..."

Box 4: Doctor: "In your case, your current medication seems to be working well without
side effects. Changing to a new medication might not provide any additional benefit and
could potentially cause new side effects..."

Important Notes on Using the Four Box System

1. The system is not used for every consultation, only when patients specifically ask for
something.
2. It's not appropriate to use the term "counseling" for all scenarios; be specific about
the type of consultation.
3. In Box 1, it's okay if patients answer "no" to your questions; the important thing is
to ask.
4. Cultural factors may influence how patients respond to questions; persist politely.
5. Put "flavor" into your questions to make them more palatable.
6. The quality of information gathered and provided is more important than the
quantity.
7. Be prepared to adapt the system to different scenarios.

Things to Avoid

1. Don't use the four-box system for every consultation.

2. Avoid jumping straight to patient-specific questions without exploring general
understanding first.
3. Don't skip Box 1 and 2 (information gathering) and go straight to explanations.
4. Avoid using overly technical language in Box 3 and 4 explanations.
5. Don't ignore cultural factors that may influence patient responses.
6. Avoid being too casual or friendly; maintain professional boundaries.
7. Don't rush through the boxes; take time to gather and provide quality information.

8-Week Vaccination Consultation

Scenario Overview

• Setting: F2 doctor in a GP practice

• Patient: 30-year-old mother with a 5-week-old son
• Reason for appointment: Mother wants information about 8-week vaccines
scheduled in 3 weeks

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Consultation Approach

Opening

Doctor: "I understand you made an appointment to speak to the doctor regarding your
son's vaccines. Is there anything in particular you would like to discuss?"

Mother: "Yes, they've given an appointment for vaccines in three weeks. I want to know
what the 8-week vaccines are about."

Doctor: "I see. May I know why you're interested in learning about these vaccines?"

Mother: "Well, I just want to be prepared and understand what they're going to do."

Box 1: Exploring Prior Knowledge and Concerns

1. General Vaccine Knowledge Doctor: "Before we discuss the specific vaccines, I'd like
to understand how much you know about vaccines in general. Could you tell me
what you understand about vaccines?" Mother: [Wait for response] Doctor: "Do you
know what a vaccine consists of?" Mother: [Wait for response] Doctor: "Can you
explain why we need to give vaccines?" Mother: [Wait for response]
2. Benefits and Risks Doctor: "What do you understand about the benefits of
vaccination?" Mother: [Wait for response] Doctor: "Do you have any understanding
of what might happen if we don't vaccinate children?" Mother: [Wait for response]
3. Vaccine Mechanism Doctor: "Can you explain how you think the vaccine system
works in the body?" Mother: [Wait for response]
4. Concerns and Opinions Doctor: "Are you worried about anything regarding
vaccines?" Mother: [Wait for response] Doctor: "Is there anything that bothers you
about vaccines?" Mother: [Wait for response] Doctor: "Do you have any opinions
against vaccines?" Mother: [Wait for response]
5. Personal Vaccination History Doctor: "Have you been vaccinated yourself when you
were young?" Mother: [Wait for response] Doctor: "Have you completed all your
vaccines?" Mother: [Wait for response]

Note: It's crucial to ask multiple questions covering different aspects, not just one general
question. This helps gauge the mother's understanding and concerns comprehensively.

Box 2: Child's Health and Development (P-BIRD)

Important: Don't ask irrelevant questions about infections or symptoms unrelated to the
vaccination query. Focus on age-appropriate questions for a 5-week-old.

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B - Birth: Doctor: "Were there any complications during birth or diagnoses made at birth?"

Mother: [Wait for response]

I - Immunizations: Note: No vaccinations are given at birth in the UK. Don't ask if the
child is up to date with vaccinations.

R - Red book: Doctor: "Do you have the red book? Have you been using it to track your
child's growth?"

Mother: [Wait for response]

D - Development: Doctor: "I'd like to ask a few questions about your baby's development. Is
that okay?"

Mother: "Yes, that's fine."

Doctor: "Is your baby making eye contact with you?"

Mother: [Wait for response]

Doctor: "How does your baby respond when touched or spoken to?"

Mother: [Wait for response]

Doctor: "Have you noticed if your baby is gaining weight appropriately?"

Mother: [Wait for response]

Doctor: "Is your baby moving their legs and arms actively?"

Mother: [Wait for response]

Additional questions: Doctor: "Has your child been diagnosed with any medical problems
since birth?"

Mother: [Wait for response]

Doctor: "Is your child currently on any medications?"

Mother: [Wait for response]

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Doctor: "Are there any allergies you're aware of?" Note: Don't specifically ask about egg
allergy for a 5-week-old.

Mother: [Wait for response]

Doctor: "Has your child had any recent illnesses or fevers?"

Mother: [Wait for response]

Vaccine Explanation (Box 3)

Doctor: "Thank you for answering those questions. Now, let me explain everything about
the vaccines your child will receive at 8 weeks:

1. What is a vaccine? A vaccine contains inactive particles from bacteria or viruses.

These particles can't cause infection, but they stimulate our immune system to
produce defenses against future infections.
2. How do vaccines work? When we introduce these inactive particles into the body,
they induce our system to produce defenses against future infections. If your child
encounters a similar infection in the future, their body can fight it off on its own,
reducing complications.
3. 8-week vaccines: At 8 weeks, we give three vaccines: two injections and one oral
drop. All are given on the same day.

a) Six-in-one vaccine (injection): This single injection protects against six different
infections:

o Diphtheria: This is a bacteria that causes severe throat infections. It can lead
to serious complications and may require hospitalization.
o Tetanus: This bacteria is found in soil and can enter the body through cuts
or wounds. It affects muscles and nerves and is difficult to treat once
established.
o Pertussis (Whooping cough): This bacterial infection causes prolonged
coughing fits that can affect a child's development.
o Polio: This is a virus that affects nerves and can cause paralysis. There's no
cure, so prevention through vaccination is crucial.
o Haemophilus influenzae type b (Hib): This bacteria can cause serious
infections including chest infections, ear infections, and meningitis. It's
important to note this is different from the flu virus.
o Hepatitis B: This virus causes inflammation of the liver. There's currently no
cure, which is why prevention through vaccination is so important.

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b) Meningococcal B vaccine (injection): This protects against meningitis, which is an

inflammation of the covering of the brain. Meningitis can be very serious and potentially
life-threatening. c) Rotavirus vaccine (oral drops): This protects against a virus that causes
severe diarrhea and vomiting. These symptoms can lead to dehydration, which sometimes
requires hospital admission.

Do you have any questions about what I've explained so far?"

Mother: [Wait for response and address any questions]

Addressing Common Concerns (Box 4)

Doctor: "Parents often have questions about vaccines. I'd like to address some common
concerns. Is that okay?"

Mother: "Yes, please."

1. Safety Concerns Mother: "Are these vaccines safe?" Doctor: "That's a very important
question. The vaccines are very safe. They undergo rigorous safety testing before
being approved for use in children. Millions of children receive these vaccines every
year without problems. The testing process is thorough and ongoing to ensure
continued safety."
2. Side Effects Mother: "What are the side effects?" Doctor: "It's good to be prepared
for potential side effects. Common side effects include soreness at the injection site,
mild fever, and irritability. These usually resolve within a day or two. Serious side
effects are extremely rare. If you notice anything unusual or are concerned, you
should always feel free to contact us."
3. Partner's Concerns Mother: "My husband is in the Navy and doesn't want our child
vaccinated. He's heard some things from his colleagues." Doctor: "I understand your
husband has concerns. It's natural to want to protect your child. Could you explain
to him what we've discussed today? We can provide leaflets with more information
about vaccine safety and effectiveness. I'd also be happy to discuss this with him if
he has specific concerns. It's important that both parents feel comfortable with the
decision."
4. Personal Experience Mother: "I haven't had any vaccines and I'm fine. Does my
child really need them?" Doctor: "I'm glad you're healthy. However, we strongly
advise vaccinating your child. These vaccines protect against serious infections,
some of which have no treatment. Also, if you were to contract one of these
infections, you could pass it to your child. Vaccination protects both your child and
those around them, including vulnerable individuals who can't be vaccinated. It's
about community protection as well as individual health."

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5. Autism Concerns Mother: "I've heard vaccines can cause autism. Is that true?"
Doctor: "I'm glad you brought this up. It's a common concern, but I want to
reassure you that there is no link between any vaccines and autism. This has been
extensively studied in large populations, and vaccines have been consistently shown
to be safe and not cause autism. The original study suggesting a link was thoroughly
discredited and retracted."
6. Multiple Vaccines at Once Mother: "Isn't it too much to give all these vaccines at
once?" Doctor: "This is a good question. It might seem like a lot, but a child's
immune system is remarkably capable. They encounter thousands of foreign
substances every day that they build immunity against. The amount in vaccines is
very small in comparison. Giving vaccines together reduces the number of
appointments needed and ensures protection starts as early as possible."
7. Mandatory vs. Recommended Doctor: "While these vaccines are not legally
mandatory, they are strongly recommended due to the severity of the diseases they
prevent. Some of these infections can have serious complications, and vaccines are
the best way to protect your child. We advise following the complete vaccination
schedule for optimal protection."

Closing the Consultation

Doctor: "Do you have any other questions or concerns about the vaccines that we haven't
discussed?"

Mother: [Wait for response and address any final questions]

Doctor: "Thank you for coming in to discuss this important topic. I hope I've been able to
provide you with the information you needed. Remember, if you have any more questions
before your appointment, please don't hesitate to contact us. We're here to support you in
making the best decisions for your child's health."

Important Notes for the Doctor

1. Always maintain a pro-vaccine stance in your approach.

2. Don't suggest that vaccines are optional or that it's fine to skip them.
3. Emphasize the importance and safety of vaccines consistently.
4. Be prepared to address common misconceptions calmly and with factual
information.
5. Offer additional resources (leaflets, websites) for more information.
6. Be willing to discuss concerns with other family members if needed.
7. Avoid using overly technical language; explain concepts in simple terms.
8. Don't rush the consultation; allow time for questions and ensure understanding.
9. Be empathetic to concerns while firmly advocating for vaccination.

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10. Remember that your goal is to provide clear, factual information to help the parent
make an informed decision about vaccination.

Pap Smear Consultation Scenarios

Overview of Scenarios

There are three main scenarios for pap smear consultations:

1. 25-year-old lesbian patient, angry about receiving a pap smear letter

2. 30-year-old non-lesbian patient who hasn't had a pap smear recently
3. 25-year-old transgender man (female to male) asking about pap smear necessity

Scenario 1: 25-year-old Lesbian Patient

Initial Approach

Doctor: "How may I help you today?"

Patient: "Doctor, I think they have sent me a wrong letter."

Doctor: "I see. Can you tell me a little bit more about this letter? Why do you think it's
wrong?"

Patient: "I've clearly told everyone in this practice that I'm a lesbian. Why did they send me
a letter for a pap smear? I don't need that!"

Addressing the Patient's Anger

1. Acknowledge and reassure: Doctor: "I can see that you're quite upset about this,
which is understandable. Let me explain everything to you, but first, I'd like to ask
you some questions to better understand your situation. Is that okay?"
2. Check prior knowledge: Doctor: "Before we discuss further, I'd like to understand
what you know about pap smears. Could you tell me:
o How much do you know about pap smears?
o Have you done any research about them?
o Do you know why we do pap smears and what conditions we're trying to
identify?
o Are you aware of the benefits of having a pap smear?
o Do you know who usually receives pap smears and at what age?"
3. Inquire about cervical cancer awareness: Doctor: "I'd also like to ask:
o Have you heard about cervical cancer?

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o Do you know what causes cervical cancer?

o Are you familiar with human papillomavirus (HPV)?
o Have you heard about any infections related to cervical cancer?"
4. Address concerns: Doctor: "Are you concerned about anything regarding the pap
smear? Are you worried about the procedure itself?"
5. Understand expectations: Doctor: "I understand you wanted to talk to a doctor
about this. Is there any particular way you're expecting us to help you regarding this
issue?"

Risk Factor Assessment

1. General health: Doctor: "Before we discuss further, I'd like to ask a few general
health questions:
o Do you have any ongoing medical problems?
o Are you taking any medications?
o Has anyone in your family been diagnosed with any serious medical
conditions or cancers?"
2. Sexual history (preface with apology for intrusive questions): Doctor: "I'm sorry, but
I need to ask you some questions about your sexual life. Some of these might be a
bit intrusive. If you're not comfortable, please let me know. Is it okay if I proceed?"
Patient: "Yes, go ahead." Doctor:
o "Are you currently sexually active?"
o "Do you have a current partner?" (Don't ask about gender)
o "Do you practice safe sex? Do you use any barrier methods?"
o "How long have you been in this relationship?"
o "Apart from your current partner, have you had any other partners?"
o "I'm sorry to ask this, but have you ever had any male partners in the past?"

If yes to male partners: "Did you practice safe sex with them?"

o "How long have you been sexually active overall?"

o "Have you ever been tested or treated for any sexually transmitted
infections?"

Explanation

Doctor: "Thank you for answering those questions. Now, let me explain everything about
pap smears:

1. A pap smear is a national screening program.

2. We screen for two things: a) Human papillomavirus (HPV) infection b) Early
changes in the cervix (neck of the womb)

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3. Cervical cancer is caused by HPV, which is sexually transmitted.

4. Cervical cancer grows slowly and is preventable if detected early.
5. The program is for anyone with a cervix, regardless of gender identity or sexual
orientation.
6. It's recommended for ages 25 to 65.
7. Anyone who has been sexually active once is advised to have pap smears.
8. The test is done every three years up to age 50.

The reason you received this letter is that when someone turns 25, the system automatically
generates a letter based on biological sex and age. It's not because someone checked your
individual details. This happens for everyone when they turn 25, regardless of their sexual
orientation or gender identity.

Based on the information you've shared; you do have some risk factors because you're
sexually active. Anyone who is sexually active, regardless of their sexuality, has some risk.
Your previous partners, including any male partners, also contribute to this risk.

I apologize that this wasn't explained to you earlier. However, it's in your best interest to
have the pap smear. Do you understand why it's necessary for you to have it? Do you want
me to explain anything further?"

Patient: "I think I understand now, but I'm still not sure about getting it done."

Doctor: "I understand your hesitation. Remember, pap smears are about cancer
prevention, not about sexual activity. They're important for all women, regardless of sexual
orientation. Is there anything specific that's making you uncertain?"

Patient: "I'm just not comfortable with the idea."

Doctor: "I see. Would it help if I explained the procedure in more detail? We can also
discuss ways to make it more comfortable for you. Your health is our priority, and we want
to ensure you're comfortable while also getting the necessary preventive care."

Scenario 2: 30-year-old Non-Lesbian Patient

Initial Approach

Doctor: "I understand you've come for a follow-up about your ankle injury. How are you
doing?"

Patient: "I'm doing fine."

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Doctor: "That's good to hear. We've noticed from your notes that you haven't had a pap
smear recently. Can I please ask why?"

Patient: "I've been very busy."

Consultation Approach

1. Check understanding: Doctor: "I understand being busy can make it difficult to
keep up with health screenings. Can I please ask what your understanding is about
pap smears?"
2. Risk factor assessment: (Follow the same risk factor assessment as in Scenario 1)
3. Explanation: (Provide the same explanation about pap smears as in Scenario 1)
4. Emphasize importance: Doctor: "Given your age and risk factors, it's important that
you have regular pap smears. They're a crucial part of preventive health care for
women. Can we schedule one for you soon? We can try to find a time that fits your
busy schedule."

Scenario 3: 25-year-old Transgender Man

Initial Approach

Doctor: "How may I help you today?"

Patient: "I made an appointment to ask about whether I need to go for vaccines."

Doctor: "I see. Before we discuss vaccines, can you tell me a bit about your medical history?
I understand you're a transgender man, is that correct?"

Patient: "Yes, that's right."

Consultation Approach

1. Clarify patient's situation: Doctor: "Thank you for sharing that. To ensure I give you
the most accurate information:
o Have you undergone any hormonal treatments?
o Have you had any surgical procedures related to your transition?
o Do you still have a cervix?"
2. Check understanding about pap smears: (Follow the same approach to check
understanding about pap smears as in Scenario 1)
3. Risk factor assessment: (Follow the same risk factor assessment as in Scenario 1,
being mindful of the patient's gender identity and using appropriate language)

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4. Explanation: (Provide the same explanation about pap smears as in Scenario 1, with
additional emphasis on the following) Doctor: "Pap smears are recommended for
anyone with a cervix, regardless of gender identity. As you still have a cervix, it's
important for you to have regular pap smears to screen for cervical cancer and HPV.
Your gender identity doesn't change your biological risk for cervical cancer."
5. Address specific concerns: Doctor: "I understand that as a transgender man, the
idea of a pap smear might be uncomfortable or cause gender dysphoria. Are there
any specific concerns you have about the procedure?" Patient: [Expresses concerns]
Doctor: "Thank you for sharing that. We can discuss ways to make the experience
more comfortable for you. This might include using gender-neutral language during
the procedure, having a trusted person present, or any other accommodations that
would help you feel more at ease. Your health and comfort are both important to
us."

Important Notes for All Scenarios

1. Always be respectful of the patient's identity and orientation. Use the patient's
preferred pronouns and terms.
2. Don't make assumptions about sexual practices based on orientation or identity.
3. Apologize when asking sensitive questions, but explain why they're necessary for
proper health care.
4. Focus on the medical necessity of pap smears, regardless of the patient's sexual
orientation or gender identity.
5. Be prepared to explain why the screening system generates letters automatically at
age 25.
6. Emphasize that pap smears are about cancer prevention, not about sexual activity or
gender identity.
7. Be patient and willing to repeat explanations if necessary.
8. Offer additional resources or information if the patient seems interested or
concerned.
9. Don't ask irrelevant questions about discharge or other unrelated symptoms.
10. Avoid examining the patient unless there's a specific medical reason to do so in
relation to the pap smear discussion.

Things to Avoid

1. Don't ask about male or female partners for lesbian patients; instead, ask about
"partners" in general.
2. Avoid using technical medical terms without explanation.
3. Don't dismiss or minimize the patient's concerns or anger.

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4. Avoid making the patient feel judged for their sexual history or lack of previous pap
smears.
5. Don't rush the patient or show impatience, even if they're taking time to understand
or express themselves.
6. Avoid suggesting that pap smears are optional or unnecessary for any group.
7. Don't forget to address the emotional aspects of the discussion, especially for
patients who may feel uncomfortable or anxious about the procedure.

Surgical Abortion Consultation

Scenario Overview

• Setting: F2 doctor in a GP practice

• Patient: 32-year-old woman
• Reason for appointment: Patient wants to know about surgical abortion

Consultation Approach

Opening

Doctor: "How may I help you today?"

Patient: "I want to know about surgical abortion."

Doctor: "Can I please ask you why you want to know about surgical abortion? Is there any
particular reason you want to discuss this?"

Patient: "I'm going to have an abortion."

Doctor: "I see. When are you planning to have it?"

Patient: "Next week."

Doctor: "And where are you going to have it?"

Patient: "At the abortion clinic."

Doctor: "I understand that you are going to have an abortion next week at the abortion
clinic, and you want to know more about it. Is that correct?"

Patient: "Yes, that's right."

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Box 1: Exploring Patient's Knowledge and Concerns

1. Prior Knowledge: Doctor: "How much do you know about abortion in general?"
Patient: [Waits for response] Doctor: "Have you done any reading about it?" Patient:
[Waits for response] Doctor: "What is your understanding of the procedure?"
Patient: [Waits for response]
2. Specific Interests: Doctor: "There are different aspects of abortion we can discuss,
such as:
o Preparation before the procedure
o Anesthesia and pain management
o The procedure itself
o Aftercare Which of these would you like to know more about?" Patient:
[Waits for response]
3. Concerns: Doctor: "Is there anything that worries you about this procedure?"
Patient: [Waits for response] Doctor: "Do you have any specific concerns you'd like
to address?" Patient: [Waits for response]

Box 2: Patient's Health and Circumstances

Divide this section into four parts:

2.1 OBG History:

Doctor: "I need to ask you some questions about your pregnancy and medical history. Is
that okay?" Patient: "Yes, that's fine."

Doctor: "How far along are you in this pregnancy?" Patient: "I'm eight weeks pregnant."

Doctor: "Have you done any pregnancy tests or had any scans?" Patient: [Waits for
response]

Doctor: "Do you have any children?" Patient: [Waits for response]

Doctor: "Have you been pregnant before?" Patient: [Waits for response]

Doctor: "Have you had any miscarriages?" Patient: [Waits for response]

Doctor: "Have you had any previous terminations?" Patient: [Waits for response]

Doctor: "Have you had any surgeries in your abdomen?" Patient: [Waits for response]

Doctor: "Have you ever tried to become pregnant before?" Patient: [Waits for response]

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Doctor: "Have you had any fertility testing?" Patient: [Waits for response]

2.2 Menstrual and Contraceptive History:

Doctor: "Can you tell me about your usual menstrual cycle?" Patient: [Waits for response]

Doctor: "What contraception do you usually use?" Patient: [Waits for response]

2.3 General Health (MAP-TOSA):

Doctor: "I'd like to ask you some general health questions now. Do you have any ongoing
medical conditions?" Patient: [Waits for response]

Doctor: "Do you have any allergies?" Patient: [Waits for response]

Doctor: "Are you currently taking any medications?" Patient: [Waits for response]

Doctor: "What is your occupation?" Patient: [Waits for response]

Doctor: "How would you describe your social support system?" Patient: [Waits for response]

Doctor: "Have you been experiencing any anxiety or depression?" Patient: [Waits for
response]

2.4 Reasons and Support:

Doctor: "Can I please ask what is the reason you plan to have an abortion?" Patient: [Waits
for response]

Doctor: "Do you have any other stresses in your life?" Patient: [Waits for response]

Doctor: "Are there any financial constraints you're concerned about?" Patient: [Waits for
response]

Doctor: "How long have you been with your partner?" Patient: [Waits for response]

Doctor: "Is your partner generally supportive?" Patient: [Waits for response]

Doctor: "How is your family? Are they generally supportive?" Patient: [Waits for response]

Doctor: "Have you discussed this with anyone else?" Patient: [Waits for response]

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Doctor: "Do you smoke, drink alcohol, or use any recreational drugs?" Patient: [Waits for
response]

Note: Do not perform a physical examination at this stage.

Box 3: Explanation of Surgical Abortion

Doctor: "Thank you for answering those questions. Now, let me explain to you about the
surgical abortion procedure. I'll cover the preparation, anesthesia, the procedure itself, and
aftercare. Please feel free to stop me at any point if you have questions."

1. Preparation: "As you are less than 10 weeks pregnant, you don't need much
preparation. You can go to the clinic and be discharged on the same day. You don't
need to fast. The only preparation is medication to soften your womb and cervix.
There are two options: a) Misoprostol: This is given on the same day, one hour
before the procedure. It's placed under the tongue. b) Mifepristone: This is taken 24
hours before the procedure. The clinic will advise which option they prefer to use."
2. Anesthesia and Pain Management: "For pregnancies less than 10 weeks, local
anesthesia is typically used. This means you'll be awake during the procedure. The
process involves:
1. Applying a numbing gel around your cervix
2. Injecting a local anesthetic into the cervix
3. They can also offer additional pain relief if needed

You might feel some discomfort, but it shouldn't be severely painful."

3. Procedure: "The main procedure is called manual vacuum aspiration. Here's what
happens:
1. A small vacuum tube is inserted through the cervix
2. The tissue is removed by suction
3. This usually takes about 10-15 minutes

If this isn't successful, they might perform a procedure called dilatation and curettage
(D&C). This involves:

4. Dilating the cervix with rods

5. Using an instrument called a curette to remove the tissue
6. This might take another 10-15 minutes

It's important to note that we always refer to what's removed as 'tissue', not 'baby'."

4. Aftercare: "After the procedure:

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1. You'll be asked to stay at the clinic for about four hours for observation
2. Then you can go home
3. You should rest for 24 hours after returning home
4. After that, you can resume normal activities as you feel comfortable

Some important points to remember:

o If you become sexually active, you'll need to use contraception immediately

after the procedure
o You may experience some bleeding, similar to a period, which can last up to
two weeks
o Emotionally, most women feel relieved after the procedure, but some might
experience sadness or guilt. This is normal and to be expected
o We'll give you information on how to monitor for signs of infection and
manage bleeding

Do you have any questions about what I've explained so far?"

Box 4: Addressing Specific Concerns

Doctor: "Patients often have some specific questions. Let me address a couple of common
ones:"

Patient: "Will this cause any problems for future pregnancies?"

Doctor: "If your treatment is not complicated, it shouldn't cause any problems with future
pregnancies. The vast majority of women who have had a surgical abortion go on to have
normal pregnancies when they choose to."

Patient: "Will I be supported?"

Doctor: "Yes, you'll be supported for both your medical and psychological needs. This
includes:

1. Medical support: We'll advise you on how to manage any medical issues like
infections or bleeding. You'll have follow-up care to ensure your physical recovery.
2. Psychological support: We offer post-abortion counseling through a special clinic
called NUPAS (National Unplanned Pregnancy Advisory Service). They can provide
emotional support and help you process any feelings you might have after the
procedure.

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Remember, it's normal to have a range of emotions after an abortion, and support is
available if you need it."

Important Notes

1. Always use sensitive and neutral language throughout the consultation.

2. Consistently refer to "tissue" rather than "baby" when discussing the procedure.
3. Don't ask why the patient wants an abortion until later in the consultation (2.4).
4. Be prepared to provide information on all aspects of the procedure: preparation,
anesthesia, the procedure itself, and aftercare.
5. Offer information on both emotional and physical aftercare.
6. Be ready to address concerns about future fertility.
7. Provide information on post-abortion support services.
8. Remember to check the patient's understanding at regular intervals.
9. Be prepared to repeat information if necessary.
10. Maintain a non-judgmental and supportive demeanor throughout the consultation.

Things to Avoid

1. Don't judge the patient's decision or reasons for seeking an abortion.

2. Avoid using emotive language when describing the procedure.
3. Don't perform a physical examination unless specifically indicated.
4. Avoid making assumptions about the patient's feelings or circumstances.
5. Don't rush through the explanation – ensure the patient understands each part.
6. Avoid minimizing potential emotional responses post-procedure.
7. Don't forget to address the patient's specific concerns.
8. Avoid medical jargon without explanation.
9. Don't neglect to offer information about contraception post-procedure.
10. Avoid pushing the patient to discuss the procedure with others if they're not
comfortable doing so.

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Dermatology
I. Introduction to Dermatological Diagnosis

The key to dermatological diagnosis is specificity. Always provide a specific diagnosis name.
Avoid vague terms or scenarios:

• Don't use terms like "melanotic" or "non-melanotic" without further specification

• Avoid using "worst-case scenario" or "best-case scenario" approaches
• Don't create multiple scenarios; focus on the most likely diagnosis

Remember: If you don't provide a specific name for the condition, you're losing valuable
diagnostic information. The name is crucial - if the name is wrong, everything that follows
will be wrong.

II. Initial Patient Presentation

Patients typically present with one of two main complaints:

1. A lump on the skin

2. A rash

Initial patient statement examples:

• "I've noticed a lump on my skin."

• "I've developed a rash."

III. Consultation Structure

Unlike other medical scenarios where you might start with duration ("How long have you
had these symptoms?"), dermatology consultations follow a specific structure:

1. Morphology
2. Evolution
3. Symptoms

This structure is crucial for accurate diagnosis.

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IV. Detailed Consultation Process

1. Morphology

a. Location

• Question: "Where on your body is the [lump/rash]?"

• Importance: Different lesions appear in different locations. Knowing the common
places for each condition is crucial.
• Possible patient responses:
o "It's on my arm."
o "I noticed it on my back."
o "It's on my face, near my nose."

b. Lesion Description

Ask specific questions about the appearance of the lesion:

• Type:
o Question: "Is it a raised lump, or is it flat against your skin?"
o Possible responses:
§ "It's raised above my skin."
§ "It's flat and doesn't stick out."
• Size:
o Question: "How big is it? Can you compare it to something, like a coin?"
o Possible responses:
§ "It's about the size of a dime."
§ "It's larger than a quarter."
• Color:
o Question: "What color is the [lump/rash]?"
o Possible responses:
§ "It's red."
§ "It's the same color as my skin."
§ "It's pink with some darker spots."
• Pigmentation:
o Question: "Is there any brown or black coloration within or around the
[lump/rash]?"
o Possible responses:
§ "Yes, there are some darker brown spots within it."
§ "No, it's all one color."
• Shape:
o Question: "What shape is it? Is it round, or does it have an irregular shape?"

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o Possible responses:
§ "It's perfectly round."
§ "It has jagged edges and isn't a regular shape."
• Appearance:
o Question: "Are there any scales or flakes on or around the [lump/rash]?"
o Possible responses:
§ "Yes, it seems to be flaking."
§ "No, the surface is smooth."

2. Evolution

• Duration:
o Question: "How long have you had this [lump/rash]?"
o Possible responses:
§ "I first noticed it about two months ago."
§ "It appeared suddenly last week."
• First Notice:
o Question: "How did you first notice it?"
o Possible responses:
§ "I felt an itch and when I scratched, I noticed the lump."
§ "I saw it while I was getting dressed."
• Changes:
o Question: "Has it changed since you first noticed it? This could be in size,
shape, or color."
o Possible responses:
§ "It seems to be getting larger."
§ "The color has gotten darker."
§ "It started as a small dot but has spread out."

3. Symptoms

Ask about all possible symptoms:

• Pain:
o Question: "Is there any pain associated with the [lump/rash]?"
o Possible responses:
§ "Yes, it's painful to touch."
§ "No pain, but it feels uncomfortable."
• Itching:
o Question: "Does it itch?"
o Possible responses:
§ "Yes, it's very itchy, especially at night."

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§ "It itches occasionally, but not constantly."

• Tingling:
o Question: "Do you feel any tingling or unusual sensations in the area?"
o Possible responses:
§ "Sometimes it feels like pins and needles."
§ "No unusual sensations."
• Bleeding:
o Question: "Has there been any bleeding from the [lump/rash]?"
o Possible responses:
§ "Yes, it bleeds if I scratch it."
§ "No bleeding at all."
• Blisters:
o Question: "Have you noticed any blisters forming?"
o Possible responses:
§ "Yes, small blisters keep appearing and then popping."
§ "No blisters, just the rash."
• Pus or fluid:
o Question: "Is there any pus or fluid coming from the [lump/rash]?"
o Possible responses:
§ "Yes, sometimes it oozes a clear fluid."
§ "No, it's always dry."
• Ulcers:
o Question: "Have you noticed any open sores or ulcers in the area?"
o Possible responses:
§ "Yes, there's a small open sore in the center."
§ "No open sores, just the raised area."
• Scars:
o Question: "Has it left any scars or marks on your skin?"
o Possible responses:
§ "The older areas seem to be leaving dark marks as they heal."
§ "No, the skin looks normal where it's healed."

V. Additional Assessment

1. Surrounding Area

• Question: "How does the skin around the [lump/rash] look? Is there any swelling or
other lumps?"
• Possible responses:
o "The skin around it looks red and puffy."
o "There are smaller bumps surrounding the main one."

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2. Other Body Parts

• Question: "Have you noticed similar [lumps/rashes] on other parts of your body?"
• Possible responses:
o "Yes, I have a similar one on my leg."
o "No, this is the only one."
• Question: "Have you ever had something like this before?"
• Possible responses:
o "I had something similar last year, but it went away on its own."
o "This is the first time I've experienced anything like this."

3. Risk Factors

For Rashes:

• Question: "Has anyone close to you, like family members or coworkers, had a
similar rash?"
• Possible responses:
o "My child had a rash last week, but it looked different."
o "No one I know has had anything similar."

Sun Exposure (crucial for all skin lesions):

• Question: "How much time do you typically spend in the sun? Do you do any
outdoor activities or use tanning beds?"
• Possible responses:
o "I work outdoors as a landscaper, so I'm in the sun most of the day."
o "I use a tanning bed twice a week."
o "I try to avoid the sun and always wear sunscreen."

4. Cancer-related Symptoms (if applicable)

• Question: "Have you experienced any unexplained weight loss recently?"

• Question: "Have you been feeling more tired than usual?"
• Question: "Have you had any unexplained pain elsewhere in your body?"

5. MAFTOSA Assessment

Medical History:

• Focus on immunosuppression
• Question: "Do you have any medical conditions that affect your immune system?"

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• Possible responses:
o "I have HIV."
o "I had a kidney transplant and take immunosuppressants."

Allergies:

• Question: "Do you have any known allergies, especially to medications or substances
that come in contact with your skin?"

Prescription Medications:

• Question: "Are you currently taking any medications? Specifically, are you on any
medications for arthritis or other autoimmune conditions?"
• Possible responses:
o "I take methotrexate for my rheumatoid arthritis."
o "I'm on prednisone for my asthma."

Travel History:

• Question: "Have you traveled anywhere recently, especially to tropical or foreign

countries?"

Occupation:

• Question: "What kind of work do you do? Does it involve being outdoors or
working with animals?"
• Possible responses:
o "I'm a gardener, so I work outside most days."
o "I work on a farm and handle animals regularly."
o "I'm a professional runner, so I sweat a lot during training."

Social History:

• Question: "Do you have any hobbies or activities that involve sun exposure or skin
contact with various substances?"

Anxieties/Concerns:

• Question: "What are your main concerns about this [lump/rash]?"

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6. Family History

• Question: "Does anyone in your family have a history of skin conditions or skin
cancer, particularly melanoma?"

VI. Physical Examination

1. Observe the lesion carefully.

2. Describe your observations to the patient in simple terms:

Example dialogue: "I've had a close look at the area you've shown me. What I can see is
[insert detailed description]. The lump appears to be [color] and is roughly [size]. Its shape
is [regular/irregular]. I notice [additional details like redness, scaling, etc.]. The
surrounding skin shows [description of surrounding area]."

VII. Diagnosis

Always provide a specific diagnosis based on the gathered information. Avoid vague terms
or creating multiple scenarios. Focus on the most likely diagnosis given the patient's
presentation and your examination.

VIII. Communication Tips

• Be specific and detailed in your questioning.

• Explain your observations to the patient in simple, non-technical language.
• Don't hesitate to describe what you see, even if you're unsure of the diagnosis.
• Ensure the patient understands your explanation and diagnosis.

IX. Things to Avoid

• Don't say "hmm" and move on after examining the lesion. Always provide a
description.
• Avoid using highly technical terms like "macular papular rash" when explaining to
the patient.
• Don't give vague or generalized diagnoses.
• Avoid creating multiple scenarios or using "best case/worst case" language.

X. Key Points to Remember

• The name (diagnosis) is crucial - if the name is wrong, everything is wrong.

• Dermatology consultations are typically straightforward if you ask the right
questions in the right order.

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• Always consider sun exposure as a factor, especially for patients who actively seek
sun exposure.
• Be thorough in your examination and explanation to the patient.
• Follow the structure: Morphology, Evolution, Symptoms.
• Don't be afraid to describe what you see, even if you're not sure of the diagnosis.
• Always provide a specific diagnosis, not a range of possibilities.

Moles and Basal Cell Carcinoma

I. Mole (Benign Nevus)

Typical Presentation

• Patient age: Young adult (e.g., 25-28 years old)

• Setting: General Practice (GP) clinic
• Reason for visit: Cosmetic concerns, often related to upcoming events (e.g.,
wedding)

Detailed Patient Scenario

Patient: "I've made an appointment because I want to get this mole removed. I'm getting
married soon, and I don't want it to be visible in my wedding dress."

Doctor: "Congratulations on your upcoming wedding. Can you tell me more about this
mole?"

Patient: "It's on my shoulder, and I'm worried people will see it when I'm wearing my
dress."

Doctor: "I understand your concern. Let's go through some questions to get a better
understanding of the situation."

Comprehensive History Taking

1. Location: Doctor: "Where exactly on your shoulder is the mole?" Patient: "It's on the
top of my right shoulder."
2. Duration: Doctor: "How long have you had this mole?" Patient: "It's been there for
many years, as long as I can remember."
3. Reason for current visit: Doctor: "Why have you decided to have it checked now?"
Patient: "As I mentioned, I'm getting married soon. I'll be wearing a strapless dress,
and I don't want the mole to be visible in the photos or to my guests."

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4. Evolution: Doctor: "Has there been any change in the mole recently? This could be
in color, size, or shape." Patient: "No, it's stayed the same as far as I can tell."
5. Symptoms: Doctor: "Does the mole cause any discomfort, itching, or pain?" Patient:
"No, I don't feel anything from it. It's just there."
6. Impact on daily life: Doctor: "Apart from your concerns about the wedding, does
the mole affect your daily life in any way?" Patient: "Not really, I usually forget it's
there. It's just the wedding that's made me think about it."

Physical Examination

Doctor: "I'd like to have a look at the mole now, if that's okay with you."

Patient: "Of course."

Doctor: "Thank you. What I can see is a slightly raised, pigmented lesion on your shoulder.
It's roughly [size], [color], and [shape]. The borders appear regular, and the color is
consistent throughout."

Diagnosis and Explanation

Doctor: "Based on what you've told me and my examination, this appears to be a benign
mole, also known as a nevus. A mole is a pigmented, abnormal growth of the skin, but it's
not harmful or cancerous."

Patient: "That's a relief. So, can it be removed?"

Treatment Options Discussion

Doctor: "There are several options for mole removal, but I need to explain a few important
points first."

1. Surgical curettage: Doctor: "One option is to cut it off surgically. This is usually very
effective but will leave a scar."
2. Freezing therapy: Doctor: "We can use liquid nitrogen to freeze the mole. This
might require several visits and will also leave a small scar."
3. Topical treatment: Doctor: "There are creams, like salicylic acid, that can be applied.
These are less invasive but take longer and may not be as effective."
4. Laser treatment: Doctor: "Laser removal is another option. It usually leaves minimal
scarring but may require multiple sessions."

Patient: "Will I have a noticeable scar? I'm worried about exchanging one visible mark for
another."

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Doctor: "That's a valid concern. All these methods may leave some form of scar. Surgical
removal typically leaves the largest scar, while laser treatment usually leaves the least
noticeable mark. However, everyone's skin reacts differently."

NHS Coverage and Private Treatment

Doctor: "It's important for you to know that mole removal for cosmetic reasons is not
typically covered by the NHS. It's considered a private procedure, similar to most dental
work."

Patient: "Oh, I didn't realize that. So, I'd have to pay for it myself?"

Doctor: "Yes, that's correct. The NHS only covers mole removal if it's medically necessary.
For example, if it was causing repeated pain or significant disturbance to your daily life."

Patient: "I see. What would qualify as significant disturbance?"

Doctor: "It would need to be more than occasional discomfort. For instance, if it caused
pain every day when you put on clothing, or if it repeatedly bled or got infected. Wanting it
removed for a special occasion, while understandable, doesn't meet the criteria for NHS
treatment."

Concluding the Consultation

Doctor: "Given that this mole isn't causing any medical issues, my recommendation would
be to leave it as is. However, if you decide you want it removed for your wedding, I can
provide you with information on private dermatology clinics."

Patient: "Thank you, doctor. I'll think about it and maybe look into the private options."

Doctor: "That sounds like a good plan. Remember, if you ever notice any changes in the
mole - like changes in size, shape, or color - please come back to have it checked."

Basal Cell Carcinoma (BCC)

General Information

• Location determines referral urgency:

1. Back of head: Routine referral
2. Nose or face: Two-week cancer pathway
3. Forehead/hairline: Two-week cancer pathway
• Key point: Any lesion above the neck that is not pigmented is likely to be BCC

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Scenario 1: BCC on Back of Head

Typical Presentation

Patient: "My wife noticed this growth on the back of my head. Sometimes it bleeds when I
brush my hair, so she insisted I get it checked."

Doctor: "I'm glad you've come in. Let's go through some questions to understand more
about this growth."

Comprehensive History Taking

1. Duration and evolution: Doctor: "How long have you had this growth on your
head?" Patient: "I'm not sure exactly. My wife noticed it a few months ago, but it
could have been there longer." Doctor: "Have you noticed any changes in its size or
appearance since you first became aware of it?" Patient: "It seems to be slowly getting
bigger, I think."
2. Symptoms: Doctor: "You mentioned it bleeds sometimes. How often does this
happen?" Patient: "Maybe once or twice a week when I'm brushing my hair." Doctor:
"Is there any pain or discomfort associated with it?" Patient: "No pain really, just the
occasional bleeding."
3. Risk factors: Doctor: "Have you spent a lot of time in the sun over the years?
Perhaps for work or leisure?" Patient: "Actually, yes. I worked in Dubai for about 10
years. I was often outdoors in the sun."
4. Previous treatments: Doctor: "Have you ever had any treatments for skin growths
before?" Patient: "Now that you mention it, I had something frozen off my forehead
last year. The doctor called it a... what was it... basal cell something?"

Physical Examination

Doctor: "I'd like to examine the growth now if that's alright."

Patient: "Of course, go ahead."

Doctor: "Thank you. What I can see is a raised, pearly growth on the back of your head. It
has a slightly shiny appearance and there's a small area that looks like it might bleed easily."

Diagnosis Delivery

Doctor: "Based on what you've told me and my examination, I believe this growth is what
we call a basal cell carcinoma."

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Patient: "Carcinoma? Does that mean it's cancer?"

Doctor: "Yes, basal cell carcinoma is a type of skin cancer. However, I want to reassure you
that it's a very treatable form of skin cancer. It grows slowly and very rarely spreads to other
parts of the body."

Patient: "Oh, I see. Is it because of my time in Dubai?"

Doctor: "Sun exposure is indeed a major risk factor for this type of skin cancer, so your
time working outdoors in Dubai likely contributed to its development."

Management Plan

Doctor: "I'm going to refer you to a dermatologist for treatment. Given the location of the
growth, this will be a routine referral rather than an urgent one."

Patient: "What will the treatment involve?"

Doctor: "The dermatologist will likely recommend either surgical removal of the growth or
freezing therapy, similar to what you had on your forehead. They'll do a biopsy to confirm
the diagnosis and then proceed with treatment."

Patient: "Will I need to take time off work?"

Doctor: "The procedure is usually done as an outpatient, so you shouldn't need much time
off. However, you might want to take a day or two to recover, especially if they opt for
surgical removal."

Scenario 2: BCC on Nose

Typical Presentation

Patient: "I've got this growth on my nose. It's making it uncomfortable to wear my glasses."

Doctor: "I'm sorry to hear that. Let's take a closer look and get some more information."

Comprehensive History Taking

(Similar questions to Scenario 1, adapted for nose location)

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Physical Examination

Doctor: "The growth on your nose appears raised and has a pearly, translucent quality.
There's also some visible blood vessels within it."

Diagnosis and Management

Doctor: "This growth appears to be a basal cell carcinoma, a type of skin cancer. Due to its
location on your face, I'm going to refer you urgently to a dermatologist. This will be
through what we call a two-week cancer pathway."

Patient: "Cancer? That sounds scary."

Doctor: "I understand your concern, but I want to reassure you. Basal cell carcinomas,
while they are a type of skin cancer, are very treatable and rarely spread beyond the original
site. The urgent referral is because of the location, not because it's a particularly aggressive
cancer."

Scenario 3: BCC on Forehead/Hairline

Typical Presentation

Patient: "I've noticed this growth on my forehead, right at my hairline. It wasn't there two
weeks ago."

Doctor: "Thank you for coming in promptly. Let's get some more details about this
growth."

Comprehensive History Taking

(Similar questions to previous scenarios, emphasizing recent appearance)

Diagnosis and Management

Doctor: "Based on its appearance and location, this is likely a basal cell carcinoma. Given
that it's on your face and has appeared recently, I'm going to refer you urgently to a
dermatologist through our two-week cancer pathway."

Important Points for BCC

• Any lesion above the neck and not pigmented is likely BCC
• Lesions on the face typically follow the two-week cancer pathway

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• Reassure patients:
o BCCs are treatable
o They don't typically spread or cause severe complications
• Physical appearance: Often presented as a shiny, pearly growth

III. General Guidelines for Skin Lesion Diagnosis

1. Location-based preliminary diagnosis:

o Above neck, not pigmented: Likely BCC
o Below neck, not pigmented: Likely squamous cell carcinoma
o Anywhere, pigmented: Likely a mole
2. Evolution is key for pigmented lesions:
o Any change in size, color, or shape of a mole: Suspect melanoma
3. Visual diagnosis in clinical settings:
o Images or lesions may appear blurry or unclear
o Rely more on the history than the visual appearance
o With proper history-taking, diagnosis can often be made before visual
examination
4. Patient reactions:
o Overreaction often indicates less severe conditions
o Underreaction may indicate more serious conditions
o Note: This is a general trend, not an absolute rule
5. Communication tips:
o Be clear and direct when delivering diagnoses
o Provide reassurance, especially for BCC:
§ Emphasize treatability
§ Explain low risk of spread or complications

Remember: In dermatology, what you hear (the history) is often more important than what
you see (the physical appearance of the lesion). Always take a thorough history and use it as
your primary diagnostic tool.

Things to Avoid

1. Don't use vague terms like "melanotic" or "non-melanotic"

2. Avoid creating "worst-case" or "best-case" scenarios
3. Don't say "hmm" and move on after examining a lesion without explanation
4. Avoid using highly technical terms when explaining to patients
5. Don't give vague or generalized diagnoses

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Squamous Cell Carcinoma (SCC)

Typical Presentation

• Patient: Female, around 60 years old

• Location: Forearm
• Duration: About 2-3 months, or "about a month"
• Patient's initial thought: Often mistaken for an abscess or infection

Comprehensive History Taking

1. Location: Doctor: "Where exactly is the lesion located?" Patient: "It's on my

forearm."
2. Duration: Doctor: "How long has this lesion been present?" Patient: "I first noticed
it about 2-3 months ago."
3. Evolution: Doctor: "Have you noticed any changes in the lesion since it first
appeared?" Patient: "It seems to be slowly getting larger."
4. Symptoms: Doctor: "Does the lesion cause any pain, itching, or other discomfort?"
Patient: "It's a bit tender to touch, but otherwise doesn't bother me much."
5. Medical History: Doctor: "Do you have any ongoing medical conditions?" Patient:
"Yes, I have rheumatoid arthritis." Doctor: "Are you taking any medications for
that?" Patient: "Yes, I'm on methotrexate."
6. Sun Exposure: Doctor: "Have you had much sun exposure over the years, either for
work or leisure?" Patient: "I do enjoy gardening, so I suppose I've had quite a bit of
sun exposure."

Physical Examination

Doctor: "I'm going to examine the lesion now. It appears to have a slightly shiny
appearance, which can sometimes be confusing. However, the location on the forearm is a
key factor in determining the diagnosis."

Diagnosis Delivery

Doctor: "Based on the examination and the information you've provided, this could be a
condition called squamous cell carcinoma. I want to emphasize that this is a suspicion at
this point, not a definitive diagnosis."

Patient: "Carcinoma? Does that mean cancer?"

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Doctor: "Yes, squamous cell carcinoma is a type of skin cancer. However, it's important to
note that it's generally very treatable, especially when caught early. We'll need to refer you
to a specialist for a definitive diagnosis and treatment plan."

Management Plan

Doctor: "I'm going to refer you to a dermatologist through what we call a cancer pathway.
This ensures you'll be seen quickly, usually within two weeks."

Patient: "What will happen at the dermatologist?"

Doctor: "The dermatologist will likely perform a biopsy to confirm the diagnosis. If it is
squamous cell carcinoma, the usual treatment is to surgically remove the lesion. In some
cases, they might recommend additional treatments like chemotherapy or radiotherapy. It's
also worth noting that while most of these cancers are treated successfully, about 5% can
spread to other parts of the body, which is why prompt treatment is important."

Key Points for SCC

• Location below the neck (e.g., forearm) is typical for SCC

• Can be confused with basal cell carcinoma due to shiny appearance
• Always use cautious language: "This could be..." or "This is possibly..."
• Refer via cancer pathway to dermatology
• Treatment typically involves surgical removal and biopsy
• Inform patient about potential for spread (about 5% of cases)
• Methotrexate use for rheumatoid arthritis is a significant detail to note

Melanoma
Scenario 1: Melanoma on Shoulder

Typical Presentation

• Patient: Usually older, around 60 years old

• Location: Shoulder
• Duration: Present for many years (e.g., 7-8 years)
• Recent changes: Itching, bleeding on touch, growing

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Comprehensive History Taking

1. Location and Duration: Doctor: "Where is the lesion located and how long has it
been there?" Patient: "It's on my shoulder and it's been there for many years, at least
7 or 8."
2. Recent Changes: Doctor: "Have you noticed any recent changes in the lesion?"
Patient: "Yes, it's become itchy and it bleeds when I touch it. I think it might be
getting bigger too."
3. Sun Exposure: Doctor: "Can you tell me about your sun exposure over the years?"
Patient: "My husband and I are gardeners, so we spend a lot of time outdoors."
Doctor: "Do you use sunscreen or wear protective clothing when you're working
outside?" Patient: [Note patient's response]
4. Other Symptoms: Doctor: "Apart from the itching and bleeding, have you noticed
any other symptoms?" Patient: [Note any additional symptoms]
5. Personal and Family History: Doctor: "Do you or any close family members have a
history of skin cancer or other skin conditions?" Patient: [Note the response]

Physical Examination

Doctor: "I'm going to examine the lesion now. What I can see is an irregular lesion with
different colors within it - there are areas of black, brown, and pink. This variation in color
and irregular shape are important features."

Diagnosis Delivery

Doctor: "Based on what I've seen and what you've told me, this could be a condition called
melanoma. Melanoma is a type of skin cancer."

Patient: "That sounds serious. What does this mean?"

Doctor: "Melanoma is indeed a serious form of skin cancer, but when caught early, it can
often be treated successfully. The changes you've noticed and promptly reported are very
important."

Management Plan

Doctor: "I'm going to refer you urgently to a dermatologist through our two-week cancer
pathway. They will likely perform a biopsy to confirm the diagnosis."

Patient: "What happens after that?"

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Doctor: "If it is confirmed as melanoma, the main treatment is usually surgery to remove
the lesion. They might also do something called a sentinel lymph node biopsy, where they
check the nearest lymph gland. Depending on the results, further treatments like
chemotherapy, radiotherapy, or newer treatments like immunotherapy might be
recommended."

Scenario 2: Melanoma Behind the Ear

Typical Presentation

• Patient: Male
• Location: Behind the ear
• Duration: Recently noticed (e.g., wife noticed it two weeks ago)
• Recent changes: Growing, changing

Comprehensive History Taking

1. Location and Duration: Doctor: "Where exactly is the lesion and when did you first
notice it?" Patient: "It's behind my ear. Actually, my wife noticed it about two weeks
ago."
2. Recent Changes: Doctor: "Have you or your wife noticed any changes in the lesion
since it was first spotted?" Patient: "Yes, my wife says it seems to be growing and
changing."
3. Sun Exposure: Doctor: "Can you tell me about your sun exposure? Do you work
outdoors or spend a lot of time in the sun?" Patient: "I'm a gardener, so I'm outside
quite a bit. We also like to travel to Spain for holidays."
4. Symptoms: Doctor: "Does the lesion cause any discomfort or other symptoms?"
Patient: [Note any symptoms]
5. Personal and Family History: Doctor: "Do you or any close family members have a
history of skin cancer or other skin conditions?" Patient: [Note the response]

Physical Examination

Doctor: "I'm going to examine the lesion closely now. Even though it might not be very
clear to see, I can observe different shades within the lesion - there's a dark spot, some
brown areas, and lighter brown parts. This variation is an important feature."

Diagnosis Delivery and Management

[Similar to Scenario 1]

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Key Points for Melanoma

• Any pigmented lesion showing evolution (change in size, color, or shape) should
raise suspicion of melanoma
• Typical appearance: Irregular shape, multiple colors within the lesion
• Always refer via two-week cancer pathway
• Treatment typically involves surgery, possibly sentinel lymph node biopsy, and may
include chemotherapy, radiotherapy, or newer treatments like immunotherapy
• Thorough history-taking is crucial - don't miss asking about recent changes
• The "two weeks" mention in history shouldn't be confused with the referral pathway
• Occupation (e.g., gardener) and travel habits are important for assessing sun
exposure risk

Seborrheic Keratosis
Typical Presentation

• Patient: Female, around 60 years old

• Location: On the breast
• Duration: Variable, may report recent slow growth
• Family history: May have family history of skin cancer (e.g., melanoma in both
parents)

Comprehensive History Taking

1. Location and Duration: Doctor: "Where is the lesion located and how long have
you had it?" Patient: "It's on my breast. I'm not sure how long it's been there, but I've
noticed it seems to be slowly growing recently."
2. Family History: Doctor: "Do you have any family history of skin conditions or skin
cancers?" Patient: "Yes, both my mother and father had melanoma."
3. Sun Exposure: Doctor: "Can you tell me about your sun exposure over the years?"
Patient: [Note patient's response]
4. Symptoms: Doctor: "Does the lesion cause any discomfort or other symptoms?"
Patient: [Note any symptoms]
5. Personal Medical History: Doctor: "Do you have any other medical conditions or
take any medications regularly?" Patient: [Note the response]

Physical Examination

Doctor: "I'm going to examine the lesion now. What I can see is a growth that has what we
call a 'stuck-on' appearance. It looks a bit like a wart, but it's not actually a wart."

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Diagnosis Delivery

Doctor: "Based on my examination, this appears to be a condition called seborrheic

keratosis. This is a benign growth, which means it's not harmful or cancerous."

Patient: "That's a relief. Do I need to have it removed?"

Doctor: "Seborrheic keratosis doesn't usually require treatment as it doesn't cause harm.
However, given your family history of melanoma, I think it would be best to have you seen
by a dermatologist."

Management Plan

Doctor: "I'm going to refer you to a dermatologist on an urgent basis, but not through the
cancer pathway. This is mainly because of your family history of melanoma, not because I
think this growth is cancerous."

Patient: "What will happen at the dermatologist?"

Doctor: "The dermatologist will likely do a few things:

1. They'll examine this growth more closely, possibly using a special tool called a
dermascope.
2. They might take a small sample (biopsy) of the growth to confirm the diagnosis.
3. Given your family history, they'll probably want to do a full body skin check to look
for any potentially concerning lesions.
4. They might take photos of your skin to keep for future comparison.
5. They may decide to remove this growth, especially if it's bothering you."

Patient: "Why do I need to be checked if you don't think it's cancer?"

Doctor: "While this particular growth doesn't appear cancerous, your family history puts
you at higher risk for skin cancers like melanoma. The dermatologist visit is an opportunity
for a thorough skin check and to establish baseline documentation of your skin. This can
help catch any potential issues early in the future."

Key Points for Seborrheic Keratosis

• Benign growth, often described as having a "stuck-on" appearance

• Usually doesn't require treatment
• Family history of skin cancer may warrant referral and full skin check
• Dermatologists may use a dermascope for examination

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• May be removed if bothersome or for cosmetic reasons

• Urgent referral (but not cancer pathway) is appropriate given family history

Seborrheic Keratosis - Male Patient

Typical Presentation

• Patient: Male, around 60-70 years old

• Location: On the back
• Duration: Growing slowly over the last 7 years
• Family history: No relevant family history

Comprehensive History Taking

1. Location and Duration: Doctor: "Where is the lesion located and how long have
you had it?" Patient: "It's on my back. I've noticed it growing slowly for about 7 years
now."
2. Family History: Doctor: "Do you have any family history of skin conditions or skin
cancers?" Patient: "No, not that I'm aware of."
3. Changes and Symptoms: Doctor: "Have you noticed any changes in the lesion other
than slow growth?" Patient: "Not really, it's just been getting bigger very gradually."
Doctor: "Does the lesion cause any discomfort or other symptoms?" Patient: "No, I
don't have any symptoms from it."
4. Sun Exposure: Doctor: "Can you tell me about your sun exposure over the years?"
Patient: [Note patient's response]
5. Personal Medical History: Doctor: "Do you have any other medical conditions or
take any medications regularly?" Patient: [Note the response]

Physical Examination

Doctor: "I'm going to examine the lesion now. What I can see is a growth that has what we
call a 'stuck-on' appearance. It looks a bit like a wart, but it's not actually a wart."

Diagnosis Delivery

Doctor: "Based on my examination and the information you've provided; this appears to be
a condition called seborrheic keratosis. This is a benign growth, which means it's not
harmful or cancerous."

Patient: "That's good to hear. Do I need to have it removed?"

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Doctor: "Seborrheic keratosis doesn't usually require treatment as it doesn't cause any
harm. It's a very common condition, especially as we get older."

Management Plan

Patient: "I understand it's not harmful, but I'd like to have it removed for cosmetic reasons.
Is that possible?"

Doctor: "I understand your concern about the appearance. However, removal for cosmetic
reasons is not typically covered by the NHS. If you wish to have it removed for cosmetic
purposes, I would advise you to consider having this done privately."

Patient: "I see. How would I go about doing that?"

Doctor: "I can provide you with information about local private dermatology clinics that
offer this service. They would be able to give you more details about the procedure and
associated costs."

Follow-up Instructions

Doctor: "While this growth doesn't need treatment, it's important to keep an eye on it. If
you notice any significant changes in its appearance - particularly changes in shape, size, or
color - please come back to have it checked. These changes could indicate that we need to
reassess the diagnosis."

Key Points for Seborrheic Keratosis (Male Patient Scenario)

• Benign growth, often described as having a 'stuck-on' appearance

• Slow growth over many years is typical and not concerning
• Usually doesn't require treatment
• Removal for cosmetic reasons is not covered by NHS and should be done privately
• Advise patient to monitor for significant changes and return if such changes occur

General Tips for Seborrheic Keratosis Consultations

1. Reassure the patient about the benign nature of the growth.

2. Distinguish between medical necessity and cosmetic preference:
o Clearly explain that the condition doesn't require medical treatment.
o Be prepared to discuss options for cosmetic removal if the patient expresses
interest.
3. Provide clear follow-up instructions:
o Educate patients on what changes warrant a return visit.

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o Emphasize the importance of monitoring, even though the condition is

benign.
4. Be sensitive to cosmetic concerns:
o While removal might not be medically necessary, acknowledge the patient's
feelings about the lesion's appearance.
o Provide clear information about private treatment options without
pressuring the patient.
5. Use age-appropriate counseling:
o For older patients (60-70 years), be respectful when discussing cosmetic
concerns. Avoid dismissive language like "What cosmetic reason for 60 years
old, 70 years old?"
6. Be thorough in history-taking:
o Even if the condition appears benign, always ask about changes, symptoms,
and risk factors.
7. Explain the diagnosis in simple terms:
o Use analogies like "stuck-on appearance" to help patients understand the
nature of the growth.
8. Provide a safety net:
o Always advise patients to return if they notice concerning changes, even for
benign conditions.

General Tips for Dermatological Consultations

1. Quality over quantity in questioning: Focus on asking relevant, high-quality

questions rather than trying to ask about everything.
2. Always ask about evolution: For any skin lesion, changes in size, shape, or color are
crucial information.
3. Consider location: Remember that location can be a key factor in determining the
likely diagnosis (e.g., SCC more common below the neck, BCC above the neck).
4. Use cautious language: When delivering a potential diagnosis, use phrases like "This
could be..." or "This is possibly..." rather than definitive statements.
5. Explain referral reasons: Clearly explain to patients why you're referring them,
especially if it's due to family history rather than suspicion of the current lesion
being cancerous.
6. Be thorough but relevant: Ensure you're asking all the important questions, but
don't get sidetracked with irrelevant information.
7. Reassure appropriately: For less serious conditions like seborrheic keratosis, reassure
the patient about its benign nature. For more serious conditions, balance honesty
about the potential severity with reassurance about treatability.
8. Emphasize the importance of sun protection: For all patients, especially those with
significant sun exposure, stress the importance of sun protection measures.

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9. Don't be misled by blurry images: In clinical settings, images may not be clear. Rely
more on the history than the visual appearance.
10. Be aware of patient reactions: Overreaction often indicates less severe conditions,
while underreaction may suggest more serious issues. However, this is not a hard
and fast rule.
11. Remember the importance of family history: This can significantly impact
management decisions, even for benign-appearing lesions.
12. Consider occupational factors: Occupations with high sun exposure (e.g., gardeners)
are relevant to skin cancer risk.
13. Don't miss key medications: Medications like methotrexate can be relevant to skin
cancer risk.
14. Be aware of the "two-week trap": Don't confuse a patient mentioning a two-week
duration with the two-week cancer referral pathway.

Rash Consultations in Dermatology

I. Initial Presentation

Patient: "I have a rash on my body."

Doctor: "I understand you're here about a rash. I'm going to ask you a series of questions to
help me understand your condition better. We'll start with the appearance of the rash,
then discuss how it developed, and finally talk about any symptoms you're experiencing. Is
that okay?"

Patient: "Yes, that's fine."

II. Consultation Structure

The consultation should follow this specific order:

1. Morphology
2. Evolution
3. Symptoms

It's crucial to adhere to this structure for a thorough assessment.

III. Detailed Consultation Process

1. Morphology

Doctor: "Let's start by discussing the appearance of your rash."

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Location:

• Question: "Which part of your body is affected by the rash?"

• Possible response: "It's mainly on my arms and chest."

Size:

• Question: "How big is the rash? Can you compare it to something familiar, like a
coin or your palm?"
• Possible response: "The individual spots are about the size of a dime, but they cover
an area about as big as my hand on each arm."

Color:

• Question: "What color is the rash?"

• Possible response: "It's mostly red, with some darker spots in the center."

Shape:

• Question: "Can you describe the shape of the rash? Is it round, irregular, or does it
have a specific pattern?"
• Possible response: "The spots are mostly round, but some seem to merge together in
irregular shapes."

Distribution:

• Question: "Is the rash in just one area, or is it spread across different parts of your
body?"
• Possible response: "It started on my arms, but now it's on my chest too. It's not on
my legs or face though."

2. Evolution

Doctor: "Now, I'd like to understand how this rash developed over time."

Onset:

• Question: "How did the rash start? Was it sudden or gradual?"

• Possible response: "It seemed to appear quite suddenly. I noticed it when I woke up
one morning."

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Initial location:

• Question: "Where did you first notice the rash?"

• Possible response: "I first saw it on my left arm."

Spread:

• Question: "How has the rash spread since it first appeared?"

• Possible response: "It started on my left arm, then appeared on my right arm, and
finally spread to my chest."

Speed of progression:

• Question: "How long did it take for the rash to spread to its current extent?"
• Possible response: "It spread to both arms within a day, and then to my chest over
the next two days."

Modifying factors:

• Questions:
o "Is there anything that seems to make the rash better?"
o "Is there anything that makes it worse?"
o "Have you noticed any changes with weather, heat, or after taking any
medications?"
• Possible responses:
o "Cold compresses seem to help a bit."
o "It gets worse when I'm warm or after a hot shower."
o "I haven't noticed any changes with medication."

3. Symptoms

Doctor: "Now, let's talk about any symptoms you're experiencing along with this rash."

• Pain: "Is the rash painful at all?"

• Itching: "Do you experience any itching?"
• Blisters: "Have you noticed any blisters forming?"
• Pus or oozing: "Is there any fluid or pus coming from the rash?"
• Scales: "Are there any flaky or scaly areas?"
• Ulcers: "Have you noticed any open sores or ulcers?"

For children or if relevant for adults, also ask about:

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• Fever: "Have you had any fever?"

• Respiratory symptoms: "Have you experienced any runny nose, wheezing, or
sneezing?"
• Other infection signs: "Have you had any other signs of infection?"

Always inquire about signs of allergic reactions:

• "Have you experienced any difficulty breathing?"

• "Any swelling of your lips, eyes, face, or tongue?"
• "Have you felt faint or collapsed at any point?"

For pediatric cases, include questions about:

• Ear pulling: "Has your child been pulling at their ears?"

• Urination changes: "Have you noticed your child crying while urinating?"
• Diarrhea: "Has your child had any diarrhea?"

IV. Examining the Rash

After completing the morphology, evolution, and symptoms sections, inform the patient:

Doctor: "Thank you for that information. Before I ask you any more questions, I'd like to
have a look at the rash. Is that okay with you?"

Patient: "Yes, that's fine."

Doctor: "Thank you. I'm going to examine the rash now."

[Examine the rash or look at the provided image]

Important notes:

1. Do not return the image to the patient if it's a picture.

2. Keep the image with you throughout the rest of the consultation.
3. If you accidentally give the image back, do not ask for it again. Rely on your
memory.

After examination:

Doctor: "I've had a look at the rash. I'd like to ask you some more questions based on what
I've seen."

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V. Further Questioning

Continue with relevant questions based on your observations:

Doctor: "Based on what I've seen, I have a few more questions for you."

[Ask questions relevant to your differential diagnoses]

Complete the MAPTOSA assessment:

• Medical history: "Do you have any ongoing medical conditions?"

• Allergies: "Do you have any known allergies?"
• Prescription medications: "Are you currently taking any medications?"
• Travel history: "Have you traveled anywhere recently?"
• Occupational factors: "Does your work expose you to any chemicals or irritants?"
• Social history: "Have you made any recent changes to your diet or lifestyle?"
• Anxieties/concerns: "What are your main concerns about this rash?"

VI. Diagnosis and Description

After completing your questions:

Doctor: "Based on my examination and the information you've provided, what I can see is
[detailed description of the rash]. This appears to be [diagnosis]."

Provide a clear, specific diagnosis rather than vague descriptions.

VII. Key Points to Remember

1. Always follow the order: Morphology → Evolution → Symptoms → Examine rash

→ Further questions → Diagnosis
2. Be thorough in your questioning, but also efficient
3. Always examine the rash before completing your questions
4. Keep the rash image (if provided) with you throughout the consultation
5. Tailor your questions based on what you observe in the rash
6. Consider age-specific factors (e.g., different questions for pediatric cases)
7. Always consider potential allergic reactions, regardless of the rash type
8. Provide a clear, specific diagnosis rather than vague descriptions
9. The history you take is often more important than what you can see
10. Quality of questions is more important than quantity

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VIII. Things to Avoid

1. Don't skip the structured approach (Morphology → Evolution → Symptoms)

2. Avoid asking irrelevant questions just to increase the number of questions asked
3. Don't return the rash image to the patient during the consultation
4. Avoid making a diagnosis without examining the rash
5. Don't forget to ask about potential allergic reactions
6. Avoid using overly technical terms when explaining to the patient
7. Don't dismiss the patient's concerns, even if the condition seems minor to you

Cholinergic Urticaria

Case Presentation

• Patient: 3–4-year-old child

• Brought by: Mother
• Chief complaint: Rash

Initial Conversation

Mother: "Doctor, I'm concerned about a rash my child has been getting."

Doctor: "I understand your concern. Can you tell me more about what you've noticed?"

Mother: "Well, my child was playing outside today and developed a rash. I actually just
received a text from my mother (the child's grandmother) that the rash has disappeared
now. But the same thing happened yesterday after my child had a shower."

Doctor: "Thank you for that information. Let's go through some questions to understand
this better."

Detailed History Taking

1. Timing and Triggers: Doctor: "When exactly does the rash appear?" Mother: "It
seems to happen when my child gets warm, like after playing outside or having a
shower." Doctor: "How long does the rash typically last?" Mother: "It doesn't last
long. It disappears quite quickly, usually within an hour." Doctor: "Are there any
other activities that seem to trigger it?" Mother: "Not that I've noticed, just the
playing and showering so far."
2. Appearance: Doctor: "Can you describe what the rash looks like when it's present?"
Mother: "It's like small, red bumps all over the skin." Doctor: "Does it appear in any

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specific areas of the body?" Mother: "It seems to be all over, but I notice it most on
the chest and arms."
3. Associated Symptoms: Doctor: "Does your child complain of any itching or pain
with the rash?" Mother: "Yes, it seems to be quite itchy." Doctor: "Have you noticed
any difficulty breathing or swelling of the face or lips?" Mother: "No, nothing like
that. Just the rash and itching."
4. Past Medical History: Doctor: "Has your child experienced this before these recent
incidents?" Mother: "No, this is new for us." Doctor: "Does your child have any
allergies or other medical conditions we should be aware of?" Mother: "No, they've
been pretty healthy overall."

Physical Examination

Doctor: "I understand the rash isn't present right now, but I'd still like to examine your
child if that's okay."

[Conduct general examination]

Diagnosis

Doctor: "Based on the information you've provided; this condition is called cholinergic
urticaria."

Explanation to Patient

Doctor: "Cholinergic urticaria is a condition where the skin reacts to heat produced by the
body. It's often triggered by activities that raise body temperature, like exercise or hot
showers. These are sometimes called 'heat bumps'."

Mother: "Is it serious? Why does it happen?"

Doctor: "It's generally not serious, but I understand it can be worrying. It happens because
of a reaction in the skin involving a chemical called acetylcholine. When the body heats
up, this triggers the reaction, causing the temporary rash."

Management Plan

1. Treatment: Doctor: "The main treatment is antihistamine medication. You can buy
this from a pharmacy without a prescription." Mother: "How often should I give it?"
Doctor: "You should always keep the medication readily available. You can give it to
your child when the rash develops, or even before activities you know might trigger
it, like before a shower or playing outside on a warm day."

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2. Prevention: Doctor: "Prevention is often the best approach. Here are some tips:
o Try reducing the temperature of the water for showers. Lukewarm water is
less likely to trigger the rash.
o Adjust the temperature at home if it's too warm.
o If your child is going to play outside on a hot day, you can give the
antihistamine medication beforehand.
o When traveling to hot countries, have the medication on hand."
3. Safety Netting: Doctor: "In rare cases, a severe allergic reaction called anaphylaxis
can occur. It's very unlikely, but it's important you know what to watch for:
o Swelling of the lips, eyes, or face
o Difficulty breathing
o Dizziness or fainting If you notice these symptoms, call an ambulance
immediately."

Addressing Common Concerns

Mother: "Could this be meningitis or some kind of infection? I've heard rashes can be
serious."

Doctor: "I understand your concern, but I can reassure you that this condition is not
infectious, and it's not meningitis. Let me explain why:

• Meningitis rash doesn't disappear quickly like this does.

• A meningitis rash typically looks like purple spots and doesn't fade when you press
on it.
• Also, a child with meningitis would be very unwell, with symptoms like high fever,
severe headache, and neck stiffness, which your child doesn't have.
• The fact that the rash comes and goes with heat is very characteristic of cholinergic
urticaria, not an infection."

Mother: "That's a relief. So we don't need to worry about it spreading to other children?"

Doctor: "No, you don't need to worry about that. This isn't contagious. It's simply your
child's skin reacting to heat."

Follow-up Instructions

Doctor: "If the symptoms worsen, don't improve with the antihistamines, or if you notice
any of the severe symptoms we discussed, please come back or seek medical attention.
Otherwise, you can manage this at home with the strategies we've discussed."

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Scabies

Case Presentation

• Patient: 19-year-old male

• Chief complaint: Itchy rash on hands

Initial Conversation

Patient: "Doctor, I've got this really itchy rash on my hands. It's driving me crazy."

Doctor: "I'm sorry to hear that. Let's go through some questions to understand what might
be causing this rash."

Detailed History Taking

1. Location and Spread: Doctor: "Is the rash only on your hands, or have you noticed
it anywhere else?" Patient: "It started on my hands, but now I think I'm seeing it in
other places too." Doctor: "Can you be more specific about where else you're seeing
it?" Patient: "Well, it seems to be in between my fingers, and I think I'm seeing some
on my wrists and maybe my groin area too." Doctor: "Have you noticed any lines or
tracks on your skin?" Patient: "Now that you mention it, yeah, I think I see some
little lines."
2. Duration and Evolution: Doctor: "When did you first notice this rash?" Patient: "It
started about a week ago, just after I got back from my trip." Doctor: "Has it changed
or spread since it first appeared?" Patient: "Yeah, it seems to be spreading and
getting itchier."
3. Associated Symptoms: Doctor: "Apart from itching, do you have any other
symptoms?" Patient: "No, just the itching, but it's really intense, especially at night."
Doctor: "Is the itching worse at any particular time, like at night?" Patient: "Yes,
exactly! It's much worse when I'm trying to sleep."
4. Travel History: Doctor: "You mentioned a trip. Where did you travel to?" Patient: "I
went to Cambodia with a friend." Doctor: "That's interesting. Did you stay in any
hostels or crowded accommodations?" Patient: "Yes, we stayed in hostels to save
money. Is that important?" Doctor: "It can be, yes. Were these shared rooms with
multiple beds?" Patient: "Yeah, most of them had bunk beds with several people in a
room."
5. Contacts: Doctor: "Has your friend or anyone else you've been in close contact with
developed similar symptoms?" Patient: "My friend doesn't have any symptoms, but
we stayed in the same places." Doctor: "Have you been in close contact with anyone
else since returning home?" Patient: "Just my family and girlfriend."

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Physical Examination

Doctor: "I'd like to examine the rash now, if that's okay. Could you show me your hands
and any other areas where you've noticed the rash?"

[Patient shows affected areas]

Doctor: "Thank you. I can see some small bumps and lines on your skin, particularly
between your fingers and on your wrists. These lines are particularly characteristic. I'd also
like to check a few other areas if that's alright."

[Examine other typical scabies sites: armpits, groin area, buttocks]

Diagnosis

Doctor: "Based on your history of staying in crowded accommodations, the intense itching
that's worse at night, and the characteristic appearance of the rash, especially those little
lines we saw, I believe this condition is called scabies."

Explanation to Patient

Doctor: "Scabies is a parasitic infestation. It's caused by tiny mites that burrow into the
skin, causing the itchy rash you're experiencing. It's not an infection, but rather an
infestation, similar to how you might think of a flea infestation on a pet."

Patient: "Mites? That sounds disgusting. How did I get this?"

Doctor: "Scabies is very contagious in crowded conditions, like the hostels you stayed in.
The mites can spread through close skin-to-skin contact or sharing bedding or clothes. It's
actually quite common, especially among travelers staying in hostels."

Management Plan

1. Treatment: Doctor: "The treatment is a cream called permethrin 5%. You'll need to
apply it to your entire body from the neck down, not just the areas where you see
the rash." Patient: "Even where I don't see the rash?" Doctor: "Yes, that's right. The
mites could be present even where you can't see them. You'll need two treatments,
one week apart." Patient: "Will this stop the itching right away?" Doctor: "The
itching might persist for a while, even after treatment. You can take antihistamines
for this if needed. It's important to complete both treatments even if the itching
improves."

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2. Decontamination: Doctor: "You'll need to wash all your clothing, bedding, and
linens in high temperature water and dry them at high heat. Any items that can't be
washed should be sealed in a plastic bag for at least 72 hours."
3. Contact Treatment: Doctor: "All household members and sexual partners should
also be treated, even if they don't have symptoms. The mites can spread before
symptoms appear." Patient: "Even my family and girlfriend? But they don't have any
itching." Doctor: "Yes, it's important they get treated too, to prevent reinfestation.
You should also inform your friend from the trip to speak to their GP about getting
treated, even if they don't have symptoms."
4. Follow-up: Doctor: "If symptoms persist after two treatments, please come back for
reassessment. It's important to complete both treatments and follow all the
decontamination steps to ensure the scabies is fully eradicated."
5. Doctor: "Do you have any questions about the treatment or anything we've
discussed?"

Patient: "This seems like a lot to handle. Will I need to take time off work?"

Doctor: "You're not required to stay off work, but you might find it more comfortable to
start the treatment on a Friday evening so you have the weekend to manage any initial
discomfort. Remember, scabies is common and treatable, so try not to worry too much."

Key Points to Remember

• Scabies is highly contagious in crowded conditions (like hostels)

• The characteristic sign is itchy lines or tracks on the skin
• Common areas affected include hands (especially between fingers), wrists, armpits,
groin, and buttocks
• Treatment involves not just the patient, but also close contacts and
decontamination of personal items
• Two treatments are necessary to ensure complete eradication
• Itching may persist for some time even after successful treatment

Acne Vulgaris

I. Case Presentation and Initial Approach

• Patient: 17-year-old male

• Consultation type: Telephone consultation
• Chief complaint: Initially described as a "scar" on forehead
• Note: Picture of the rash is available on the table from the beginning of the
consultation

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Initial Conversation:

Doctor: "Hello, I understand you've sent a picture of your rash. How may I help you
today?"

Patient: "I have a scar on my forehead."

Doctor: "Would you like to tell me more about it?"

Patient: "Well, it's this acne I have."

[Note: At this point, the patient may become reluctant to speak further]

II. Addressing Patient's Reluctance

It's crucial to pick up on the patient's reluctance to speak and address it directly. This is a
key part of the consultation, especially in this scenario.

Doctor: "I notice you seem a bit hesitant to talk about this. Is there anything bothering you
about this situation? Is there anything you'd like to tell me?"

[If patient remains reluctant]

Doctor: "You don't seem very interested in talking about this. Is the weather bothering you?
Or is there something else on your mind?"

III. Uncovering Underlying Issues

Patient: "I've been getting bullied at school. They say I'm not hygienic and that's why I have
acne."

Doctor: "I'm very sorry to hear that you're being bullied. That must be very difficult for you.
I want you to know that acne is not related to poor hygiene. Let's talk more about what's
going on, and I'll explain everything about acne to you."

IV. Detailed History Taking

1. Duration: Doctor: "How long have you had this acne?" Patient: "It's been on and off
for the last two to three years, since I became a teenager."
2. Symptoms: Doctor: "Can you tell me about any symptoms you're experiencing?"
o Ask about:
§ Pain: "Does the acne cause you any pain?"
§ Itching: "Do you experience any itching?"

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§ Presence of "white stuff": "Do you see any white material in the acne?"
[Note: This is not pus, but it's important to use the patient's language]
§ Fever: "Have you had any fever?"
§ Blisters: "Have you noticed any blisters?"
§ Ulcers: "Are there any open sores or ulcers?"
3. Self-treatment: Doctor: "Have you been doing anything to try to treat this yourself?"
Patient: "I've been washing my face three to four times a day to try to keep it clean."
[Note: This excessive washing is important to address in the management plan]
4. Impact on daily life: Doctor: "How has this acne been affecting your daily life and
mood?" [Note patient's response about bullying and any other impacts]
5. Past medical history: Doctor: "Have you had any other skin conditions or general
health issues?" [Note any relevant medical history]
6. Medications: Doctor: "Are you currently taking any medications or have you used
any treatments for your acne?" [Note any current or past treatments]

V. MAPTOSA Assessment

Complete the MAPTOSA assessment:

• Medical history: "Do you have any ongoing medical conditions?"

• Allergies: "Do you have any known allergies?"
• Prescription medications: "Are you taking any prescribed medications?"
• Travel history: "Have you traveled anywhere recently?"
• Occupational factors: "Are you currently in school or working?"
• Social history: "Can you tell me a bit about your home life and social activities?"
• Anxieties/concerns: "What are your main worries about this acne?"

VI. Examination

Doctor: "I've had a chance to look at the picture you sent. Based on what I can see, this
appears to be a mild form of acne."

[Note: Do not return the picture to the patient or ask for it again if you've accidentally
given it back]

VII. Diagnosis and Explanation

Doctor: "Based on the information you've provided and the picture you sent, this
condition is called acne vulgaris. It's a mild form of acne."

"Acne is a chronic inflammation of the skin, which means it's a long-term condition that
causes the skin to become inflamed."

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VIII. Patient Education and Counseling

1. Cause of acne: "First, I want to emphasize that acne is not caused by poor hygiene.
The exact mechanism isn't fully understood, but many doctors believe it's due to
hormonal changes, especially in teenagers. It's a normal part of growing up for many
people."
2. Excessive cleaning: "It's important to know that excessive cleaning or scrubbing the
area can actually make acne worse. I understand you've been washing your face 3-4
times a day, but this can cause dryness and irritation, which can exacerbate the
condition. I'd recommend reducing that to just twice a day with a gentle cleanser."
3. Picking and scratching: "Try to avoid picking or scratching at the acne. Persistent
picking and scratching can increase the risk of scarring."

IX. Treatment Plan

1. Topical medication: "I'm going to recommend a medication called benzoyl peroxide.

You should apply this once in the evening. When you first start using it, it might
cause some skin irritation, but this usually gets better over time."
2. Skincare products: "When choosing skincare products, look for ones that are non-
alkaline or slightly acidic pH. You can usually find this information on the product
label. Avoid products with oily substances." [Note: You can mention to remember
"lemon" as an example of acidity, but do NOT recommend using lemon on the
skin]
3. Follow-up: "I'd like you to follow up with us in three months to see how this
treatment is working. If it's not effective, we might consider adding an antibiotic
cream. If that doesn't work, we may refer you to a dermatologist."

X. Addressing Psychological Impact

Doctor: "Living with a long-term skin condition can be challenging, especially when it
affects how you feel about yourself or how others treat you. How are you coping with this
emotionally?"

[Discuss any emotional or psychological impacts and consider referral for counseling if
necessary]

XI. Closing the Consultation

Doctor: "Do you have any questions about what we've discussed today? Remember, acne is
a common condition, especially in teenagers, and it's not a reflection of your hygiene or
your worth as a person. If you continue to have troubles with bullying, please don't hesitate

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to speak with your teachers or counselors at school. And of course, we're here if you need
any further help or advice."

Key Points to Remember

1. Always be alert for signs of reluctance or distress in patients, especially teenagers,

and probe gently for underlying issues.
2. Acne vulgaris is common in teenagers and is not caused by poor hygiene.
3. Excessive cleaning can worsen acne. Advise patients to wash only twice daily with a
gentle cleanser.
4. Treatment typically starts with benzoyl peroxide applied once daily in the evening.
5. Recommend non-alkaline or slightly acidic pH skincare products. Avoid oil-based
products.
6. Follow-up in three months; consider antibiotics if initial treatment is ineffective.
7. Always assess the psychological impact of long-term skin conditions.
8. The consultation is not just about treating physical symptoms, but also addressing
emotional well-being and providing reassurance and education.

Things to Avoid

1. Don't dismiss or minimize the patient's concerns about their appearance or the
bullying they're experiencing.
2. Avoid using highly technical terms without explanation.
3. Don't recommend using home remedies like lemon juice on the skin.
4. Avoid suggesting that the acne is due to poor hygiene or diet.
5. Don't rush through the consultation, even if the patient is initially reluctant to talk.
6. Avoid making guarantees about how quickly the acne will clear up.

Impetigo and Herpes Labialis

I. General Distinctions

1. Causative Agent:
o Impetigo: Bacterial (Staphylococcus aureus)
o Herpes Labialis: Viral (Herpes Simplex Virus)
2. Pain:
o Impetigo: Not painful
o Herpes Labialis: Painful (Remember: "Herpes hurts")
3. Appearance:
o Impetigo: Golden crusts
o Herpes Labialis: Blisters
4. Location:

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o Impetigo: Can be on various parts of the face

o Herpes Labialis: Specifically on the lips, especially at the vermilion border

Impetigo

Case Presentation

• Patient: Female, breastfeeding mother

• Chief complaint: Rash on face
• Note: Patient may be upset due to perceived mistreatment at pharmacy

Initial Approach

Patient: [Throws paper in front of the doctor] "Doctor, look! I have this rash on my face.
They gave me the wrong medication at the pharmacy, and now it has spread everywhere!"

Doctor: "I'm sorry to hear about your experience. May I have a look at the rash, please?"

[Doctor examines the picture]

Doctor: "Thank you. Can I please ask you some questions regarding this rash?"

Detailed History Taking

1. Evolution: Doctor: "Can you tell me how this rash started?" Patient: "It started as
one blister or dot and then spread like this." Doctor: "How long ago did it first
appear?" [Note patient's response]
2. Symptoms: Doctor: "Is the rash painful?" Patient: "No, it's not painful, but it feels a
bit rough and raw." Doctor: "Have you experienced any fever or other symptoms?"
[Note patient's response] Doctor: "Is there any itching?" [Note patient's response]
Doctor: "Have you noticed any golden crusts forming on the rash?" [Note patient's
response]
3. Household contacts: Doctor: "Who else is at home with you?" Patient: "I have a one-
year-old child." Doctor: "Are you breastfeeding?" Patient: "Yes, I am." Doctor: "Has
anyone else at home developed similar symptoms?" [Note patient's response]
4. Sexual activity: Doctor: "I apologize if this seems personal, but it's important for
your treatment. Have you or your partner been practicing oral sex recently?" [Note
patient's response]
5. Allergies: Doctor: "Do you have any allergies to medications?" Patient: "Yes, I'm
allergic to penicillin."
6. Previous treatments: Doctor: "Can you tell me more about the medication the
pharmacy gave you?" [Note patient's response]

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Physical Examination

Note the presence of golden crusts on the face. Observe the spread and distribution of the
rash.

Diagnosis

Doctor: "Based on the information you've provided and my examination, this condition is
called impetigo. It's a bacterial infection caused by bacteria called Staphylococcus aureus."

Treatment Plan

1. Medication: Doctor: "I'm going to prescribe a cream called fusidic acid. I understand
that you're allergic to penicillin, but this medication is safe for you to use despite
that allergy. Apply it 2-3 times a day, covering the entire affected area."
2. Infectivity: Doctor: "This condition is contagious. Your ability to spread this
infection to others remains for 48 hours from the start of treatment. During this
time:
o Avoid close contact with others, including kissing
o Don't go to work
o Cover the lesion
o Wear a mask
o Avoid sharing towels, linens, or bedding
o Unfortunately, you should avoid breastfeeding for at least 48 hours. You'll
need to use alternative feeding methods during this time to protect your
child."
3. Follow-up: Doctor: "If the condition doesn't improve after a few days of treatment,
please come back for a follow-up."
4. Hygiene measures: Doctor: "It's important to maintain good hygiene. Wash your
hands frequently, especially after touching the affected areas. However, avoid
excessive washing of the face as this can irritate the skin further."

Herpes Labialis

Case Presentation

• Patient: Male, works as a model

• Chief complaint: Blisters in mouth
• Family: Has a wife and daughter

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Initial Approach

Patient: "Doctor, I've developed some blisters in my mouth."

Doctor: "I'm sorry to hear that. Can you tell me more about these blisters?"

Detailed History Taking

1. Symptoms: Doctor: "Are the blisters painful?" Patient: "Yes, they're quite sore."
Doctor: "Did you experience any sensation before the blisters appeared, like
tingling?" Patient: "Yes, I did feel a tingling sensation before they showed up."
2. Duration and Evolution: Doctor: "When did you first notice these blisters?" [Note
patient's response] Doctor: "Have you had this before?" [Note patient's response]
3. Associated Symptoms: Doctor: "Have you experienced any fever or other
symptoms?" [Note patient's response]
4. Household contacts: Doctor: "Has your wife or daughter developed any similar
symptoms?" [Note patient's response]
5. Occupation concerns: Doctor: "You mentioned you're a model. Has this affected
your work?" [Note patient's response]

Physical Examination

[Note: The picture may be in black and white]

Doctor: "I'm going to examine your lips now, particularly where the skin meets the inner
part of the lip."

Look for multiple painful blisters, especially at the vermilion border (where skin meets
mucosa).

Diagnosis

Doctor: "Based on your symptoms and my examination, this condition is called herpes
labialis, also known as a cold sore. It's caused by a virus that leads to painful infections on
the lips."

Treatment Plan

1. Natural course: Doctor: "This condition is self-limiting, which means it will settle on
its own. It typically takes about 10 days to resolve."

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2. Symptom management: Doctor: "To manage the pain, you can take over-the-counter
painkillers like paracetamol. You can also buy cold sore cream from the pharmacy,
which contains antiviral medication."
3. Infectivity: Doctor: "This condition is contagious. To prevent spreading it:
o Cover the lesion
o Wash your hands with soap and water after touching the lesion
o Avoid close contact, kissing, or oral sex until it heals
o Try to avoid close contact with your daughter, as it can be passed to her"
4. Work concerns: Doctor: "You mentioned you're a model. You can go to work, but
you might want to inform your employer about the condition. It's up to you
whether you feel comfortable working with visible cold sores."
5. Duration: Doctor: "The condition typically lasts about 10 days from the initial
tingling sensation. Remember: 'Tingling for 10' - this might help you recall the
duration."

IV. Key Points to Remember

1. Impetigo:
o Bacterial infection, not painful
o Golden crusts are characteristic
o Treat with fusidic acid cream
o Contagious for 48 hours after starting treatment
o Avoid breastfeeding during this time
2. Herpes Labialis:
o Viral infection, painful
o Tingling sensation precedes blisters
o Self-limiting, lasts about 10 days
o Treat symptoms with painkillers and over-the-counter cold sore creams
o Contagious until healed
3. Examination Techniques:
o For impetigo, look for golden crusts and spreading pattern
o For herpes labialis, focus on the vermilion border of the lips
4. Patient Communication:
o Be prepared for potentially upset patients (especially in impetigo cases)
o Address lifestyle concerns (breastfeeding for impetigo, modeling career for
herpes labialis)
o Explain infectivity and prevention measures clearly
5. Things to Avoid:
o Don't dismiss patient concerns or emotions
o Avoid recommending excessive face washing for impetigo
o Don't forget to ask about tingling sensation in suspected herpes labialis cases

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o For impetigo, don't assume it's related to poor hygiene

Tinea Manuum

Case Presentation

• Patient: Male
• Chief complaint: Rash on hand
• Duration: Couple of weeks
• Family: Wife is pregnant

Initial Approach

Doctor: "Hello, I understand you've come in about a rash on your hand. Can you tell me
more about it?"

Patient: "Yes, I've had this rash on my hand for a couple of weeks now. It's itchy and I'm
worried because my wife is pregnant."

Detailed History Taking

1. Duration and Evolution: Doctor: "When did you first notice this rash?" Patient: "It
started about two weeks ago." Doctor: "Has it changed in any way since it first
appeared?" Patient: "It seems to be spreading slowly."
2. Symptoms: Doctor: "You mentioned it's itchy. Can you describe the itching?"
Patient: "It's pretty constant and gets worse when my hand gets warm." Doctor:
"Have you noticed any scaling or flaking of the skin?" Patient: "Yes, there are some
scales, especially around the edges."
3. Appearance: Doctor: "Can you describe the shape of the rash?" Patient: "It's round
in shape, like a ring."
4. Family concerns: Doctor: "You mentioned your wife is pregnant. What are your
specific concerns about that?" Patient: "I'm worried that I might pass this on to her
and it could affect the pregnancy."
5. Previous treatments: Doctor: "Have you tried any treatments for this rash so far?"
Patient: "I've been using some over-the-counter hydrocortisone cream, but it doesn't
seem to help much."

Physical Examination

Observe the rash, noting its round shape, scaling, and location on the hand. Look for any
signs of secondary bacterial infection.

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Diagnosis

Doctor: "Based on your description and my examination, this condition is called tinea
manuum. It's important to use this specific name. Tinea manuum is a type of fungal
infection, also known as ringworm, that affects the hand."

Treatment Plan

1. Medication: Doctor: "I'm going to prescribe a cream called clotrimazole 1%. You
should apply this cream two to three times a day for four weeks." Patient: "How
much should I apply?" Doctor: "When you squeeze the tube, use about half a
centimeter of cream. This amount is enough to cover an area the size of your palm.
Remember, for dry fungal lesions like this, we need a longer treatment period of
four weeks."
2. Duration of treatment: Doctor: "It's important to continue the treatment for the full
four weeks, even if the rash seems to improve earlier. This ensures we completely
eradicate the fungus."
3. Addressing patient's concerns: Doctor: "Regarding your wife's pregnancy, it is
possible to pass this infection to her, but it's highly unlikely to cause any problems
with the pregnancy. However, if she does develop any symptoms, she should see a
doctor." Patient: "Is there any risk if she needs treatment?" Doctor: "The cream we're
prescribing for you is generally safe, but if the infection doesn't respond to cream
and requires oral medication, those tablets are not recommended for pregnant or
breastfeeding women. That's why it's important to try to prevent spread and treat
your infection effectively."
4. Prevention of spread: Doctor: "To help prevent spreading the infection:
o Avoid sharing towels or other personal items
o Wash your hands thoroughly after applying the cream
o Keep the affected area clean and dry
o Avoid excessive hand washing, as this can dry out the skin and potentially
worsen the condition"
5. Follow-up: Doctor: "If the rash doesn't improve after four weeks of treatment, please
come back for a follow-up appointment. We may need to consider other treatment
options at that point."

Key Points for Tinea Manuum

• Always use the specific name "tinea manuum" in the diagnosis

• Treatment is with clotrimazole 1% cream for four weeks
• Dry fungal lesions require longer treatment periods
• Generally low risk for pregnancy, but oral medications should be avoided in
pregnant women

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• Prevent spread through good hygiene practices

Measles

Case Presentation

• Setting: Student Health Center (GP practice near university)

• Patient: 19-year-old male university student
• Chief complaint: Rash
• Consultation type: Telephone consultation
• Note: Picture of the rash is available from the beginning of the consultation

Initial Approach

Doctor: "Hello, I understand you've called about a rash. I have the picture you sent in front
of me. Can you tell me more about what's been happening?"

Patient: "Hi doctor, yes, I've developed this rash and I'm not sure what it is. It started a
couple of days ago."

Detailed History Taking

1. Evolution of rash: Doctor: "When exactly did this rash first appear?" Patient: "It
started about two days ago." Doctor: "Where on your body did it start, and how has
it spread?" Patient: "It started on my face and has been spreading down to my chest
and arms." Doctor: "What color was it when it first appeared?" Patient: "It was red
and blotchy from the beginning."
2. Associated symptoms: Doctor: "Have you had any fever?" Patient: "Yes, I've been
feeling quite hot and achy." Doctor: "Any flu-like symptoms such as runny nose,
cough, or sore throat?" Patient: "Yes, I've had a runny nose and a bit of a cough."
Doctor: "Before the rash appeared, did you notice any white spots in your mouth?"
Patient: "Now that you mention it, I did notice some white spots inside my cheeks a
few days ago."
3. Systemic review: Doctor: "I need to ask about some specific symptoms. Have you
experienced any of the following:
o Confusion or altered consciousness?
o Difficulty breathing?
o Severe headache?
o Convulsions or fits?" Patient: "No, I haven't had any of those. Just feeling
generally unwell with the fever and rash."

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4. Vaccination history: Doctor: "Have you been vaccinated against measles? This would
have been part of the MMR vaccine." Patient: "I'm not sure. I think I might have
missed some vaccinations when I was younger."
5. Contact history: Doctor: "Have you been in contact with anyone who has had a
similar rash or been diagnosed with measles?" Patient: "Not that I know of, but there
are a lot of students around and I'm not always sure who's sick."

Diagnosis

Doctor: "Based on the information you've provided and the picture of your rash, this
condition is called measles. Measles is a viral infection that causes a rash and other
symptoms like the ones you're experiencing."

Treatment Plan

1. Self-limiting nature: Doctor: "Measles is generally a self-limiting condition, which

means it will settle on its own. However, we need to manage your symptoms and
take precautions to prevent spread."
2. Supportive treatment (FFR): Doctor: "To help manage your symptoms, remember
FFR:
o Fever: Take paracetamol as needed to control your fever
o Fluids: Drink plenty of fluids, at least two liters per day, to stay hydrated
o Rest: Get plenty of rest to help your body fight the infection"
3. Self-isolation: Doctor: "You need to self-isolate for four days from the onset of the
rash. This is because you can spread the infection to others during this time."
4. Warning signs: Doctor: "If you experience any of the following, seek immediate
medical help:
o Shortness of breath or difficulty breathing
o Uncontrolled fever that doesn't respond to paracetamol
o Altered consciousness or confusion
o Convulsions or fits"
5. Follow-up and vaccination: Doctor: "Once you've recovered, please make an
appointment for the MMR vaccination to prevent future infections. It's important
to complete your vaccination schedule."
6. Notification: Doctor: "Measles is a notifiable condition, which means I'm required
by law to report it to the local health protection agency. They may contact you for
contact tracing purposes. I'm telling you this because it means sharing some of your
information, which would normally be confidential."

Addressing Specific Concerns

Patient: "Can I go to my exam next week?"

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Doctor: "Your ability to spread the infection to others lasts for four days from the onset of
the rash. If your exam is after this four-day period, you can attend from an infectivity
standpoint. However, for your own benefit, it's best to wait until you've fully recovered to
avoid any complications. When exactly is your exam, and when did your rash first appear?"

Patient: "The rash started two days ago, and my exam is in 5 days."

Doctor: "In that case, you would be past the infectious period for your exam. However, you
might still be recovering and not feeling your best. I'd recommend contacting your
university to explain the situation and see if you can reschedule or make alternative
arrangements."

Patient: "Can I visit my parents this weekend?"

Doctor: "Do your parents have any serious or long-term medical conditions that might
affect their immune system?"

Patient: "No, they're both pretty healthy."

Doctor: "In that case, you can visit them after the four-day infectious period. However, it's
best to wait until you've fully recovered, both to protect them and to ensure you're feeling
well enough to travel. I'd recommend postponing your visit until next week if possible."

Key Points to Remember

1. Measles is a viral infection causing characteristic rash and flu-like symptoms

2. It's self-limiting but requires self-isolation for four days from rash onset
3. Supportive treatment with FFR (Fever medication, Fluids, Rest)
4. It's a notifiable condition requiring report to health protection agency
5. Vaccination (MMR) is recommended after recovery
6. Always consider the specific timeline of symptom onset when advising about
activities

Things to Avoid

1. Don't forget to ask about Koplik spots (white spots in the mouth)
2. Avoid dismissing the seriousness of measles, even though it's often self-limiting
3. Don't neglect to explain the reason for notifying the health protection agency
4. Avoid giving blanket permission for activities without considering the specific
timeline of the illness

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Hemangioma

Case Presentation

• Patient: Two-week-old child (youngest age typically seen)

• Chief complaint: Lump on tummy
• Risk factor: Premature birth

Initial Approach

Doctor: "Hello, I understand you've brought your baby in because of a lump on their
tummy. Can you tell me more about what you've noticed?"

Mother: "Yes, I noticed this lump on my baby's tummy. It wasn't there when they were
born, and I'm worried because my baby was born prematurely."

Detailed History Taking

1. Morphology: Doctor: "Can you describe the lump for me? What does it look like?"
Mother: "It's a raised, reddish area on the skin. It seems to be getting larger."
Doctor: "What color is it exactly?" Mother: "It's bright red, almost like a strawberry."
Doctor: "What's the shape of the lump?" Mother: "It's round, about the size of a
grape."
2. Evolution: Doctor: "When did you first notice this lump?" Mother: "I first saw it
about a week ago, when my baby was just a week old." Doctor: "Has it grown or
changed in any way since then?" Mother: "Yes, it seems to be getting slightly larger
and more raised."
3. Symptoms: Doctor: "Have you noticed any bleeding from the lump?" Mother: "No,
there hasn't been any bleeding." Doctor: "Have you seen any ulcers or breaks in the
skin over the lump?" Mother: "No, the skin looks intact." Doctor: "Does your baby
seem bothered by it in any way? Do they cry when you touch it?" Mother: "No, they
don't seem to notice it at all."
4. Birth History: Doctor: "You mentioned your baby was born prematurely. At how
many weeks of your pregnancy did you give birth?" Mother: "I gave birth at 34
weeks." Doctor: "Were there any complications during the pregnancy or delivery?"
Mother: "No, other than the premature birth, everything else was normal."

Physical Examination

Observe the lump, noting its size, color, and any signs of ulceration or bleeding. Confirm
it's a raised, bright red, round lesion on the baby's abdomen.

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Diagnosis

Doctor: "Based on my examination and the information you've provided, this condition is
called a hemangioma. Hemangiomas are overgrowths of blood vessels on the skin. They're
quite common, especially in premature babies."

Treatment Plan and Patient Education

1. Natural Course: Doctor: "Hemangiomas are generally self-limiting, which means

they will disappear on their own. However, this can take about five to seven years.
During this time, it may grow larger before it starts to shrink."
2. Skin Care: Doctor: "The skin over the hemangioma is very delicate and can easily
become dry. To care for it:
o Avoid excessive cleaning or washing of the area
o Don't use bubble baths or harsh soaps on the area
o You can apply a gentle, fragrance-free moisturizing cream to keep the skin
from drying out
o As your child grows, we may recommend using sunscreen on the area to
protect it from sun damage"
3. Preventing Complications: Doctor: "To prevent complications:
o Trim your baby's nails daily. This is crucial because newborns' nails grow very
quickly, and we want to prevent any accidental scratching of the
hemangioma.
o If you notice any ulceration or bleeding, let us know right away."
4. Managing Bleeding: Doctor: "Although it's rare, if the hemangioma starts bleeding:
o Apply firm pressure with a clean piece of cloth or tissue for five minutes
o If the blood soaks through the cloth within those five minutes, you can
replace it with a fresh one, but don't lift pressure for more than a few
seconds
o If bleeding continues for more than five minutes despite pressure, take your
child to the nearest hospital immediately"
5. Follow-up: Doctor: "We'll want to monitor the hemangioma as your child grows.
Let's schedule a follow-up appointment in a month. Please come back sooner if you
notice any significant changes or have concerns."
6. Reassurance: Doctor: "Remember, while hemangiomas can look worrying, they're
benign growths and usually don't cause any problems. Our main goal is to protect
the skin and monitor for any changes."

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Cellulitis

Case Presentation

• Patient: Approximately 60-year-old female

• Chief complaint: Rash on one leg, painful and slightly feverish
• Risk factor: Recent insect bite (yesterday)
• Note: Patient is allergic to penicillin

Initial Approach

Doctor: "Hello, I understand you've come in because of a rash on your leg. Can you tell me
more about what you're experiencing?"

Patient: "Yes, I've developed this rash on my leg. It's a bit painful and I think I might have a
slight fever. I'm worried because it seems to be spreading."

Detailed History Taking

1. Morphology and Evolution: Doctor: "Can you describe the rash for me? What does
it look like?" Patient: "It's red and swollen, and feels warm to touch." Doctor: "Is it
on one leg or both?" Patient: "It's just on my left leg." Doctor: "When did you first
notice this rash?" Patient: "I noticed it this morning when I woke up." Doctor: "How
has it changed since you first noticed it?" Patient: "It seems to be spreading slowly
across my leg. It started near my ankle and now it's almost up to my knee."
2. Symptoms: Doctor: "You mentioned it's painful. Can you describe the pain?"
Patient: "It's a constant aching pain, and it hurts more when I touch the area or
walk." Doctor: "Have you measured your temperature?" Patient: "I haven't measured
it, but I feel a bit warm and shivery."
3. Recent Events: Doctor: "Have you had any injuries or insect bites recently?" Patient:
"Actually, I did get an insect bite on that leg yesterday afternoon when I was
gardening."
4. Medical History: Doctor: "Do you have any ongoing medical conditions, such as
diabetes?" Patient: "No, I don't have diabetes or any other chronic conditions."
Doctor: "Are you taking any medications regularly, particularly steroids or
chemotherapy drugs?" Patient: "No, I'm not on any regular medications." Doctor:
"Do you have any allergies to medications?" Patient: "Yes, I'm allergic to penicillin. It
gives me a rash."
5. Systemic Symptoms: Doctor: "I need to ask about some specific symptoms. Have
you experienced any of the following:
o Feeling very unwell or dizzy?
o Fast breathing or shortness of breath?

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o Confusion or difficulty concentrating?

o Nausea or vomiting?" Patient: "No, I haven't had any of those symptoms. I
just feel a bit under the weather with the fever."

Physical Examination

Observe the rash, noting its extent, color, and any signs of spreading. Check vital signs
including temperature, blood pressure, heart rate, and oxygen saturation.

Doctor: "I can see the rash on your left leg. It's quite red and there's some swelling. Your
temperature is slightly elevated at 38°C (100.4°F), but your blood pressure, heart rate, and
oxygen levels are all normal."

Diagnosis

Doctor: "Based on my examination and the information you've provided, this condition is
called cellulitis. It's an infection of the deeper layers of skin, likely caused by bacteria
entering through the insect bite you mentioned yesterday."

Treatment Plan

1. Medication: Doctor: "Given your allergy to penicillin, I'm going to prescribe an

antibiotic called doxycycline. The dosage will be:
o 200mg for the first day (this is called a loading dose)
o Then 100mg daily for the next 5-7 days It's important to complete the full
course of antibiotics, even if you start feeling better before it's finished."
2. Symptom Management: Doctor: "You can take paracetamol for pain and fever if
needed. Also, elevating your leg when you're resting can help reduce swelling and
discomfort."
3. Monitoring: Doctor: "If you don't see improvement within 48 hours of starting the
antibiotic, or if you start feeling worse, please come back or seek medical attention.
We may need to do some blood tests or consider hospital admission."
4. Warning Signs: Doctor: "If you start feeling very unwell, develop high fever, or
notice the rash spreading rapidly, please go to the hospital immediately. These could
be signs that the infection is becoming more serious."
5. Follow-up: Doctor: "Let's schedule a follow-up appointment in 3-4 days to check
your progress. Remember, you can always come back sooner if you're worried."

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Key Points to Remember

1. Hemangioma:
o Most common in premature infants
o Self-limiting but can take 5-7 years to resolve
o Focus on skin care and preventing complications
o Careful management of any bleeding (5-minute rule)
o Daily nail trimming is crucial
2. Cellulitis:
o Caused by skin infection, often through a break in the skin (like an insect
bite)
o Treatment is with antibiotics (doxycycline if penicillin-allergic)
o Monitor for signs of spreading or systemic illness
o Follow-up within 48 hours if not improving
o Assessment of hemodynamic stability is crucial in decision-making

Things to Avoid

1. In hemangioma cases:
o Don't panic or cause unnecessary worry to parents
o Avoid harsh soaps or excessive washing of the area
o Don't forget to emphasize the importance of daily nail trimming
2. In cellulitis cases:
o Don't confuse insect bites with tick bites (which are associated with Lyme
disease)
o Avoid dismissing seemingly minor symptoms, as cellulitis can progress
rapidly
o Don't forget to assess for hemodynamic stability and consider hospital
admission if necessary

Chickenpox (Varicella)

Case Presentation

• Patient: Child
• Chief complaint: Rash throughout the body
• Symptoms: Unwell, fever, sleepy

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Initial Approach

Mother: "Doctor, my child has developed a rash all over their body. It started behind the
ear and on the face, and now it's everywhere. They're also feeling unwell with a fever and
sleeping a lot."

Doctor: "Thank you for bringing this to my attention. Let's take a closer look at this rash
and discuss what's been happening in detail."

Detailed History Taking

1. Rash evolution: Doctor: "When did you first notice the rash?" Mother: "I first
noticed it behind the ear about two days ago." Doctor: "How has it spread since
then?" Mother: "It quickly spread to the face, and now it's all over the body."
2. Associated symptoms: Doctor: "You mentioned fever and sleepiness. Can you tell
me more about these symptoms?" Mother: "The fever started yesterday, and they've
been sleeping much more than usual." Doctor: "Has your child been eating and
drinking normally?" Mother: "They're not very interested in food, but they're still
drinking some water."
3. Itching: Doctor: "Is the rash itchy?" Mother: "Yes, they've been trying to scratch it."
4. Contact history: Doctor: "Has your child been in contact with anyone who had
chickenpox recently?" Mother: [Note response]
5. Vaccination history: Doctor: "Has your child received the chickenpox vaccine?"
Mother: [Note response]

Physical Examination

Doctor: "I'm going to examine your child now. The rash appears as small, fluid-filled
blisters on reddened skin. They're at different stages, which is typical for chickenpox."

Diagnosis

Doctor: "Based on the symptoms and the appearance of the rash, this condition is
chickenpox. Chickenpox is caused by a virus called varicella-zoster, which causes these
characteristic blisters on the skin."

Explanation and Management

1. Nature of the condition: Doctor: "Chickenpox is a self-limiting condition, which

means it will resolve on its own without specific treatment. However, we need to
manage the symptoms and prevent complications."
2. Treatment (FFR): Doctor: "The main treatment involves what we call FFR:

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o Fever management: Use paracetamol as needed. It's important to avoid

aspirin in children with chickenpox as it can cause complications.
o Fluids: Ensure your child drinks plenty of fluids to prevent dehydration.
Offer small amounts frequently if they're not interested in drinking much at
once.
o Rest: Allow your child to rest as much as they need. Their body is fighting
the virus, so extra sleep is normal and beneficial."
3. Symptom management: Doctor: "To help with itching and discomfort:
o You can apply calamine lotion to soothe the skin.
o Dress your child in loose, cotton clothing to prevent overheating and reduce
irritation to the skin.
o Keep your child's nails short and clean to prevent scratching and potential
infection. Consider putting soft gloves or socks on their hands at night.
o You can buy an antihistamine from the pharmacy to help with itching. Make
sure it's age-appropriate."
4. Complications and safety netting: Doctor: "Watch out for signs of:
o Dehydration: Look for dry mouth, less frequent urination, or dark urine.
o Bacterial infection: If you notice any areas becoming very red, swollen, or
painful, or if there's pus, contact us immediately.
o Breathing difficulties: If your child has trouble breathing or chest pain, seek
immediate medical attention.
o High fever: If the fever is very high or doesn't respond to paracetamol, let us
know."
5. Infectivity and return to school: Doctor: "Chickenpox is contagious from 2 days
before the rash appears until all the blisters have crusted over. This usually takes
about 5 days from the onset of the rash. Your child can return to school once all
lesions have crusted over, typically about 5 days after the rash first appeared.
However, it's best to wait until they feel well enough to participate in school
activities."
6. Follow-up: Doctor: "If you're concerned about any new symptoms or if your child's
condition worsens, please don't hesitate to contact us. Otherwise, chickenpox
typically runs its course in about 7-10 days."

Erythema Nodosum

Case Presentation

• Patient: 40-year-old female

• Occupation: Airport worker
• Chief complaint: Rash on both legs
• Recent history: Flu last week

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Initial Approach

Doctor: "Hello, I understand you've come in with a rash on your legs. Can you tell me
more about what you're experiencing?"

Patient: "Yes, I've developed this rash on both my legs. It's a bit painful and itchy. I had the
flu last week, and I'm not sure if that's related."

Detailed History Taking

1. Morphology and Evolution: Doctor: "Can you describe the rash for me? What does
it look like?" Patient: "It's red and raised, almost like bumps under the skin." Doctor:
"When did you first notice this rash?" Patient: "I noticed it a couple of days ago."
Doctor: "Has it changed since you first noticed it?" Patient: "It seems to be spreading
a bit and getting more painful."
2. Symptoms: Doctor: "You mentioned it's painful and itchy. Can you describe the
pain?" Patient: "It's a deep, aching pain, and the areas are tender to touch." Doctor:
"On a scale of 1 to 10, how would you rate the pain?" Patient: [Note response]
Doctor: "Does anything make the pain better or worse?" Patient: [Note response]
3. Systemic Review: Doctor: "I need to ask about some other symptoms. Have you
experienced any:
o Persistent cough or difficulty breathing?
o Unexplained weight loss?
o Night sweats?
o Changes in your vision?
o Any joint pain or swelling?
o Any digestive issues like diarrhea or abdominal pain?
o Any other unusual symptoms?" [Note patient's responses to each]
4. Medical History: Doctor: "Have you ever been diagnosed with conditions like
tuberculosis, HIV, or any autoimmune diseases?" Patient: "No, I haven't." Doctor:
"Have you ever been diagnosed with a condition called psoriasis?" Patient: "No, I
haven't had any skin conditions before." Doctor: "Any history of cancer in you or
your family?" Patient: [Note response]
5. Occupational History: Doctor: "You mentioned you work at an airport. Can you tell
me more about your role there? Does it involve any specific exposures or travel?"
Patient: [Note detailed response]
6. Recent Travel: Doctor: "Have you traveled anywhere recently, either for work or
leisure?" Patient: [Note response]

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Physical Examination

Doctor: "I'm going to examine your legs now. The rash appears as red, tender nodules
under the skin. This is characteristic of a condition called erythema nodosum."

Diagnosis

Doctor: "Based on my examination and the information you've provided; this condition is
called erythema nodosum. It's an inflammation of the fat tissue under the skin."

Treatment Plan and Further Testing

1. Cause: Doctor: "Erythema nodosum can be triggered by various factors, including

recent infections like the flu you had. However, we need to rule out other potential
causes."
2. Immediate management: Doctor: "For now, we'll focus on managing your
symptoms:
o You can take ibuprofen for pain relief. Take it with food to avoid stomach
upset.
o If the itching is bothersome, an over-the-counter antihistamine like cetirizine
may help.
o Elevating your legs when resting can help reduce swelling and discomfort.
o Apply cool compresses to the affected areas for additional relief."
3. Further testing: Doctor: "I'd like to arrange some blood tests to check for signs of
inflammation and to rule out other conditions. We'll be testing for:
o Signs of inflammation (ESR and CRP)
o Complete blood count
o Liver and kidney function
o Tuberculosis (TB) screening
o HIV test (with your consent)
o Markers for autoimmune conditions Sometimes, erythema nodosum can be
associated with more serious conditions like tuberculosis, sarcoidosis, or
certain infections. We'll test for these to be thorough."
4. Work considerations: Doctor: "Erythema nodosum itself is not infectious, so you
should be able to continue working. However, if you're uncomfortable or in pain,
you might want to take a few days off to rest. I can provide a sick note if needed."
5. Follow-up: Doctor: "Let's schedule a follow-up appointment in a week to review your
blood test results and see how you're progressing. If your symptoms worsen before
then, please come back to see us."
6. Safety netting: Doctor: "If you develop any new symptoms, especially fever, severe
pain, or any of the symptoms we discussed in the systemic review, please seek
medical attention promptly."

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Paronychia

Case Presentation

• Patient: 20-year-old male

• Chief complaint: Pain and swelling in big toe
• Trigger: Hit toe on tea table

Initial Approach

Patient: "Doctor, I think I might have gout. My grandfather had it, and I've got this pain in
my big toe after I hit it on the tea table."

Doctor: "I understand your concern, but let's not jump to conclusions. Gout is less
common in young people, and trauma can cause similar symptoms. Let's talk more about
what you're experiencing with your toe. Can you describe the pain and any other symptoms
you're having?"

Detailed History Taking

1. Pain characteristics: Doctor: "Can you describe the pain? Is it constant or does it
come and go?" Patient: "It's pretty constant, and it gets worse when I try to move my
toe or put pressure on it." Doctor: "On a scale of 1 to 10, how would you rate the
pain?" Patient: [Note response]
2. Associated symptoms: Doctor: "Apart from the pain, have you noticed any:
o Redness around the nail?
o Swelling?
o Any discharge or pus?
o Numbness or tingling?
o Any change in the color of your nail?" Patient: "It's definitely red and
swollen. I haven't seen any pus, and there's no numbness. The nail looks
normal, I think."
3. Onset and evolution: Doctor: "When exactly did this start, and how has it changed
since then?" Patient: "It started right after I hit my toe on the table a couple of days
ago. It's been getting more swollen and painful since then."
4. Previous episodes: Doctor: "Have you ever had anything like this before?" Patient:
"No, this is the first time."
5. Alleviating/Aggravating factors: Doctor: "Is there anything that makes it feel better
or worse?" Patient: "It feels worse when I'm walking or wearing tight shoes. Keeping
it elevated seems to help a bit."

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6. General health: Doctor: "Do you have any other medical conditions or take any
medications regularly?" Patient: [Note response]
7. Footwear and hygiene: Doctor: "Can you tell me about the types of shoes you
usually wear? How often do you trim your toenails?" Patient: [Note response]

Physical Examination

Doctor: "I'm going to examine your toe now. Let me know if anything I do causes pain."

[Examine the toe, noting redness, swelling, and any signs of infection around the nail.
Check for signs of ingrown toenail.]

Diagnosis

Doctor: "Based on my examination and what you've told me, this condition is called
paronychia. It's an inflammation of the skin around the nail, often caused by an ingrown
toenail. It's not gout, despite the similarity in location."

Treatment Plan

1. For mild cases (redness without pus): Doctor: "Since there's no sign of pus, we'll
start with a topical treatment:
o I'm prescribing fucidic acid cream. Apply it 2-3 times a day around the nail.
o You can take over-the-counter painkillers like ibuprofen if needed for pain
and inflammation."
2. For cases with pus: Doctor: "If you start to see any pus or if the pain gets much
worse, you'll need to come back. We might need to drain the infection and start you
on oral antibiotics. If this happens and you remember you're allergic to penicillin,
make sure to tell the doctor as we'd need to use a different antibiotic, likely
doxycycline."
3. Prevention and home care: Doctor: "To help prevent this from happening again and
to promote healing:
o Soak your foot in warm salt water for about 15 minutes, 3-4 times a day.
o Don't cut your nails too short. Let the nail grow out of the skin.
o You can gently place some cotton wool or dental floss between the nail and
the skin to guide the nail as it grows.
o Wear wider shoes to reduce pressure on your toes.
o Avoid picking at your nails."
4. Follow-up: Doctor: "If it doesn't improve within a week, or if you start to see pus or
experience increased pain, please come back to see us."

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5. For severe cases or recurrence: Doctor: "In some cases, we might need to refer you to
a podiatrist for a procedure called nail avulsion, where part or all of the nail is
removed. But let's see how it responds to this treatment first."

Psoriasis
Case Presentation 1: Elbow Psoriasis

• Patient: Young adult (male or female)

• Chief complaint: Rash on elbow

Initial Approach

Patient: "Doctor, I've developed this rash on my elbow. It's been there for a while and
doesn't seem to be going away."

Doctor: "I see. Let's take a closer look at this rash and discuss what's been happening in
detail."

Detailed History Taking

1. Morphology and Evolution: Doctor: "Can you describe the rash for me? What does
it look like?" Patient: "It's red and scaly, and seems to be getting thicker." Doctor:
"When did you first notice this rash?" Patient: "I first noticed it about a month ago."
Doctor: "Has it changed since you first noticed it?" Patient: "It started small but has
been slowly getting larger."
2. Symptoms: Doctor: "Is the rash itchy or painful?" Patient: "It's a bit itchy, especially
when it gets dry." Doctor: "Does anything seem to make it better or worse?" Patient:
[Note response]
3. Distribution: Doctor: "Is the rash only on your elbow, or have you noticed it
anywhere else?" Patient: "I've noticed some similar patches on my other elbow and a
bit on my scalp." Doctor: "Have you noticed any changes in your nails, like pitting
or thickening?" Patient: [Note response]
4. Systemic symptoms: Doctor: "Have you experienced any other symptoms like:
o Joint pain or stiffness, especially in the morning?
o Changes in your nails?
o Any digestive issues like diarrhea or stomach pain?
o Unexplained weight loss?
o Any eye problems like redness or irritation?" [Note patient's responses to
each]

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5. Family history: Doctor: "Does anyone in your family have psoriasis or other skin
conditions?" Patient: "I'm not sure about psoriasis specifically, but my aunt has some
kind of skin problem." Doctor: "What about other conditions like arthritis or
inflammatory bowel disease in your family?" Patient: [Note response]
6. Impact on life: Doctor: "How is this rash affecting your daily life or mood?" Patient:
"It's making me self-conscious, especially when I wear short sleeves. I'm worried
about what people might think."
7. Previous treatments: Doctor: "Have you tried any treatments for this rash so far?"
Patient: "I've been using some over-the-counter hydrocortisone cream, but it doesn't
seem to help much."
8. Lifestyle factors: Doctor: "Do you smoke or drink alcohol?" Patient: [Note response]
Doctor: "How would you describe your stress levels recently?" Patient: [Note
response] Doctor: "What's your typical diet like?" Patient: [Note response]

Physical Examination

Doctor: "I'm going to examine your skin now, including the areas you mentioned on your
elbows and scalp. I'll also take a look at your nails."

[Conduct thorough examination, noting the appearance, distribution, and any associated
nail changes]

Doctor: "The rash on your elbows shows well-defined, red, scaly plaques. This is very
characteristic of psoriasis. I can also see some similar patches on your scalp."

Diagnosis

Doctor: "Based on my examination and the information you've provided; this condition
appears to be psoriasis. Let me explain what that means in detail."

Explanation and Treatment Plan

1. Definition: Doctor: "Psoriasis is:

o An inflammation of the skin that manifests as a rash with reddish, scaly
patches.
o An autoimmune condition, which means your body's defense system is
mistakenly attacking your own tissues.
o A systemic condition that can affect not just your skin, but also your nails,
joints, and other parts of your body.
o A chronic condition that tends to come and go throughout life, with flare-
ups occurring at any time."
2. Initial treatment: Doctor: "We'll start with a two-pronged approach:

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o I'm prescribing a cream called Dermovate. This is a strong steroid cream

available only by prescription. It's important to note that this is different
from over-the-counter hydrocortisone. Apply it twice daily to the affected
areas.
o I'm also prescribing a vitamin D preparation cream to use alongside the
Dermovate.
o Use both of these for four weeks.
o For your scalp, I'll prescribe a Dermovate scalp application."
3. Application instructions: Doctor: "Apply the creams thinly and gently. Don't use
them on your face unless specifically instructed. For the scalp application, part your
hair and apply directly to the affected areas."
4. Lifestyle changes: Doctor: "Some lifestyle changes can help manage psoriasis:
o If you smoke, quitting can help improve your symptoms.
o Regular exercise and maintaining a healthy weight can also be beneficial.
o Stress management techniques might help, as stress can trigger flare-ups.
Consider activities like meditation or yoga.
o A healthy, balanced diet rich in fruits, vegetables, and omega-3 fatty acids
may be helpful."
5. Follow-up: Doctor: "Let's schedule a follow-up appointment in one month to see
how you're responding to the treatment. If there's no improvement, we may need to
refer you to a dermatologist for more specialized treatment."
6. Potential specialist treatments: Doctor: "If we do need to refer you, a dermatologist
might consider treatments like:
o Ultraviolet light therapy
o Oral medications like methotrexate or cyclosporine
o Newer biological treatments that target specific parts of the immune system
They might also recommend joining a support group, which many patients
find helpful."
7. Monitoring: Doctor: "Given that psoriasis can affect more than just your skin, we'll
want to monitor you for signs of joint involvement or other related conditions. If
you start experiencing joint pain or stiffness, especially in the morning, please let us
know."
8. Triggers and self-care: Doctor: "Try to identify any triggers that worsen your
psoriasis. These could include stress, certain foods, or even specific skincare
products. Keeping your skin moisturized can help reduce symptoms. Use gentle,
fragrance-free moisturizers regularly."
9. Addressing concerns: Doctor: "I understand this diagnosis might be overwhelming.
Do you have any questions or concerns you'd like to discuss?"

Remember, for all these conditions, thorough history taking and careful examination are
crucial for accurate diagnosis. Always consider the patient's overall health status, lifestyle

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factors, and any risk factors when formulating a treatment plan. The key is to be thorough
in questioning, observant in examination, and clear in explanation and instructions to the
patient.

Things to avoid:

1. Don't dismiss the patient's initial self-diagnosis (like gout in the paronychia case)
without explanation.
2. Avoid using highly technical terms without explanation.
3. Don't forget to address the psychological impact of visible skin conditions like
psoriasis.
4. Avoid rushing through the explanation of chronic conditions like psoriasis; patients
need time to process the information.
5. Don't neglect to mention potential side effects of treatments, especially for long-
term use of topical steroids.

Lyme Disease
Case Presentation

• Setting: GP office
• Patient: Adult
• Chief complaint: Rash on arm
• Risk factor: Tick bite one month ago while walking in the bush

Initial Approach

Doctor: "I understand you've come in because of a rash on your arm. Can you tell me more
about it?"

Patient: "Yes, I noticed this circular rash on my arm. It's been there for about a month
now."

Detailed History Taking

1. Rash characteristics (Morphology): Doctor: "Can you describe the rash for me in
detail? What does it look like?" Patient: "It's a circular red rash, almost like a target
or bull's-eye." Doctor: "What's the size of the rash?" Patient: [Note patient's response]
Doctor: "Has the rash changed since you first noticed it?" (Evolution) Patient: "It's
gotten a bit larger, but otherwise looks the same."
2. Symptoms: Doctor: "Do you have any symptoms associated with the rash, such as
itching or pain?" Patient: "No, it doesn't itch or hurt at all." [Note: It's important to

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recognize that Lyme disease rash (erythema migrans) typically doesn't cause skin
symptoms]
3. Tick bite history: Doctor: "Have you had any tick bites recently, perhaps while
spending time outdoors?" Patient: "Actually, yes. I was walking in the bush about a
month ago and found a tick on me afterward." Doctor: "Do you remember how
long the tick was attached?" Patient: [Note patient's response]
4. Systemic symptoms: Doctor: "I need to ask about some other symptoms you might
be experiencing. Have you had any:
o Fever or night sweats?
o Unusual tiredness?
o Swollen glands?
o Headaches?
o Unusual sensations like tingling or numbness? (This could indicate nervous
system involvement)
o Difficulty concentrating or 'brain fog'?
o Joint pain or muscle aches?
o Changes in your vision? (This could indicate eye involvement)
o Irregular heartbeat or heart palpitations? (This could indicate heart
involvement)" [Note patient's responses to each]

[Remember: Lyme disease can affect multiple systems, particularly those associated with
"romance": brain, eyes, heart, skin, and joints]

5. Travel history: Doctor: "Have you traveled to any areas known for tick-borne
diseases recently?" Patient: [Note response]
6. Outdoor activities: Doctor: "Besides the bush walk a month ago, do you frequently
engage in outdoor activities?" Patient: [Note response]

Physical Examination

Doctor: "I'm going to examine the rash now. The circular, target-like appearance is very
characteristic of a condition called erythema migrans, which is associated with Lyme
disease."

[Conduct thorough examination, noting size, color, and any central clearing of the rash]

Diagnosis

Doctor: "Based on the appearance of your rash, which shows the classic 'target' or 'bull's-eye'
pattern we call erythema migrans, and your history of a tick bite, this condition is likely to
be Lyme disease. Lyme disease is an infection caused by bacteria called Borrelia, which is
transmitted through tick bites."

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Explanation and Treatment Plan

1. Nature of the condition: Doctor: "Lyme disease is an infection that can affect
various parts of your body. It primarily impacts areas associated with 'romance': your
brain, eyes, heart, skin, and joints. Early treatment is crucial to prevent
complications."
2. Treatment: Doctor: "We're going to start you on an antibiotic called doxycycline
immediately. You'll need to take this for seven days. The dosage will be [specify
dosage]. It's important to complete the full course of antibiotics even if you start
feeling better."
3. Referral: Doctor: "I'm also going to refer you urgently to the infectious diseases
department. They'll confirm the diagnosis with a blood test called ELISA and check
some inflammatory markers like ESR (Erythrocyte Sedimentation Rate). They may
continue or adjust your treatment based on these results."
4. Follow-up: Doctor: "The infectious diseases team will handle your follow-up care.
However, if you develop any new symptoms before your appointment with them,
please come back to see me or seek immediate medical attention if the symptoms
are severe."
5. Prevention: Doctor: "For future prevention, when you're in areas where ticks might
be present:
o Wear long sleeves and pants
o Use insect repellent
o Check yourself thoroughly for ticks after being outdoors
o Remove any ticks promptly if you find them"
6. Expectations: Doctor: "With proper treatment, most people recover fully from Lyme
disease. However, it's important to start treatment early, which is why we're acting
quickly in your case."

Key Points to Remember for Lyme Disease

1. The characteristic "target" or "bull's-eye" rash (erythema migrans) is diagnostic

2. Always ask about tick bites when presented with an unusual rash
3. The rash typically doesn't cause skin symptoms like itching or pain
4. Consider Lyme disease when a patient presents with the characteristic rash and
neurological, cardiac, or joint symptoms
5. Treatment is with doxycycline for 7 days
6. Urgent referral to infectious diseases is necessary for confirmation and follow-up
7. Never confuse the Lyme disease rash with tinea or ringworm, which typically have
central clearing

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Folliculitis

Case Presentation

• Patient: 18-year-old female

• Chief complaint: Rash in pubic area

Initial Approach

Doctor: "Hello, I understand you've come in because of a rash. Can you tell me more about
it?"

Patient: "Yes, I've developed a rash... um, down below."

Doctor: "I see. To make sure I understand correctly, can you be more specific about where
exactly the rash is located?"

Patient: "It's on the lower part of my tummy, around my genital area."

Detailed History Taking

1. Rash characteristics (Morphology): Doctor: "Can you describe the rash for me?
What does it look like?" Patient: "It's red and bumpy. There are lots of little red
spots." Doctor: "Are the bumps all the same size, or are some larger?" Patient: [Note
patient's response] Doctor: "When did you first notice this rash?" (Evolution)
Patient: [Note patient's response] Doctor: "Has it changed since you first noticed it?"
Patient: [Note patient's response]
2. Symptoms: Doctor: "Is the rash itchy, painful, or causing any discomfort?" Patient:
[Note patient's response]
3. Recent activities: Doctor: "Have you had any recent skin treatments or hair removal
in that area?" Patient: "Well, I had a Brazilian wax about a week ago." Doctor: "Was
this your first time getting a Brazilian wax?" Patient: [Note patient's response]
4. Systemic symptoms: Doctor: "Have you experienced any fever, general illness, or
noticed any discharge from the rash?" Patient: [Note patient's response]
5. Personal hygiene: Doctor: "Have you made any changes to your personal hygiene
routine recently?" Patient: [Note patient's response]
6. Clothing: Doctor: "What type of underwear do you usually wear? Cotton, synthetic,
or something else?" Patient: [Note patient's response]

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Physical Examination

Doctor: "I'm going to examine the rash now. What I can see are multiple small, red bumps
around the hair follicles. This appearance is consistent with a condition called folliculitis."

[Note: The rash may appear as redness scattered across the area, similar to a "Saudi Arabian
desert" - not necessarily with obvious follicular involvement or pus]

Diagnosis

Doctor: "Based on the appearance of the rash and your recent history of waxing, this
condition is called folliculitis. It's an inflammation of the hair follicles, which are the root
portions of the hairs."

Explanation and Treatment Plan

1. Cause: Doctor: "This mild form of folliculitis is likely caused by the recent waxing.
The process can irritate the hair follicles, leading to this kind of rash."
2. Prognosis: Doctor: "The good news is that this will likely go away on its own in a few
weeks. However, we can take some steps to help it resolve and make you more
comfortable."
3. Treatment: Doctor: "Here's what I recommend:
o Use a topical antiseptic called chlorhexidine. You can buy this from a
pharmacy and use it to wash the area 2-3 times a day. This is the same active
ingredient as in some mouthwashes, but please use a product specifically
designed for skin use.
o If there's itching, you can use an over-the-counter antihistamine.
o For any pain or discomfort, you can use hot packs on the area and take over-
the-counter painkillers if needed.
o Keep the area clean and dry. Avoid tight clothing or synthetic materials that
don't breathe well. Cotton underwear is best.
o Avoid sweating in the area if possible. If you exercise, try to shower soon
after."
4. Follow-up: Doctor: "This should resolve on its own, but if you develop a fever,
notice any discharge, or the rash gets significantly worse, please come back to see
me."
5. Future prevention: Doctor: "For future hair removal, you might want to consider
other methods that are less likely to irritate the skin. If you do wax again, make sure
it's done by a professional and follow their aftercare instructions carefully."

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Key Points to Remember for Folliculitis

1. Common in young adults, especially after hair removal procedures

2. Typically appears as small, red bumps around hair follicles, but may look like
scattered redness
3. Usually self-limiting and can be managed with topical treatments
4. Avoid prescribing antibiotics unless there are signs of more severe infection (fever,
discharge)
5. The age of the patient (18 in this case) is important to remember, as it helps
differentiate from other conditions like measles
6. Chlorhexidine is the recommended topical treatment
7. Emphasis on keeping the area clean and dry, and wearing breathable clothing

Remember, thorough history taking and careful examination are crucial for accurate
diagnosis in both conditions. Always consider the patient's age, recent activities, and
exposures when evaluating skin conditions. The key is to be thorough in questioning,
observant in examination, and clear in explanation and instructions to the patient.

Things to Avoid:

1. Don't confuse folliculitis with sexually transmitted infections or other genital rashes
2. Avoid prescribing antibiotics for mild folliculitis
3. Don't dismiss the patient's concerns or embarrassment about the location of the
rash
4. Avoid using technical terms without explanation
5. Don't forget to provide clear instructions on how to use the chlorhexidine wash

Oral Candidiasis (Oral Thrush)

Case Presentation 1: Child

• Patient: 4-5 year old child

• Brought by: Father
• Chief complaint: Not eating, rash on tongue

Initial Approach

Father: "Doctor, my son is not eating. Can you tell me what's wrong?"

Doctor: "I understand your concern. Let's start by discussing what you've noticed. You
mentioned he's not eating. Can you tell me more about that?"

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Father: "He's refusing to eat and seems uncomfortable. I noticed he has a rash on his
tongue."

Detailed History Taking

1. Rash characteristics: Doctor: "Can you describe the rash on his tongue? What does
it look like?" Father: "It's white and covers parts of his tongue." Doctor: "Is it just on
the tongue or have you noticed it anywhere else in his mouth?" Father: [Note
response] Doctor: "If you were to try and wipe it gently, does it come off or stay
firmly in place?" Father: "It seems to come off a bit when I tried to wipe it."
2. Eating habits: Doctor: "When did you first notice he wasn't eating well?" Father:
[Note response] Doctor: "Is he able to drink liquids?" Father: [Note response]
Doctor: "Does he complain of any pain or discomfort when eating or drinking?"
Father: [Note response]
3. Medical history: Doctor: "Does your son have any medical conditions?" Father:
[Note response] Doctor: "Is he taking any medications?" Father: "Yes, he uses an
inhaler for his asthma." Doctor: "Can you tell me what color the inhaler is? Is it
brown and blue, or pink and blue?" Father: [Note response - either brown and blue
or pink and blue] Doctor: "How often does he use the inhaler?" Father: [Note
response] Doctor: "Does he rinse his mouth after using the inhaler?" Father: [Note
response]
4. Other symptoms: Doctor: "Has he had any fever, cough, or other symptoms?"
Father: [Note response] Doctor: "Has he been more tired than usual?" Father: [Note
response]
5. Risk factors: Doctor: "Has he been on any antibiotics recently?" Father: [Note
response] Doctor: "Does he have any known immune system problems?" Father:
[Note response]

Physical Examination

Doctor: "I'm going to examine your son's mouth now. [To child] Can you open wide for
me? Good job!"

[Note the presence of white, patchy lesions on the tongue and possibly other parts of the
mouth. Check if the white patches can be scraped off, leaving a red, raw area underneath.]

Diagnosis

Doctor: "Based on what I've seen and what you've told me, your son has a condition called
oral thrush, also known as oral candidiasis. It's a fungal infection in the mouth caused by a
yeast called Candida."

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Explanation and Treatment Plan

1. Cause: Doctor: "This condition is often seen in children who use steroid inhalers.
The steroid can sometimes allow the yeast, which is normally present in small
amounts, to grow more than usual. The inhaler your son uses contains a steroid
medication."
2. Treatment: Doctor: "We're going to treat this with an antifungal medication called
miconazole. It comes as an oral gel."
3. Application: Doctor: "You'll need to apply the gel to the affected areas in your son's
mouth 2-3 times a day for about 2-3 weeks. Here's how to apply it:
o Wash your hands thoroughly.
o Put a clean finger into your child's mouth and gently rub the gel on the
affected areas.
o Try to avoid your child eating or drinking for about 30 minutes after
application.
o Continue the treatment for at least 7 days after the symptoms have cleared."
4. Inhaler use: Doctor: "It's important that your son continues to use his inhaler as
prescribed for his asthma. However, to prevent this from happening again:
o Make sure he rinses his mouth with water after each use of the inhaler.
o If possible, use a spacer device with the inhaler.
o Consider giving the inhaler just before meals, as eating and drinking can
help rinse the mouth naturally."
5. Diet: Doctor: "While your son is recovering, try to avoid giving him sugary foods
and drinks, as these can encourage yeast growth."
6. Follow-up: Doctor: "If the thrush doesn't improve after a week of treatment, or if
your son develops any new symptoms like fever or difficulty swallowing, please bring
him back to see me."

Case Presentation 2: Elderly Patient

• Patient: Approximately 80 years old

• Chief complaint: Similar to child case - difficulty eating, white patches in mouth

[Follow similar history-taking and examination process as above, with these additional
considerations:]

Additional questions: Doctor: "Do you have any chronic medical conditions, such as
diabetes?" Patient: [Note response]

Doctor: "Are you currently undergoing any treatments for cancer or other conditions that
might affect your immune system?" Patient: [Note response]

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Doctor: "Are you taking any medications, including over-the-counter drugs or

supplements?" Patient: [Note response]

Doctor: "Do you wear dentures? If so, how do you clean them?" Patient: [Note response]

Doctor: "Have you noticed any changes in the amount of saliva in your mouth? Does your
mouth feel dry?" Patient: [Note response]

Treatment remains the same (miconazole oral gel), but with these additional instructions:

• If patient wears dentures, remove them during sleep and when applying the gel.
• Emphasize the importance of good oral hygiene and regular dental check-ups.
• Consider prescribing an antimicrobial mouthwash if oral hygiene is poor.
• Schedule a follow-up appointment in one week to monitor progress, given the
patient's age and potential comorbidities.

Syphilis
Case Presentation 1: Primary Syphilis in GP Setting

• Patient: Adult male

• Chief complaint: Rash on penis

Initial Approach

Doctor: "I understand you've come in because of a rash. Can you tell me more about it?"

Patient: "Yes, I've noticed a rash on my penis. I'm a bit worried about it."

Detailed History Taking

1. Rash characteristics: Doctor: "Can you describe the rash for me? Where exactly is it
on your penis?" Patient: "It's on the shaft. It's just one spot." Doctor: "How long have
you had this rash?" Patient: [Note response] Doctor: "Is it painful or itchy?" Patient:
"No, it doesn't hurt or itch at all." Doctor: "Have you noticed any discharge or
bleeding from the area?" Patient: [Note response]
2. Sexual history: Doctor: "To help understand what might be causing this, I need to
ask you some questions about your sexual history. Is that okay?" Patient: [Await
consent] Doctor: "Are you sexually active?" Patient: "Yes, I am." Doctor: "Do you
have sex with men, women, or both?" Patient: "I have sex with men." Doctor: "When
was your last sexual encounter?" Patient: [Note response] Doctor: "Do you use

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protection during sex? If so, how consistently?" Patient: [Note response] Doctor:
"Have you had any new sexual partners recently?" Patient: [Note response]
3. Other symptoms: Doctor: "Have you noticed any other symptoms, like fever, fatigue,
swollen lymph nodes, or a rash anywhere else on your body?" Patient: [Note
response]
4. Medical history: Doctor: "Do you have any chronic medical conditions?" Patient:
[Note response] Doctor: "Are you taking any medications regularly?" Patient: [Note
response] Doctor: "Do you have any allergies to medications?" Patient: "Yes, I'm
allergic to penicillin." Doctor: "What happens when you take penicillin?" Patient:
[Note response - important to distinguish between true allergy and side effects]
5. Risk factors: Doctor: "Have you ever been tested for HIV or other sexually
transmitted infections?" Patient: [Note response]

Physical Examination

Doctor: "I'm going to examine the rash now. What I can see is a single, firm, painless sore
on the shaft of your penis. This is characteristic of a condition called a chancre."

Diagnosis

Doctor: "Based on the appearance of this sore and your history, I suspect this could be
primary syphilis. Syphilis is a sexually transmitted infection caused by a bacteria called
Treponema pallidum."

Management Plan

1. Referral: Doctor: "I'm going to refer you to a GUM (genitourinary medicine) clinic
for confirmatory testing and treatment. They specialize in sexually transmitted
infections and can provide comprehensive care."
2. Testing: Doctor: "At the GUM clinic, they'll likely take a swab of the sore and do
some blood tests. They'll also probably test for other STIs, including HIV, as it's
common to have more than one infection at a time."
3. Treatment: Doctor: "The usual treatment for syphilis is penicillin, but since you're
allergic, they'll likely prescribe an alternative antibiotic called doxycycline. This will
be taken twice a day for one month."
4. Partner notification: Doctor: "It's important that any sexual partners you've had in
the last three months are also tested and treated if necessary. The GUM clinic will
discuss this with you in more detail and can help with contacting partners
anonymously if needed."
5. Follow-up: Doctor: "Make sure to attend all follow-up appointments at the GUM
clinic to ensure the infection has been fully treated. They'll likely want to do repeat
blood tests to confirm the infection is gone."

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6. Safe sex practices: Doctor: "Until you've completed treatment and had follow-up
tests confirming the infection is gone, it's important to abstain from sexual contact
or use condoms consistently to prevent transmitting the infection."

Case Presentation 2: Secondary Syphilis in GUM Clinic

• Patient: Adult male

• Setting: GUM clinic for test results discussion
• Test results: Treponema pallidum antibodies positive

Initial Approach

Doctor: "Hello, I understand you're here to discuss your test results. Your blood test has
come back positive for syphilis antibodies. Let's talk about what this means and what the
next steps are."

Detailed History Taking

1. Previous symptoms: Doctor: "You mentioned you had a rash before. Can you tell
me more about it?" Patient: "Yes, I had a rash but it's gone now." Doctor: "Where
was the rash located? What did it look like?" Patient: [Note response] Doctor: "Did
you notice any sores or ulcers before the rash appeared?" Patient: [Note response]
2. Current symptoms: Doctor: "Are you experiencing any symptoms now? For
example:
o Headaches or difficulty concentrating?
o Changes in your vision or hearing?
o Skin rashes, especially on your palms or soles?
o Hair loss?
o Sore throat?
o Fever or generally feeling unwell?
o Any heart palpitations or chest pain?" Patient: [Note responses to each]
3. Sexual history: Doctor: "I need to ask about your recent sexual history to help with
contact tracing. When was your last sexual encounter?" Patient: "I went to a party
recently and had sex with some people there." Doctor: "Was this a specific event or
venue?" Patient: [Note response] Doctor: "Do you know any of these partners' names
or contact information?" Patient: "No, it was all anonymous." Doctor: "Do you have
any regular sexual partners besides this event?" Patient: [Note response] Doctor: "Do
you use protection during sex? If so, how consistently?" Patient: [Note response]
4. Medical history: Doctor: "Do you have any chronic medical conditions?" Patient:
[Note response] Doctor: "Are you taking any medications regularly?" Patient: [Note

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response] Doctor: "Do you have any allergies to medications, particularly penicillin?"
Patient: "No, no allergies."

Diagnosis and Management

1. Diagnosis confirmation: Doctor: "The positive antibody test confirms that you have
syphilis. Based on your history, it seems you're in the secondary stage of the
infection. This means the bacteria has spread throughout your body, but it's still
very treatable."
2. Treatment: Doctor: "The treatment for syphilis is an antibiotic called benzathine
benzylpenicillin. It's given as a single injection. This is usually enough to cure the
infection."
3. Procedure: Doctor: "The injection will be given into a large muscle, usually your
buttock. It might be a bit uncomfortable, but it's over quickly. You might have some
soreness at the injection site for a day or two."
4. Side effects: Doctor: "Some people experience what's called a Jarisch-Herxheimer
reaction within the first 24 hours after treatment. This can include fever, chills, and
worsening of any syphilis symptoms you have. It's not dangerous and usually passes
within a day."
5. Partner notification: Doctor: "It's crucial that we try to notify your recent sexual
partners so they can be tested and treated if necessary. While you don't have their
contact information, could you provide details about the party organizers? We can
anonymously inform them about potential exposure." Doctor: "We have specialized
health advisors who can help with contacting partners anonymously. They're very
experienced and will handle this sensitively."
6. Follow-up: Doctor: "We'll need to do follow-up blood tests to ensure the treatment
has been effective. Let's schedule your next appointment for three months from
now. If all is well then, we'll do another test at six months."
7. Prevention: Doctor: "For future prevention, it's important to use protection during
sexual encounters and to get regular STI screenings. We recommend testing every
three months for sexually active gay and bisexual men."
8. Additional testing: Doctor: "We should also test for other STIs, including HIV,
hepatitis B, and hepatitis C. Is that okay with you?" [Proceed with additional testing
as agreed]

Key Points to Remember

1. Oral Candidiasis (Thrush):

o Often associated with steroid inhaler use in children and
immunosuppression in elderly
o Presents as white, removable patches in the mouth

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o Treated with miconazole oral gel for 2-3 weeks

o Prevent recurrence by rinsing mouth after inhaler use
o Consider underlying conditions in elderly patients
2. Syphilis:
o Primary stage presents with a single, painless sore (chancre)
o Secondary stage may have systemic symptoms and rash
o Diagnosed through physical exam and blood tests
o Treated with benzathine benzylpenicillin injection (if not allergic) or
doxycycline (if penicillin-allergic)
o Partner notification and follow-up testing are crucial
o Always consider and test for co-infections (HIV, hepatitis)

Remember, thorough history taking and careful examination are crucial for accurate
diagnosis in both conditions. Always consider the patient's age, risk factors, and sexual
history when evaluating these conditions. The key is to be thorough in questioning,
observant in examination, and clear in explanation and instructions to the patient.

Things to Avoid:

1. Don't forget to ask about inhaler use in children with oral thrush
2. Avoid dismissing oral thrush in adults without considering underlying conditions
3. Don't neglect to ask about penicillin allergy in syphilis cases
4. Avoid judgmental language when discussing sexual history
5. Don't forget to discuss partner notification in syphilis cases
6. Avoid using medical jargon without explanation
7. For Oral Candidiasis:
1. Don't forget to address the impact on the child's eating habits and provide
advice on managing this during treatment.
2. In elderly patients, consider the possibility of interaction between miconazole
gel and other medications, especially warfarin.
3. Emphasize the importance of continuing inhaler use in asthmatic children,
despite the thrush.
8. For Syphilis:
1. Always maintain a high index of suspicion for syphilis, as its presentation can
be varied and subtle.
2. Don't forget to counsel patients about the potential for a Jarisch-Herxheimer
reaction after treatment.
3. Emphasize the importance of completing the full course of treatment, even if
symptoms improve quickly.
4. In cases of penicillin allergy, confirm the nature of the allergy before
prescribing alternative treatments.

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9. General points:
1. Always maintain patient confidentiality, especially in sensitive cases like STIs.
2. Provide clear, written instructions for medication use and follow-up
appointments.
3. Offer psychological support or referral if the patient appears distressed by the
diagnosis.

Detailed Conversations:

For Oral Candidiasis in children: Doctor: "I understand it might be challenging to apply
the gel to your child's mouth. Here's a tip: you can try applying it with a clean cotton swab
or a soft, clean cloth wrapped around your finger. This might make it easier to reach all the
affected areas."

Parent: "What if my child spits out the gel or refuses to let me apply it?"

Doctor: "That can be tricky. Try to make it into a game, or offer a reward after application.
If you're really struggling, let me know and we can discuss alternative treatments.
Remember, it's important to persist with the treatment to clear the infection completely."

For Syphilis: Doctor: "I understand receiving this diagnosis can be overwhelming. Do you
have any questions or concerns you'd like to discuss?"

Patient: "I'm worried about telling my partners. What if they get angry?"

Doctor: "I understand your concern. Remember, our health advisors are experienced in
handling these situations sensitively. They can help notify partners anonymously if you
prefer. The most important thing is ensuring everyone gets the care they need. Would you
like me to arrange for you to speak with a health advisor about this?"

Patient: "Yes, that would be helpful. Thank you."

Doctor: "Of course. I'll arrange that for you. Remember, syphilis is treatable, and by
addressing it promptly, you're taking care of your health and potentially your partners'
health too."

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Genital Herpes

Case Presentation

• Patient: Female, 26 weeks pregnant

• Chief complaint: Rash "down below"

Initial Approach

Doctor: "Hello, I understand you've come in because of a rash in your genital area. Can
you tell me more about it?"

Patient: "Yes, I've noticed a painful rash down below. I'm worried because I'm pregnant."

Detailed History Taking

1. Rash characteristics (Morphology): Doctor: "Can you describe the rash for me in
detail? What does it look like?" Patient: "It's painful and there are multiple small
blisters." Doctor: "Are the blisters filled with fluid or are they dry?" Patient: [Note
response] Doctor: "When did you first notice this rash?" Patient: [Note response]
Doctor: "Has it changed since you first noticed it?" (Evolution) Patient: [Note
response]
2. Symptoms: Doctor: "Apart from the pain, are you experiencing any other symptoms
like itching, burning, or discharge?" Patient: [Note response] Doctor: "Have you
noticed any flu-like symptoms such as fever, body aches, or fatigue?" Patient: [Note
response]
3. Sexual history: Doctor: "I need to ask some questions about your sexual history to
help understand what might be causing this. Is that okay?" Patient: [Await consent]
Doctor: "Have you had any new sexual partners recently?" Patient: [Note response]
Doctor: "Do you or your partner have a history of similar symptoms or diagnosed
herpes?" Patient: [Note response] Doctor: "Do you use any form of protection during
sexual intercourse?" Patient: [Note response]
4. Pregnancy: Doctor: "You mentioned you're pregnant. How far along are you?"
Patient: "I'm 26 weeks pregnant." Doctor: "Have you had any complications with
your pregnancy so far?" Patient: [Note response] Doctor: "Are you receiving regular
antenatal care?" Patient: [Note response]
5. Medical history: Doctor: "Do you have any other medical conditions?" Patient: [Note
response] Doctor: "Are you taking any medications, including over-the-counter drugs
or supplements?" Patient: [Note response]

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Physical Examination

Doctor: "I'm going to examine the rash now. What I can see are multiple small, painful
blisters in your genital area. This appearance is characteristic of genital herpes."

Diagnosis

Doctor: "Based on the appearance of the rash and your symptoms, this condition is likely
genital herpes. Herpes is a viral infection that causes painful blisters."

Management Plan

1. Treatment: Doctor: "We're going to start you on an antiviral medication called

acyclovir. Since you're less than 28 weeks pregnant, you'll take this twice a day for 5-
7 days now, and then again at 36 weeks of pregnancy." Patient: "Is this safe for my
baby?" Doctor: "Yes, acyclovir is considered safe to use during pregnancy. It's
important to treat the infection to reduce the risk of complications for both you
and your baby."
2. Symptom management: Doctor: "For pain relief, you can take paracetamol. I'll also
prescribe a lidocaine cream that you can apply to the affected area for local pain
relief."
3. Referrals: Doctor: "I'm going to make two referrals for you:
o First, to the GUM (genitourinary medicine) clinic to confirm the diagnosis
and provide specialized care.
o Second, to the Maternity Assessment Unit (MAU). You'll be seen by an
obstetrician consultant who will manage your care until delivery."
4. Delivery considerations: Doctor: "If the condition isn't fully treated, there's a
possibility you might need a cesarean section for delivery. The obstetrician will
discuss this with you in more detail."
5. Partner notification: Doctor: "It's important that your partner is also tested and
treated if necessary. The GUM clinic can assist with this."
6. Follow-up: Doctor: "Make sure to attend all your appointments with the GUM
clinic and the obstetrician. If your symptoms worsen or you have any concerns,
please contact us immediately."
7. Prevention of transmission: Doctor: "To reduce the risk of transmitting the virus to
your partner or your baby during delivery:
o Avoid sexual contact when you have active lesions
o Use condoms even when you don't have visible lesions
o Avoid touching the lesions and wash your hands frequently
o Inform your healthcare providers about this diagnosis at every visit"

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Note on Management if >28 Weeks Pregnant

If the patient were more than 28 weeks pregnant, the management would differ:

• Continuous acyclovir treatment until delivery

• Higher likelihood of cesarean section

Doctor: "If you were further along in your pregnancy, we would manage this slightly
differently. You would take acyclovir continuously until delivery, and there would be a
higher chance of needing a cesarean section. However, at 26 weeks, we have time to treat
this episode and prepare for any potential recurrence near your due date."

Genital Warts

Case Presentation

• Patient: 15-year-old girl

• Chief complaint: Lump "down below"

Initial Approach

Doctor: "Hello, how can I help you today?"

Patient: "I've noticed a lump down below."

Doctor: "I see. To make sure I understand correctly, can you be more specific about where
exactly this lump is?"

Patient: "It's on my vagina."

Detailed History Taking

1. Lump characteristics (Morphology): Doctor: "Can you describe the lump for me?
What does it look like?" Patient: [Note response] Doctor: "Is it a single lump or are
there multiple?" Patient: [Note response] Doctor: "What color is it?" Patient: [Note
response] Doctor: "When did you first notice this lump?" (Evolution) Patient: [Note
response] Doctor: "Has it changed since you first noticed it?" Patient: [Note
response]
2. Symptoms: Doctor: "Is the lump causing any discomfort, pain, or itching?" Patient:
[Note response] Doctor: "Have you noticed any bleeding from the area?" Patient:
[Note response]

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3. STI symptoms: Doctor: "Have you noticed any other symptoms like unusual
discharge, pain when urinating, or bleeding between periods?" Patient: [Note
response]
4. Sexual history: Doctor: "I need to ask some questions about your sexual history to
help understand what might be causing this. I know this can be sensitive, but
everything we discuss is confidential. Is that okay?" Patient: [Await consent] Doctor:
"Are you sexually active?" Patient: [Note response] Doctor: "Can you tell me about
your partner?" Patient: "My partner is Brian. He's my boyfriend." Doctor: "As you're
under 16, we need to ask a few more questions about your partner. Is that okay?"
Patient: [Await consent] Doctor: "How old is Brian?" Patient: "He's a little older...
he's 35." Doctor: "I see. How did you meet Brian?" Patient: "He's my school
counselor." Doctor: "How long have you been in a relationship with Brian?" Patient:
[Note response] Doctor: "How did this relationship start?" Patient: [Note response]
Doctor: "Does anyone else know about this relationship?" Patient: [Note response]
Doctor: "Do your parents know about this relationship?" Patient: [Note response]
Doctor: "What has Brian said about your relationship? Has he ever asked you not to
tell anyone about it?" Patient: [Note response] Doctor: "Has Brian ever forced you to
do anything you didn't want to do?" Patient: [Note response] Doctor: "Has he ever
threatened you or been aggressive towards you?" Patient: [Note response]
5. Medical history: Doctor: "Do you have any other medical conditions?" Patient: [Note
response] Doctor: "Are you taking any medications?" Patient: [Note response]

Physical Examination

Doctor: "I'm going to examine the lump now. What I can see is consistent with a condition
called genital warts."

Diagnosis

Doctor: "Based on the examination, this could be a condition called genital warts. Genital
warts are abnormal growths caused by a virus called human papillomavirus (HPV)."

Management Plan

1. Referral: Doctor: "I'm going to refer you to a GUM (genitourinary medicine) clinic.
They'll confirm the diagnosis and provide treatment."
2. Treatment options: Doctor: "The main treatment is usually a cream called
Podophyllotoxin, also known as Warticon. It's applied directly to the warts. It can
take 1-6 months to work and might cause some irritation or discomfort. If this
doesn't work, there are other options like freezing (cryotherapy), surgery, or
electrocautery."

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3. Follow-up: Doctor: "It's important to attend all appointments at the GUM clinic.
They'll monitor your progress and adjust treatment if needed."
4. Prevention: Doctor: "To prevent future infections, it's important to use protection
during sexual activity. The GUM clinic can provide more detailed advice on this."

Addressing the Ethical Concerns

Doctor: "I need to discuss something important with you. We have some concerns
regarding your relationship with Brian. Because you are a minor, at a very young age, it's
wrong for him to be in a relationship with someone your age. This is especially concerning
because of his position as a school counselor. He's in a position of trust, which means he
has a responsibility to protect young people, not engage in relationships with them.

This situation is not your fault. Brian should be aware that this kind of relationship is not
allowed. Because of the seriousness of this situation, we are required to report this to the
appropriate authorities. I will be speaking to my seniors about this, and child protection
services will be contacted. The police may also become involved, and at some point, your
parents will need to be informed.

We advise you not to have further contact with Brian. I know this might be upsetting, but
it's important for your safety and wellbeing. Do you have any questions about what I've just
explained?"

Patient: "But I love him, and he's a really good guy. I don't want him to get in trouble."

Doctor: "I understand this is difficult to hear. However, a person in Brian's position has a
legal and moral responsibility not to engage in relationships with minors, regardless of
feelings involved. This is to protect young people like yourself. The authorities will handle
this situation appropriately."

Key Points to Remember

1. Genital Herpes:
o Presents as painful, multiple blisters
o Treatment in pregnancy depends on gestational age
o Always refer pregnant patients to obstetrics
o Consider delivery method (potential C-section)
o Acyclovir is the treatment of choice
o Two rounds of treatment if <28 weeks pregnant: immediate and at 36 weeks
o Continuous treatment if >28 weeks pregnant
2. Genital Warts:
o Caused by HPV

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o Main treatment is Podophyllotoxin (Warticon) cream

o Always refer to GUM clinic for confirmation and treatment
o Treatment can take 1-6 months to be effective
3. Ethical Considerations:
o Be alert to potential abuse or exploitation, especially with minors
o Explain concerns clearly but sensitively
o Always report concerns about minors to appropriate authorities
o Avoid judgmental language, focus on patient safety and wellbeing
o Be prepared for patient resistance or denial
o Emphasize that the situation is not the minor's fault
4. General Points:
o Always take a thorough sexual history
o Ensure confidentiality, but explain its limits (especially with minors)
o Provide clear explanations of diagnoses and treatments
o Emphasize the importance of partner notification and treatment
o Provide advice on preventing transmission and future infections

Intertrigo
Case Presentation

• Patient: Female, 65-70 years old

• Chief complaint: Rash under breast, itchy and red

Detailed History Taking

Doctor: "Can you tell me more about this rash under your breast?"

Patient: "It's red, itchy, and quite uncomfortable."

Doctor: "When did you first notice it?"

Patient: [Note response]

Doctor: "Has it changed since you first noticed it?"

Patient: [Note response]

Doctor: "Do you have any other medical conditions, such as diabetes?"

Patient: [Note response - important to check for immunocompromise]

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Diagnosis

Doctor: "Based on the location and appearance of the rash, this condition is called
intertrigo. It's an inflammation that occurs in skin folds, often due to moisture and
friction."

Management Plan

1. Treatment: Doctor: "We'll treat this with a combination approach:

o Hydrocortisone cream, a mild steroid, for a maximum of 7 days
o Clotrimazole cream, an antifungal, applied 2-3 times a day for about 2 weeks"
2. Prevention: Doctor: "Once the infection clears, you can use a barrier cream like zinc
oxide or castor oil to prevent recurrence. Also:
o Wash the affected area twice daily and pat dry gently
o Wear supportive, cotton bras
o Avoid sharing towels or flannels"

Cherry Angiomas

Case Presentation

• Patient: Male, 65 years old

• Chief complaint: Rash on body, present for 5-6 years, now spreading
• Occupation: Firefighter (note: occupation not relevant to condition)

Detailed History Taking

Doctor: "Can you tell me more about this rash?"

Patient: "I've had it for about 5-6 years, but it seems to be spreading now."

Doctor: "Are the spots raised? What color are they?"

Patient: "They're slightly raised and bright red."

Doctor: "Do they cause any discomfort or bleeding?"

Patient: [Note response]

Doctor: "Have you had much sun exposure over the years?"

Patient: [Note response - although condition not related to sun exposure, important to ask]

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Diagnosis

Doctor: "Based on your description and my examination, these are called cherry angiomas.
They're small overgrowths of blood vessels, which is why they appear bright red."

Management and Advice

Doctor: "Cherry angiomas are very common as we age. They're benign, meaning they don't
turn into cancer. They don't need treatment, but:

• Avoid scrubbing the area

• Wear comfortable, cotton clothing
• They won't disappear on their own, but they're harmless
• If any change significantly in appearance, let us know"

Molluscum Contagiosum
Case Presentation

• Patient: Child, 4-5 years old

• Chief complaint: Rash on shoulder and chest, one side only
• Duration: 2-3 days
• Additional info: Mother is pregnant and concerned about transmission

Detailed History Taking

Doctor: "Can you describe the rash you've noticed on your child?"

Mother: "It's on their shoulder and chest, just on one side. It's been there for 2-3 days."

Doctor: "Is it causing any discomfort?"

Mother: "It seems a bit itchy, but otherwise they're fine - eating, drinking, and playing
normally."

Doctor: "Have you noticed any fever or other symptoms?"

Mother: "No, they seem completely well otherwise."

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Physical Examination

Doctor: "I'm going to examine the rash now. What I can see are small, raised bumps. They
have a characteristic dimple in the center, which is typical of a condition called molluscum
contagiosum."

Diagnosis and Explanation

Doctor: "This condition is called molluscum contagiosum. It's caused by a virus called
poxvirus. It's generally harmless and will go away on its own, but this can take several
months, sometimes up to 18 months."

Management and Advice

Doctor: "Usually, we don't need to treat molluscum contagiosum as it will resolve on its
own. However:

• There's a cream called Molludab available from pharmacies. You can try this, but
there's limited evidence of its effectiveness.
• We can offer treatments like freezing or heat therapy if it's particularly bothersome.
• Watch for signs of bacterial infection, like increasing redness or pain.
• Regarding your pregnancy, the risk of transmission is low if you maintain good
hygiene practices."

Herpetic Whitlow
Case Presentation

• Patient: Male, occupation as typist

• Chief complaint: Painful blister on thumb
• Additional info: Also has a cold sore

Detailed History Taking

Doctor: "Can you tell me about this blister on your thumb?"

Patient: "It's painful and appeared yesterday."

Doctor: "Have you had anything like this before?"

Patient: [Note response - important to check for recurrence]

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Doctor: "Do you have any other medical conditions or take any medications regularly?"

Patient: [Note response - check for immunocompromise]

Doctor: "You mentioned you have a cold sore as well. When did that appear?"

Patient: [Note response]

Diagnosis

Doctor: "Based on the appearance of the blister and its association with your cold sore, this
is likely a condition called herpetic whitlow. It's caused by the same virus that causes cold
sores."

Management Plan

1. Treatment: Doctor: "Since the blister appeared within the last 48 hours, we'll start
you on an antiviral medication called acyclovir. You'll take this for 5-7 days. We'll
also give you paracetamol for pain relief."
2. Care instructions: Doctor: "Keep the area clean and covered with a dry dressing to
prevent spread."
3. Work considerations: Doctor: "I understand you're a typist and need to work. We
have a couple of options:
o I can give you a sick note if you'd prefer to stay home while it heals
o Or, if you need to work, we can provide stronger pain relief and a numbing
cream to help you type comfortably. Which would you prefer?"

Patient: [Note response and proceed accordingly]

Doctor: "Remember, it's crucial to keep the lesion covered and maintain good hand
hygiene to prevent spreading the infection."

Key Points to Remember for All Conditions

1. Always take a thorough history, including duration, evolution of symptoms, and

impact on daily life.
2. Consider the patient's overall health status, particularly any immunocompromising
conditions.
3. Provide clear explanations of the diagnosis and management plan.
4. Offer reassurance for benign conditions like cherry angiomas.
5. For infectious conditions, emphasize hygiene and prevention of spread.

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6. Be prepared to discuss how the condition might impact the patient's work or daily
activities.
7. Always follow up on any concerning changes or worsening of symptoms.

Vulval Carcinoma
Case Presentation

• Patient: Female, approximately 70 years old

• Setting: GP clinic
• Chief complaint: "Embarrassing problem" - growth on vagina
• Risk factor: History of lichen sclerosis

Initial Approach

Doctor: "Hello, I understand you have a concern that you find embarrassing. Please don't
worry, as doctors we encounter all kinds of medical issues daily. This may be the first time
we've heard about this specific problem, but we're here to help. Can you tell me more
about what's bothering you?"

Patient: "Well... it's embarrassing, but there's something growing on my vagina."

Detailed History Taking

1. Lump characteristics (Morphology): Doctor: "Can you describe this growth for me?
What does it look like?" Patient: "It's a lump, and it bleeds when I touch it." Doctor:
"How long have you noticed this growth?" (Evolution) Patient: [Note response]
Doctor: "Has it changed in size or appearance since you first noticed it?" Patient:
[Note response]
2. Symptoms: Doctor: "Apart from bleeding when touched, does it cause any other
discomfort or pain?" Patient: [Note response] Doctor: "Have you noticed any
itching, burning, or discharge?" Patient: [Note response]
3. Menstrual history: Doctor: "When was your last menstrual period?" Patient: "It was
about 10-15 years ago."
4. Urinary symptoms: Doctor: "Have you noticed any changes in your urination? Any
difficulty or pain when urinating?" Patient: [Note response]
5. Bowel symptoms: Doctor: "Have there been any changes in your bowel habits?"
Patient: [Note response]
6. Sexual history: Doctor: "Have you noticed any pain or bleeding during or after
sexual activity?" Patient: [Note response]
7. Past medical history: Doctor: "Do you have any history of skin conditions in this
area?" Patient: "Yes, I've had lichen sclerosis for about six years." Doctor: "Have you

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been receiving any treatment for the lichen sclerosis?" Patient: "Yes, I've been using a
steroid cream for it." Doctor: "How long have you been using the steroid cream?"
Patient: "For about six years now."
8. Other relevant history: Doctor: "Have you had any previous growths or
abnormalities in this area?" Patient: [Note response] Doctor: "Has anyone in your
family had similar issues or been diagnosed with vulval or other gynecological
cancers?" Patient: [Note response]

Physical Examination

Doctor: "I'd like to examine the area now, if that's okay with you. This will help me
understand better what we're dealing with."

[After examination] Doctor: "Thank you for allowing me to examine you. I can see the
growth you've described. It appears as a lump on the labia (the lips of the vagina). It looks
[describe appearance, matching the image provided - e.g., raised, with irregular borders,
possibly ulcerated]."

Diagnosis

Doctor: "Based on the examination and your history, particularly your history of lichen
sclerosis, I'm concerned this could be a condition called vulval carcinoma. This is a type of
cancer affecting the external parts of the female genitals."

Patient: "Cancer? Oh no, that sounds serious."

Doctor: "I understand this is worrying to hear. It's important to remember that we don't
have a definitive diagnosis yet, and even if it is vulval carcinoma, it's often treatable,
especially when caught early."

Management Plan

1. Referral: Doctor: "I'm going to refer you urgently to a specialist. This will be a two-
week referral, which means you should be seen within two weeks. The referral will
be to either a gynaecologist or a dermatologist, given your history of lichen
sclerosis."
2. Further testing: Doctor: "The specialist will likely take a tissue sample, called a
biopsy, to confirm the diagnosis. This involves removing a small piece of the growth
to examine under a microscope."
3. Potential treatment: Doctor: "If the diagnosis is confirmed, treatment usually
involves surgery. This might include removing the affected area and possibly
surrounding tissues. The extent of surgery will depend on how advanced the

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condition is. In some cases, they might need to remove part or all of the vulva, and
possibly nearby lymph nodes. In some cases, chemotherapy or radiotherapy might
also be recommended, either instead of or in addition to surgery. If extensive
surgery is needed, they may also discuss reconstructive options with you."
4. Risk factors: Doctor: "It's important to note that having lichen sclerosis does
increase the risk of this type of cancer. That's why it's crucial to continue follow-ups
for your lichen sclerosis as well."
5. Support: Doctor: "I understand this is a lot to take in. Do you have any questions?
Would you like me to arrange for you to speak with a counsellor or support service?"
Patient: "This is all very overwhelming. What should I do while waiting for the
specialist appointment?" Doctor: "While you're waiting:
o Continue using your lichen sclerosis medication as prescribed
o Avoid irritating the area - use gentle, fragrance-free soaps and soft toilet paper
o Don't hesitate to call if you have any increased pain, bleeding, or other
concerns
o Try to stay positive - remember, we're taking quick action to get you the care
you need"

Key Points to Remember for Vulval Carcinoma

• Always take concerns about genital growths seriously, especially in older women
• History of lichen sclerosis is a significant risk factor
• Urgent two-week referral is necessary for suspected cases
• Treatment often involves surgery, possibly followed by chemotherapy or
radiotherapy
• Emotional support is crucial throughout the diagnostic and treatment process

Tinea Capitis

Case Presentation

• Patient: Adult (gender not specified)

• Chief complaint: Persistent dandruff not responding to treatment
• Occupation: Farm worker

Initial Approach

Patient: "Doctor, I've been having this terrible dandruff. I've been washing my hair and
using ketoconazole shampoo, but nothing seems to help."

Doctor: "I'm sorry to hear you're having this problem. Can you tell me more about it?"

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Detailed History Taking

1. Scalp symptoms: Doctor: "Can you describe what you're seeing on your scalp?"
Patient: "It's very flaky and itchy. The dandruff just won't go away no matter what I
do." Doctor: "Have you noticed any hair loss?" Patient: "Yes, I think I am losing
more hair than usual, especially in the areas with the worst flaking." Doctor: "Is
there any redness on your scalp?" Patient: "Yes, it does look a bit red and inflamed."
2. Duration and evolution: Doctor: "When did you first notice this problem?" Patient:
"It's been going on for several months now." Doctor: "Has it changed or spread since
it started?" Patient: "It seems to be getting worse and covering more of my scalp."
3. Occupation: Doctor: "You mentioned you work on a farm. Can you tell me more
about your work? Do you work with animals?" Patient: "Yes, I work with cattle and
sheep regularly." Doctor: "Do you wear any head covering while working?" Patient:
[Note response]
4. Previous treatments: Doctor: "What treatments have you tried so far?" Patient: "I've
been using ketoconazole shampoo, but it doesn't seem to help. I've also tried regular
anti-dandruff shampoos." Doctor: "How often have you been using the ketoconazole
shampoo?" Patient: [Note response]
5. Other symptoms: Doctor: "Have you noticed any symptoms elsewhere on your
body? Any rashes or itchy areas?" Patient: [Note response]

Physical Examination

Doctor: "I'm going to examine your scalp now."

[After examination] Doctor: "I can see areas of scaling and some redness. There also
appears to be some hair loss in the affected areas. The hairs in these areas seem to be
breaking off close to the scalp."

Diagnosis

Doctor: "Based on the examination and your history, particularly your work with animals,
this condition is called tinea capitis. It's a fungal infection of the scalp, sometimes referred
to as scalp ringworm. It's different from regular dandruff, which is why the anti-dandruff
treatments haven't been effective."

Management Plan

1. Treatment: Doctor: "We're going to treat this with an oral antifungal medication
called griseofulvin. You'll need to take this for 4-8 weeks." Patient: "Is it safe to take
medication for that long?" Doctor: "Griseofulvin is generally well-tolerated, but like

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all medications, it can have side effects. We'll monitor you closely. It's important to
complete the full course to ensure the infection is fully treated."
2. Adjunct treatment: Doctor: "In addition, I want you to use ketoconazole shampoo
2-3 times a week while you're taking the oral medication. This will help to clear the
fungus from the surface of your scalp."
3. Follow-up: Doctor: "I'd like you to come back for a review in 4-8 weeks to check how
the treatment is working. If you notice any side effects from the medication or if the
condition seems to be getting worse, please come back sooner."
4. Decontamination: Doctor: "To prevent reinfection, you'll need to decontaminate
items that come into contact with your scalp. This includes hats, scarves,
pillowcases, and combs. Wash these items in hot water or replace them if possible."
5. Prevention: Doctor: "Given your work with animals, it's important to take
precautions to prevent reinfection:
o Consider wearing a hat or hair covering at work
o Wash your hair after work if possible
o Avoid sharing personal items like combs or hats with others
o If you notice any animals with bald patches, report this to the appropriate
person at work, as animals can carry the fungus"
6. Expectations: Doctor: "It's important to understand that while the medication will
start working quickly, it may take several weeks to see significant improvement. The
hair loss should gradually improve as the infection clears."

Key Points to Remember for Tinea Capitis

• Can be mistaken for severe dandruff

• Oral antifungal treatment is necessary; topical treatments alone are not effective
• Occupation (e.g., farm work) can be a risk factor
• Treatment duration is typically 4-8 weeks
• Decontamination of personal items is crucial to prevent reinfection
• Follow-up is important to ensure complete resolution of the infection

Tinea Pedis (Athlete's Foot)

Case Presentation

• Patient: Adult (male or female)

• Chief complaint: Itchy rash on feet, especially between toes
• Occupation: Marathon runner

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Initial Approach

Patient: "Doctor, I've got this itchy rash on my feet, especially between my toes. It's really
bothering me."

Doctor: "I'm sorry to hear that. Can you tell me more about this rash?"

Detailed History Taking

1. Rash characteristics: Doctor: "Can you describe the rash for me? What does it look
like?" Patient: "It's red and scaly, especially between my toes. The skin seems to be
peeling." Doctor: "Is it on both feet or just one?" Patient: "It's on both feet, but
worse on my right foot."
2. Symptoms: Doctor: "You mentioned it's itchy. Is it worse at any particular time?"
Patient: "It seems to be itchier at night, but it doesn't stop me from sleeping. It's also
really itchy after I run." Doctor: "Is there any pain or burning sensation?" Patient:
[Note response]
3. Duration and evolution: Doctor: "When did you first notice this rash?" Patient: "I
first noticed it about a month ago." Doctor: "Has it changed or spread since it
started?" Patient: "It started just between my toes, but now it's spreading to the soles
of my feet."
4. Occupation and activities: Doctor: "I understand you're a marathon runner. How
often do you run?" Patient: "I run about 2-3 times a week, usually long distances as
I'm training for a marathon." Doctor: "How long are your shoes and socks usually
damp after a run?" Patient: "They're pretty sweaty for a while after I run. Sometimes
I don't change out of them immediately if I'm busy."
5. Footwear: Doctor: "Can you tell me about the shoes you wear for running and day-
to-day?" Patient: "I have special running shoes for marathons. They're quite
expensive, about 200 pounds." Doctor: "What about your everyday shoes? And do
you wear socks?" Patient: [Note response]
6. Previous treatments: Doctor: "Have you tried any treatments for this rash?" Patient:
[Note response]
7. Other relevant history: Doctor: "Have you had any similar rashes before, either on
your feet or elsewhere?" Patient: [Note response] Doctor: "Does anyone in your
household have a similar rash?" Patient: [Note response]

Physical Examination

Doctor: "I'm going to examine your feet now, particularly between your toes."

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[After examination] Doctor: "I can see signs of redness and scaling, particularly between
your toes and starting to spread to the soles of your feet. This is consistent with a condition
called tinea pedis."

Diagnosis

Doctor: "Based on the examination and your history, especially your frequent running, this
condition is called tinea pedis, commonly known as athlete's foot. It's a fungal infection of
the feet."

Management Plan

1. Treatment: Doctor: "We're going to treat this with an antifungal cream, either
clotrimazole or miconazole. Apply this twice daily to the affected areas. It's
important to continue using it for 1-2 weeks after the rash has disappeared to ensure
the infection is fully treated."
2. Additional treatment: Doctor: "I'm also prescribing a hydrocortisone cream to help
with the inflammation and itching. Use this for no more than 7 days. Apply it
about 20-30 minutes after the antifungal cream."
3. Footwear advice: Doctor: "It's important to take care of your footwear:
o Ideally, you should replace old shoes. However, I understand your running
shoes are expensive. In this case, you can decontaminate them with a
disinfectant spray. Spray the inside of the shoes and let them dry completely
before wearing them again.
o Alternate between different pairs of shoes every 2-3 days to allow each pair to
dry out completely between uses.
o Wear cotton socks and change them regularly, especially after running or if
your feet get sweaty."
4. Hygiene advice: Doctor: "To prevent reinfection:
o Dry your feet thoroughly after washing, especially between the toes. You can
use a hair dryer on a cool setting to ensure they're completely dry.
o Wear protective footwear in communal areas like locker rooms or public
showers.
o Avoid scratching the affected areas, as this can spread the infection and
potentially cause a bacterial infection."
5. Running advice: Doctor: "You can continue running, but it's important to manage
sweating:
o Change out of your sweaty socks and shoes as soon as possible after running.
o Wash and thoroughly dry your feet after running.
o Consider using an antifungal powder in your shoes before running to help
absorb moisture."

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6. Follow-up: Doctor: "If the rash doesn't improve after two weeks of treatment, or if it
gets worse at any point, please come back to see me.

Abuse and Safeguarding

Introduction and Context

This guide covers a range of abuse and safeguarding scenarios, including:

1. Non-accidental injury in children

2. Elderly abuse
3. Domestic violence (various presentations)
4. LGBTQ+ abuse
5. Patient-counsellor inappropriate relationships
6. Workplace harassment
7. Rape

These scenarios are presented to medical professionals because:

• They are often the first point of contact for identifying such issues
• They have an ethical, moral, and to some extent legal duty to protect vulnerable
people
• They need to demonstrate the ability to detect subtle signs and hidden agendas

The primary objectives are to:

1. Identify and recognize signs of abuse

2. Protect vulnerable members of society
3. Guide victims to appropriate help and support

It's crucial to understand that the medical professional's role is primarily to identify, record,
and escalate concerns, not to solve the social problems directly.

General Approach to Abuse and Safeguarding Scenarios

1. Look for clues in the patient's presentation or history

2. Be aware of hidden agendas - patients may present with one issue but have
underlying concerns they're hesitant to express
3. Use a structured approach to history taking and management

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General Approach to Other Abuse Scenarios

For scenarios involving domestic violence, LGBTQ+ abuse, patient-counsellor

relationships, workplace harassment, and rape:

1. Initial Approach:
o Spend the first minute discussing the presenting complaint
o Observe body language and emotional state
o If the patient seems anxious or reluctant to talk, acknowledge this: "You
seem a bit anxious. Is there anything else you'd like to talk about?"
2. Offering Confidentiality:
o If the patient is hesitant to open up, offer confidentiality
o Do this sensitively, not as a routine statement
o Example: "Whatever we discuss will remain confidential."
3. History Taking Structure (once the patient opens up): a. Explore the situation: Ask
what, when, how questions about the abuse b. Ask what they've done about it:
"Have you tried to address this situation? What have you thought about doing?" c.
Assess impact: "How has this affected your physical health? Mental health? Sleep?
Safety? Work?" d. Take a social history: Family, partner, children, finances, friends,
work, alcohol, smoking, recreational drugs e. Take a medical history
4. Management (6 steps): a. Sympathize: "I'm sorry this has happened to you." b. Give
your point of view: Explain what you think is happening c. Provide information on
where to get help d. Explain what you as a doctor will do (e.g., arrange counselling,
make referrals) e. Inform that you'll discuss with senior colleagues f. Arrange follow-
up within two weeks

Key Points to Remember

1. Always prioritize the patient's safety and well-being

2. Maintain a non-judgmental, empathetic approach throughout
3. Be aware of hidden agendas and subtle signs of abuse
4. Use structured approaches to history taking and management
5. Be clear about what constitutes abuse and the need to involve appropriate services
6. Remember that if the patient has capacity, decisions should be made with them, not
just about them
7. Offer support to both the victim and the carer (in elderly abuse cases)
8. Document all findings and conversations accurately
9. Follow local safeguarding protocols and consult with senior colleagues
10. Arrange timely follow-up

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Things to Avoid

1. Don't accuse caregivers or potential abusers directly

2. Avoid making promises about outcomes
3. Don't ignore signs of carer stress or burnout
4. Avoid making decisions for patients who have capacity
5. Don't forget to offer support and resources to both victims and carers
6. Avoid rushing the conversation or pushing patients to disclose before they're ready
7. Don't break confidentiality unnecessarily, but remember your duty to report certain
types of abuse

Elderly Abuse Scenario

Case Presentation

• Setting: Acute medicine ward (F2 doctor)

• Patient: Elderly woman (65+)
• Presenting complaint: Fall
• Key findings: Bruises of different ages, chest pain
• Additional information: Patient has mild dementia but has given consent to speak
with daughter

Important Considerations

• The patient has given consent to speak with the daughter, indicating she has
capacity to make decisions
• This means the patient can make her own decisions, and management plans should
be discussed with her, not just the daughter

History Taking: 2-Tier Approach

Tier 1 Questions (Less Sensitive)

1. Incident Details: Doctor: "I understand you brought your mother in after a fall. Can
you tell me exactly what happened?" Daughter: "I think she must have fallen down,
so I brought her here." Doctor: "Do you know when this happened?" Daughter: "I
heard a loud bang from her room earlier today." Doctor: "Did you witness the fall?"
Daughter: "No, I didn't. I just heard the noise and found her on the floor." Doctor:
"Was anyone else at home who might have witnessed it?" Daughter: "No, it was just
me and my mother." Doctor: "How long after the fall did you bring her to the
hospital?" Daughter: "About an hour later. I wanted to make sure she was really hurt
before coming in." Doctor: "Did you call an ambulance, or did you bring her in

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yourself?" Daughter: "I brought her in myself. I didn't think it was serious enough
for an ambulance." [Note: Pay attention to any reluctance to involve other
healthcare professionals]
2. Medical and Physical Factors: Doctor: "Does your mother have any medical
conditions that might contribute to falls?" Daughter: "She has mild dementia, as you
know. And sometimes her blood pressure is a bit low." Doctor: "Does she have any
problems with mobility? Does she use any walking aids?" Daughter: "She uses a
walking stick sometimes, but she's pretty mobile for her age." Doctor: "Has she had
any previous falls or injuries?" Daughter: "She's had a couple of minor falls in the
past year, but nothing serious." Doctor: "Is she on any medications, particularly for
blood pressure or blood thinners?" Daughter: "She's on some blood pressure
medication, I think. And she takes aspirin daily."
3. Living Conditions and Independence: Doctor: "Who does your mother live with?"
Daughter: "She lives with me." Doctor: "Are you her primary carer?" Daughter: "Yes,
I am." Doctor: "How independent is your mother in her daily activities?" Daughter:
"She needs quite a bit of help these days, especially in the mornings." Doctor: "What
activities can she do herself, and what does she need help with?" Daughter: "She can
feed herself and use the toilet independently, but she needs help with bathing,
dressing, and preparing meals."
4. Daughter's Situation: Doctor: "What do you do for a living?" Daughter: "I work part-
time at a local shop and look after my mother." Doctor: "Do you have any other
responsibilities or family members to care for?" Daughter: "I have two children of my
own, both in secondary school." Doctor: "How are you coping with caring for your
mother?" Daughter: "It's... challenging. Sometimes I feel overwhelmed." Doctor:
"Have you ever reached out to social services for help?" Daughter: "No, I haven't. I
thought we could manage on our own." Doctor: "Have you been offered any help
that you or your mother declined?" Daughter: "The GP mentioned some home help
services once, but my mother wasn't keen on the idea of strangers in the house."

Tier 2 Questions (More Sensitive)

Doctor: "After examining your mother, we've found some bruises on her body. Some of
these bruises seem quite new, while others appear older. This suggests they happened on
different days. Do you know anything about these bruises?"

Daughter: "No, I don't know anything about them. Maybe she's fallen before and I didn't
notice."

Doctor: "I understand that caring for an elderly person, especially while managing work
and your own family, can be overwhelming and stressful. Sometimes, people in stressful

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situations might act out of character or do things they wouldn't normally do. Has anything
like this ever happened in your care for your mother?"

Daughter: "Actually, doctor... I have pushed my mom a few times."

Doctor: "I'm sorry to hear that. Would you like to tell me a bit more about what
happened?"

Daughter: "Every morning, I help her with everything - shower, dressing, breakfast. But
when I'm trying to leave for work, she often stands in my way. I've been late to work several
times because of this, and my employer has given me warnings. Sometimes, I get so
frustrated that I push her aside to get out. I don't know what happens after I leave."

Doctor: "I see. Thank you for being honest about this. Is there anything else that has
happened between you and your mother that you think I should know about?"

Daughter: "No, that's all. I've never neglected her or failed to feed her or anything like
that."

Assessment and Management

1. Explain the situation: Doctor: "Thank you for sharing this information with me. I'm
sorry you've been struggling with the stress of caregiving. However, I need to let you
know that pushing your mother is considered a form of abuse, even if that wasn't
your intention. We need to take some steps to ensure your mother's safety and to
get you both the support you need."
2. Outline the plan: Doctor: "Here's what we need to do:
o First, I'll speak with my senior colleagues about this situation.
o We'll provide your mother with medical treatment for her chest pain and
bruises.
o We'll need to refer your mother to social services. They will assess her needs
and discuss care options with her.
o Given that your mother has capacity to make decisions, these discussions will
primarily be with her, but they may involve you as well."
3. Address concerns: Daughter: "Are they going to take my mother away?" Doctor:
"The goal of social services is to ensure your mother's safety and well-being, while
also providing support to you as a carer. They will explore various options, which
might include additional home care support, respite care, or potentially other living
arrangements. However, removing your mother from her home would be a last
resort, only considered if other options can't ensure her safety."

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4. Provide support: Doctor: "I understand this is a difficult situation for you. There are
support services available for carers like yourself. Would you like information about
these services?"

Suspected Non-Accidental Injury in Children

I. Introduction and Context

This guide focuses on handling cases of suspected non-accidental injury in children. These
scenarios are part of a broader category of abuse and safeguarding situations, which
include:

• Non-accidental injury in children

• Elderly abuse
• Domestic violence (various presentations)
• LGBTQ+ abuse
• Patient-counsellor inappropriate relationships
• Workplace harassment
• Rape

These scenarios are presented to medical professionals because they are often the first
point of contact for identifying such issues. The primary objectives are to:

1. Identify and recognize signs of abuse

2. Protect vulnerable members of society
3. Demonstrate the ability to detect subtle signs and hidden agendas

It's crucial to understand that the medical professional's role is primarily to identify, record,
and escalate concerns, not to solve the social problems directly.

II. Case Presentation: Non-Accidental Injury

Scenario

• Patient: 3-year-old child

• Presenting complaint: Swelling in the arm
• Key finding: X-ray shows spiral fracture of the humerus
• Clue given: Spiral fracture (this is unusual and should raise suspicion)

Objectives

• Identify signs and risk factors of abuse

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• Collect information sensitively

• Escalate concerns appropriately
• Communicate effectively with the caregiver

III. Signs of Abuse and Risk Factors

Signs of Abuse

1. Type of injury (e.g., spiral fracture)

2. Late presentation
3. Inconsistent story
4. Multiple hospital visits/admissions
5. Injuries at different stages of healing
6. Presentation by someone other than primary caregiver

Risk Factors

1. Non-biological parents
2. Low socioeconomic status
3. Substance abuse in the household
4. Multiple children
5. Unplanned pregnancy
6. Difficult pregnancy/delivery
7. Child with medical problems/disabilities
8. Parental history of abuse

IV. History Taking: 3-Tier Approach

Tier 1 Questions (Less Severe)

Doctor: "I understand you brought your son in because of a swelling. Can you tell me what
happened?"

Mother: "I was changing my child this morning and found a swelling, so I brought him to
the hospital."

Doctor: "When exactly did you notice the swelling? Were you able to bring him in
immediately?"

Mother: "I noticed it around 9 am this morning. I brought him in as soon as I could."

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Doctor: "When did you last see your child before noticing the swelling? Was everything
fine then?"

Mother: "Last night everything was fine. I put him to bed around 8 pm."

Doctor: "Who was looking after the child between last night and this morning?"

Mother: "My boyfriend was looking after him while I was at work. I work night shifts at an
off-license."

Doctor: "Does anyone else help with childcare or visit your home regularly?"

Mother: "No, it's just me and my boyfriend."

Doctor: "Does your child attend school or any other activities?"

Mother: "No, he's still too young for school."

Doctor: "Has your child had any previous injuries or hospital admissions?"

Mother: "No, this is the first time."

Doctor: "How was your pregnancy with this child? Was it planned? Were there any
complications?"

Mother: "It wasn't planned, but the pregnancy was okay. The delivery was a bit difficult
though."

Doctor: "Are you and your boyfriend the biological parents?"

Mother: "I'm his biological mother, and my boyfriend is his biological father."

Doctor: "Do you have any other children?"

Mother: "No, he's my only child."

Tier 2 Questions (Moderately Severe)

Doctor: "How are things generally at home?"

Mother: "Things are okay, I guess. We manage."

Doctor: "How is your relationship with your boyfriend? Is everything okay?"

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Mother: "We have our ups and downs, but it's generally fine."

Doctor: "Are there any stresses at home?"

Mother: "Money is tight sometimes, but we get by."

Doctor: "Does anyone in the household drink alcohol excessively or use recreational
drugs?"

Mother: "My boyfriend drinks sometimes, but not excessively. We don't use drugs."

Doctor: "I'm sorry to ask this, but have you ever seen your boyfriend behave aggressively
towards anyone?"

Mother: "No, he can be moody sometimes, but he's never aggressive."

Tier 3 Questions (Severe)

Doctor: "After examining your child and reviewing the x-ray, we've found that there's a
fracture in his arm. It's a specific type called a spiral fracture, which is unusual in children
this age. This type of fracture typically occurs from a fall from a height or if someone
applies force to the arm. Do you have any idea how this might have happened?"

Mother: "No, I don't understand. He was fine last night."

Doctor: "Sometimes children can be frustrating, and parents might handle them roughly
when stressed. Is there any possibility this could have happened?"

Mother: "No, absolutely not. We would never hurt our child."

Doctor: "You mentioned your boyfriend was looking after the child last night when
everything was fine, and this morning you found the swelling. Do you have any reason to
believe this injury might be connected to your boyfriend in any way?"

Mother: "No, he said the child had a rough night and fell off the sofa, but I can't believe
that would cause this."

V. Management and Communication

Doctor: "Thank you for answering these questions. Let me explain our position. At the
moment, we're unable to provide a clear explanation for your child's injury. In situations
like this, where we have unexplained injuries in a child, there are certain steps we must
take."

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1. Outline the plan: Doctor: "Here's what we need to do:

o We'll provide medical treatment for the fracture and manage your child's
pain.
o We'll need to do a full body scan, called a bone scan.
o I'll be consulting with my senior colleagues about this case.
o We're required to make a referral to child protection services or social
services."
2. Address concerns: Mother: "Why are you involving social services? Are they going to
take my child away?" Doctor: "I understand your concern. When we encounter a
situation where a child has an unexplained injury, we are obligated to involve social
services. This is because we're concerned that such incidents could potentially recur
and might be more serious next time. Social services' role is to investigate and find
ways to prevent future incidents. Regarding your concern about your child being
taken away, I want to assure you that this isn't the first thing social services do. They
will first come to speak with you, try to understand your situation, and explore ways
they can support you in caring for your child. They might also speak with your
boyfriend. Their goal is to help you care for your child safely. Taking a child from
their parents is always the last resort, only considered if all other options have been
exhausted."
3. Handle additional questions: Mother: "Why can't I see my child right now?" Doctor:
"Your child is currently undergoing necessary tests and treatments. I assure you that
you'll be able to see him as soon as possible. We're not trying to keep you apart; we
just need to complete these important medical procedures." Mother: "Why does he
need to be admitted? Can't we just go home?" Doctor: "The admission is necessary
because your child needs treatment for the fracture, we need to conduct further
tests like the bone scan, and social services need to do their assessment. All of these
can't be completed in a single day. We want to ensure your child receives all the care
he needs." Mother: "Do you think I'm a bad mother?" Doctor: "I'm sorry if I've given
that impression. We don't think you're a bad mother at all. You've done the right
thing by bringing your child in as soon as you noticed the swelling. That's exactly
what a good, caring mother would do. Our job is to ensure the safety and well-being
of your child, and sometimes that involves asking difficult questions and taking
precautionary steps."

VI. Key Points to Remember

1. Always prioritize the child's safety and well-being.

2. Maintain a non-judgmental, empathetic approach throughout.
3. Use the 3-tier questioning system to gather information sensitively.
4. Be clear and honest about the need to involve social services.
5. Reassure the parent but don't make promises about outcomes.

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6. Document all findings and conversations accurately.

7. Follow local safeguarding protocols and consult with senior colleagues.
8. Remember that your role is to identify, record, and escalate concerns, not to solve
the social problems directly.
9. Be aware of hidden agendas - patients may present with one issue but have
underlying concerns they're hesitant to express.
10. Look for clues in the patient's story or presentation that might indicate abuse.

VII. Things to Avoid

1. Don't accuse the parent or caregiver directly of abuse.

2. Avoid using judgmental language or showing shock or disgust.
3. Don't promise confidentiality - explain that you may need to share information to
protect the child.
4. Avoid leading questions that might suggest a particular answer.
5. Don't rush the conversation - give the parent time to process and respond.
6. Avoid making assumptions based on socioeconomic status or family structure.
7. Don't ignore your instincts if something seems off, even if you can't immediately
identify why.

Domestic Violence with PV Bleeding Scenario

Case Presentation

• Setting: A&E (Emergency Department)

• Patient: 30-year-old pregnant woman
• Presenting complaint: Vaginal bleeding
• Key findings: No active bleeding found, normal scan, bruises on arm resembling
grip marks

Initial Approach

1. Enter the room with a positive, confident attitude:

o Know the patient's name beforehand
o Introduce yourself clearly: "Hello, Sandra Jones. I'm Dr. [Your Name], one of
the doctors here."
o Present a calm, reassuring demeanour - be the "light" in the room
o Maintain a positive attitude without being overly cheerful
2. Address the presenting complaint: Doctor: "I understand you came in because of
some bleeding. We've done some tests and examinations. The good news is that we
couldn't find any active bleeding, and the scan shows your baby is doing well. How

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do you feel about that?" Patient: "Does that mean I can go home?" Doctor: "You
should be able to go home soon. Before that, we want to make sure everything is
okay with you. We just need to check a few more things to ensure you and your
baby are both safe."

IV. Detecting Hidden Agenda and Encouraging Disclosure

1. Observe body language:

o Note if patient is looking down, withdrawn, or showing signs of anxiety
2. Address observed behaviour: Doctor: "Sandra, I've noticed you seem a bit down and
anxious. Is there anything you'd like to talk about?" [If no response] Doctor: "Can
you tell me how this bleeding started?" [If still no response]
3. Offer confidentiality (repeat up to 3 times if necessary): Doctor: "Sandra, I want you
to know that whatever we discuss will remain confidential. Is there anything you'd
like to share with me?"
4. Address observed injuries: Doctor: "We noticed some bruises on your arm that look
like grip marks. Can you tell me how you got these bruises?" Doctor: "Is there
anyone at home who might be hurting you?" [If still no response]
5. Express concern due to pregnancy: Doctor: "Sandra, the reason we're asking these
questions is because you're pregnant, and we want to make sure both you and your
baby are safe. If there's anything going on in your life that might be affecting your
safety, you can tell us. Everything we discuss is confidential." Patient: "I'm not
allowed to talk about this." Doctor: "Who's not allowing you to talk about this? Is it
your partner? I assure you, no one will know what we discuss here. Would you like
to tell me what's going on?" Patient: "Actually, doctor... my husband kicked me in
my stomach."

V. Detailed History Taking

Once the patient discloses, follow this structure:

1. Explore the situation (What, what, what?): Doctor: "I'm so sorry to hear that,
Sandra. Can you tell me more about what happened?" Patient: "He got angry
because dinner wasn't ready when he came home." Doctor: "How long has this kind
of behaviour been going on?" Patient: "It started about a year ago, but it's gotten
worse since I became pregnant." Doctor: "What sort of things does your husband
do? Does he physically hurt you in other ways?" Patient: "He pushes me around
sometimes, and he's slapped me before." Doctor: "Does he say things to hurt your
feelings, like calling you names or swearing at you?" Patient: "Yes, he calls me stupid
and useless all the time." Doctor: "Does he try to control what you do or who you
see?" Patient: "He doesn't like me talking to my family or friends. He checks my

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phone all the time." Doctor: "How often does this happen? Is it almost every day?"
Patient: "It's most days now. There's always something that makes him angry."
2. Actions taken (What have you done?): Doctor: "Have you tried to do anything about
this situation? Have you spoken to anyone or tried to leave?" Patient: "I've thought
about leaving, but I don't know where I'd go. I haven't told anyone." Doctor: "If you
haven't done anything, may I ask why? Are you afraid of something happening if
you do?" Patient: "I'm scared he'll hurt me worse if I try to leave. And I don't want
my baby to grow up without a father." Doctor: "Have you thought about what you
want for this relationship?" Patient: "I want him to stop, but I don't think he will. I
don't know what to do."
3. Impact assessment: Doctor: "How has this affected your health? Do you feel low or
depressed because of what's happening?" Patient: "I cry a lot when I'm alone. I feel
hopeless most of the time." Doctor: "Have you ever thought about harming yourself
because of this situation?" Patient: "Sometimes I think everyone would be better off
without me, but I wouldn't do anything because of the baby." Doctor: "Is it affecting
your sleep?" Patient: "I have trouble sleeping. I'm always worried about what might
set him off." Doctor: "Do you generally feel safe at home?" Patient: "No, I'm always
on edge, waiting for the next outburst."
4. Social history: Doctor: "Do you have any other children at home?" Patient: "No, this
is my first pregnancy." Doctor: "Is your husband the biological father of this baby?"
Patient: "Yes, he is." Doctor: "What does your husband do for a living? Does he
drink alcohol excessively or use drugs?" Patient: "He works in construction. He
drinks a lot, especially on weekends." Doctor: "How are your finances? Are you
financially dependent on your husband, or do you work as well?" Patient: "I used to
work part-time, but he made me quit when I got pregnant. I don't have any money
of my own." Doctor: "Do you have any friends or family nearby who could support
you?" Patient: "My sister lives nearby, but I haven't spoken to her in months. My
husband doesn't like her."
5. Medical history: Doctor: "Do you have any other medical problems we should know
about?" Patient: "No, I've always been healthy until now."

VI. Management Plan

Follow these six steps:

1. Express sympathy: Doctor: "Sandra, I'm truly sorry to hear about what you're going
through. This must be very difficult for you. Thank you for having the courage to
share this with me."
2. State your point of view: Doctor: "What you've described to me is domestic violence.
I want you to know that this is not okay, and it's not your fault. Domestic violence is
wrong, and you don't need to put up with this. It's actually a crime being committed

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against you, and you don't deserve this treatment. Many women go through similar
situations, but help is available. You're not alone in this."
3. Provide information on where to get help: Doctor: "There are several places where
you can get help:
o You can call the National Domestic Abuse Helpline for advice and support.
They're available 24/7 and can provide confidential advice.
o There's also an organization called Women's Aid. They're a charity that
specializes in helping women in your situation.
o In an emergency, you should always call the police on 999.
o If you're ever in immediate danger and can't get to a phone, you can go to
any Boots pharmacy and ask for 'ANI' (which stands for Action Needed
Immediately). The staff will understand you need help and provide you with
a safe space."
4. Explain what you as a doctor will do: Doctor: "As for what we can do here:
o We can offer you admission to the hospital as a temporary solution if you
don't feel safe going home. This would give you some time to think about
your next steps in a safe environment.
o If you do decide to go home, we'll arrange for your GP to follow up with you
closely.
o We'll also need to make a referral to social services. This is because exposure
to domestic violence can be harmful to children, even before they're born.
They're there to support you and your baby, not to judge you.
o Before you leave, I'll speak with my senior colleagues about your situation to
ensure we're providing you with the best possible support."
5. Consult with seniors: Doctor: "I'm going to speak with my senior colleagues about
your situation to ensure we're taking all the necessary steps to help you. This is
standard procedure in cases like this."
6. Arrange follow-up: Doctor: "We'll arrange for your GP to follow up with you within
the next two weeks. They'll check on your well-being and the progress of your
pregnancy. It's very important that you attend this follow-up appointment."

VII. Key Points to Remember

1. Maintain a non-judgmental, empathetic approach throughout.

2. Be patient in encouraging disclosure - it may take several attempts.
3. Use the structured approach to history taking once the patient opens up.
4. Be clear about what constitutes domestic violence and that it's not acceptable.
5. Provide specific information about where the patient can get help.
6. Consider the safety of both the patient and any children (including unborn) in the
household.
7. Always consult with senior colleagues in these cases.

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8. Ensure proper follow-up is arranged.

VIII. Things to Avoid

1. Don't rush the patient to disclose - be patient and gentle in your questioning.
2. Avoid using judgmental language or showing shock when the patient discloses
abuse.
3. Don't tell the patient to talk to neighbours or family members about the abuse - this
could be dangerous.
4. Avoid using technical terms like "physical abuse" or "psychological abuse" - instead,
describe the behaviours.
5. Don't forget to consider the safety of any children in the household.
6. Avoid making promises about outcomes you can't guarantee.
7. Don't suggest couples counselling or mediation - this can be dangerous in abusive
relationships.
8. Avoid pressuring the patient to leave if they're not ready - leaving can be the most
dangerous time for abuse victims.

Domestic Violence with Vaginal Bleeding

Setting

• A&E (Emergency Department)

Patient Details

• 30-year-old pregnant woman

• Presenting complaint: Vaginal bleeding

Key Findings

• No active bleeding found

• Normal scan
• Bruises on arm resembling grip marks

I. Initial Approach

A. Entering the Room

1. Know the patient's name beforehand

2. Introduce yourself clearly: "Hello, Sandra Jones. I'm Dr. [Your Name], one of the
doctors here."

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3. Present a calm, reassuring demeanour - be the "light" in the room

4. Maintain a positive attitude without being overly cheerful

B. Addressing the Presenting Complaint

Doctor: "I understand you came in because of some bleeding. We've done some tests and
examinations. The good news is that we couldn't find any active bleeding, and the scan
shows your baby is doing well. How do you feel about that?"

Patient: "Does that mean I can go home?"

Doctor: "You should be able to go home soon. Before that, we want to make sure
everything is okay with you. We just need to check a few more things to ensure you and
your baby are both safe."

II. Encouraging Disclosure

A. Observe Body Language

• Note if patient is looking down, withdrawn, or showing signs of anxiety

B. Address Observed Behaviour

Doctor: "Sandra, I've noticed you seem a bit down and anxious. Is there anything you'd like
to talk about?"

C. Offer Confidentiality (repeat up to 3 times if necessary)

Doctor: "Sandra, I want you to know that whatever we discuss will remain confidential. Is
there anything you'd like to share with me?"

D. Address Observed Injuries

Doctor: "We noticed some bruises on your arm that look like grip marks. Can you tell me
how you got these bruises?"

Doctor: "Is there anyone at home who might be hurting you?"

E. Express Concern Due to Pregnancy

Doctor: "Sandra, the reason we're asking these questions is because you're pregnant, and we
want to make sure both you and your baby are safe. If there's anything going on in your life
that might be affecting your safety, you can tell us. Everything we discuss is confidential."

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Patient: "I'm not allowed to talk about this."

Doctor: "Who's not allowing you to talk about this? Is it your partner? I assure you, no one
will know what we discuss here. Would you like to tell me what's going on?"

Patient: "Actually, doctor... my husband kicked me in my stomach."

F. Appropriate Response to Disclosure

Doctor: (Raising eyebrows to show seriousness, but not overreacting) "I'm really sorry to
hear that. That must have been very difficult for you."

[Avoid dramatic reactions like "Oh my God!" or showing shock]

III. Detailed History Taking

A. Explore the Situation (What, what, what?)

Doctor: "Can you tell me more about what happened?"

Patient: "He got angry because dinner wasn't ready when he came home."

Doctor: "How long has this kind of behaviour been going on?"

Patient: "It started about a year ago, but it's gotten worse since I became pregnant."

Doctor: "What sort of things does your husband do? Has he been physically violent in
other ways?"

Patient: "He pushes me around sometimes, and he's slapped me before."

Doctor: "Does he say things to hurt your feelings, like calling you names or swearing at
you?"

Patient: "Yes, he calls me stupid and useless all the time."

Doctor: "Does he try to control what you do or who you see?"

Patient: "He doesn't like me talking to my family or friends. He checks my phone all the
time."

Doctor: "How often does this happen? Is it almost every day?"

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Patient: "It's most days now. There's always something that makes him angry."

B. Actions Taken (What have you done?)

Doctor: "Have you tried to do anything about this situation? Have you spoken to anyone or
tried to leave?"

Patient: "I've thought about leaving, but I don't know where I'd go. I haven't told anyone."

Doctor: "If you haven't done anything, may I ask why? Are you afraid of something
happening if you do?"

Patient: "I'm scared he'll hurt me worse if I try to leave. And I don't want my baby to grow
up without a father."

Doctor: "Have you thought about what you want for this relationship?"

Patient: "I want him to stop, but I don't think he will. I don't know what to do."

C. Impact Assessment

Doctor: "How has this affected your health? Do you feel low or depressed because of what's
happening?"

Patient: "I cry a lot when I'm alone. I feel hopeless most of the time."

Doctor: "Have you ever thought about harming yourself because of this situation?"

Patient: "Sometimes I think everyone would be better off without me, but I wouldn't do
anything because of the baby."

Doctor: "Is it affecting your sleep?"

Patient: "I have trouble sleeping. I'm always worried about what might set him off."

Doctor: "Do you generally feel safe at home?"

Patient: "No, I'm always on edge, waiting for the next outburst."

D. Social History

Doctor: "Do you have any other children at home?"

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Patient: "No, this is my first pregnancy."

Doctor: "Is your husband the biological father of this baby?"

Patient: "Yes, he is."

Doctor: "What does your husband do for a living? Does he drink alcohol excessively or use
drugs?"

Patient: "He works in construction. He drinks a lot, especially on weekends."

Doctor: "How are your finances? Are you financially dependent on your husband, or do
you work as well?"

Patient: "I used to work part-time, but he made me quit when I got pregnant. I don't have
any money of my own."

Doctor: "Do you have any friends or family nearby who could support you?"

Patient: "My sister lives nearby, but I haven't spoken to her in months. My husband doesn't
like her."

Doctor: "Are you originally from this area?"

[Note response - this is important as abusive partners often isolate victims from their
support systems]

E. Medical History

Doctor: "Do you have any other medical problems we should know about?"

Patient: "No, I've always been healthy until now."

Doctor: "Are you taking any medications?"

Patient: "Just prenatal vitamins."

IV. Management Plan

A. Express Sympathy

Doctor: "Sandra, I'm truly sorry to hear about what you're going through. This must be very
difficult for you."

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B. State Your Point of View

Doctor: "What you've described to me is domestic violence. I want you to know that this is
not okay, and it's not your fault. Domestic violence is wrong, and you don't need to put up
with this. It's actually a crime being committed against you, and you don't deserve this
treatment. Many women go through similar situations, but help is available. You're not
alone in this."

C. Provide Information on Where to Get Help

Doctor: "There are several places where you can get help:

1. You can call the National Domestic Abuse Helpline for advice and support. They're
available 24/7 and can provide confidential advice.
2. There's also an organization called Women's Aid. They're a charity that specializes
in helping women in your situation.
3. In an emergency, you should always call the police on 999. If you can't speak, you
can dial 55 after calling 999, and the police will know you need help.
4. If you're ever in immediate danger and can't get to a phone, you can go to any Boots
pharmacy and ask for 'ANI' (which stands for Action Needed Immediately). The
staff will understand you need help and provide you with a safe space."

D. Explain What You as a Doctor Will Do

Doctor: "We can offer you admission to the hospital as a temporary solution if you don't
feel safe going home. If you do go home, we'll arrange for your GP to follow up with you
closely. We'll also need to make a referral to social services to ensure your baby's safety.
Before you leave, I'll speak with my senior colleagues about your situation to ensure we're
providing you with the best possible support."

E. Consult with Seniors

Doctor: "I'm going to speak with my senior colleagues about your situation to ensure we're
taking all the necessary steps to help you."

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F. Arrange Follow-up

Doctor: "We'll arrange for you to have a follow-up appointment in two weeks. It's very
important that you attend this appointment so we can check on your well-being."

Key Points to Remember

1. Maintain a non-judgmental, empathetic approach throughout.

2. Be patient in encouraging disclosure - it may take several attempts.
3. Use the structured approach to history taking once the patient opens up.
4. Be clear about what constitutes domestic violence and that it's not acceptable.
5. Provide specific information about where the patient can get help.
6. Consider the safety of both the patient and any children in the household.
7. Always consult with senior colleagues in these cases.
8. Ensure proper follow-up is arranged.
9. For insomnia cases, don't provide sleep hygiene advice - address the underlying
issue.
10. Never suggest couple counselling in cases of physical violence.
11. Remember that domestic violence can present with various complaints (e.g.,
bleeding, insomnia).
12. Be aware of the signs that might indicate domestic violence (e.g., young patient with
sleep issues, bruises).

Things to Avoid

1. Don't rush the patient to disclose - be patient and gentle in your questioning.
2. Avoid using judgmental language or showing shock when the patient discloses
abuse.
3. Don't tell the patient to talk to neighbours or family members about the abuse - this
could be dangerous.
4. Avoid using technical terms like "physical abuse" or "psychological abuse" - instead,
describe the behaviours.
5. Don't forget to consider the safety of any children in the household.
6. Avoid making promises about outcomes you can't guarantee.
7. Don't suggest couples counselling or mediation - this can be dangerous in abusive
relationships.
8. Avoid pressuring the patient to leave if they're not ready - leaving can be the most
dangerous time for abuse victims.
9. Don't provide sleep hygiene advice in cases where insomnia is due to domestic
violence.
10. Avoid overreacting or showing dramatic responses when patients disclose abuse.

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11. Don't ask leading questions like "Is there any particular reason he's arguing with
you?"
12. Avoid ignoring signs of domestic violence when patients present with other
complaints.

Domestic Violence Presenting as Insomnia

Case Details

Setting

• GP practice

Patient Details

• 32-year-old woman
• Presenting complaint: Sleeping problems

I. Initial Approach

A. Entering the Room

1. Know the patient's name beforehand

2. Introduce yourself clearly: "Hello, [Patient Name]. I'm Dr. [Your Name], one of the
doctors here."
3. Present a calm, reassuring demeanour - be the "light" in the room
4. Maintain a positive attitude without being overly cheerful

B. Addressing the Presenting Complaint

Doctor: "Hello, [Patient Name]. I understand you've come in with some sleeping problems.
Can you tell me more about that?"

Patient: "I've been having trouble sleeping for about two weeks now."

Doctor: "Can you describe what's happening? Do you have trouble falling asleep, staying
asleep, or both?"

Patient: "I have trouble falling asleep, and when I do, I wake up frequently."

Doctor: "What time do you usually go to bed, and what time do you actually fall asleep?"

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Patient: "I go to bed around 10 PM, but I might not fall asleep until 1 or 2 AM."

Doctor: "How many hours of sleep do you think you're getting each night?"

Patient: "Only about 2-3 hours a night."

Doctor: "Did anything happen around two weeks ago when this started?"

Patient: "I'm having some problems with my husband."

II. Encouraging Disclosure

A. Observe Body Language

• Note if patient is looking down, withdrawn, or showing signs of anxiety

• Pay attention to fidgeting, crossing arms, or other defensive postures
• Observe if the patient makes eye contact or avoids it

B. Address Observed Behaviour

Doctor: "[Patient Name], I've noticed you seem a bit uncomfortable and anxious. Is there
anything you'd like to talk about regarding your situation at home?"

C. Offer Confidentiality (repeat up to 3 times if necessary)

Doctor: "[Patient Name], I want you to know that whatever we discuss here will remain
confidential. Is there anything you'd like to share with me about what's going on at home?"

[If no response after first attempt] Doctor: "I understand it can be difficult to talk about
personal matters. Please remember that our conversation is confidential, and I'm here to
help you. Would you like to tell me more about the problems you mentioned with your
husband?"

[If still no response] Doctor: "Your well-being is my primary concern. Everything you say
here is protected by doctor-patient confidentiality. If there's anything happening at home
that's affecting your sleep or overall health, I'm here to listen and help."

D. Explore Potential Signs of Abuse

Doctor: "You mentioned having problems with your husband. Can you tell me more about
that? Are these problems affecting your sleep?"

Patient: "He gets angry a lot. I'm always worried about what might set him off."

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Doctor: "I'm sorry to hear that. When you say he gets angry, what does that look like? Does
he ever say or do things that frighten you?"

Patient: "He yells a lot and sometimes throws things. I'm always on edge."

Doctor: "That sounds very stressful. Has he ever physically hurt you or threatened to hurt
you?"

Patient: "He's pushed me a few times. Once he grabbed my arm so hard it left bruises."

Doctor: "I'm very concerned about what you're telling me. What you're describing sounds
like domestic abuse. It's not your fault, and there is help available. Would you like to talk
more about this?"

III. Detailed History Taking

A. Explore the Situation (What, what, what?)

Doctor: "Can you tell me more about what's been happening at home?"

Patient: "It's been getting worse over the past few months. He gets angry over small things."

Doctor: "What sort of things make him angry?"

Patient: "Anything really. If dinner's not ready on time, if I talk to my friends, if I don't
answer his calls immediately."

Doctor: "How long has this behaviour been going on?"

Patient: "It started about a year ago, but it's gotten much worse in the last few months."

Doctor: "What does he do when he gets angry? Can you describe his behaviour?"

Patient: "He yells, calls me names, sometimes he throws things or punches walls. He's
pushed me a few times."

Doctor: "Has he ever hit you or physically hurt you in any other way?"

Patient: "He's grabbed me hard enough to leave bruises. Once he slapped me across the
face."

Doctor: "Does he try to control what you do or who you see?"

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Patient: "Yes, he doesn't like me talking to my family or friends. He checks my phone and
email all the time."

Doctor: "How often does this happen? Is it almost every day?"

Patient: "It's most days now. There's always tension in the house."

B. Actions Taken (What have you done?)

Doctor: "Have you tried to do anything about this situation? Have you spoken to anyone or
tried to leave?"

Patient: "I've thought about leaving, but I don't know where I'd go. I haven't told anyone
about this."

Doctor: "If you haven't taken action, may I ask why? Are you afraid of something
happening if you do?"

Patient: "I'm scared he'll hurt me worse if I try to leave. And I'm financially dependent on
him."

Doctor: "Have you thought about what you want for this relationship?"

Patient: "I want him to stop, but I don't think he will. I don't know what to do."

C. Impact Assessment

Doctor: "How has this situation affected your health, besides the sleeping problems?"

Patient: "I'm always anxious and on edge. I've lost weight because I often feel too sick to
eat."

Doctor: "Do you feel low or depressed because of what's happening?"

Patient: "Yes, I cry a lot when I'm alone. I feel hopeless most of the time."

Doctor: "Have you ever thought about harming yourself because of this situation?"

Patient: "Sometimes I think everyone would be better off without me, but I wouldn't
actually do anything."

Doctor: "Can you tell me more about your sleep issues? What happens when you try to
sleep?"

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Patient: "I lie awake for hours, my mind racing. When I do fall asleep, I wake up at the
slightest noise, worried it might be him."

Doctor: "Do you generally feel safe at home?"

Patient: "No, I'm always walking on eggshells, waiting for the next outburst."

D. Social History

Doctor: "Do you have any children at home?"

Patient: "No, we don't have any children."

Doctor: "What does your husband do for a living?"

Patient: "He works in finance. He has a high-stress job."

Doctor: "Does he drink alcohol excessively or use drugs?"

Patient: "He drinks a lot, especially when he's stressed. I don't think he uses drugs."

Doctor: "How are your finances? Are you financially dependent on your husband?"

Patient: "Yes, I used to work as a teacher, but he convinced me to quit my job last year. I
don't have any money of my own."

Doctor: "Do you have any friends or family nearby who could support you?"

Patient: "My sister lives in the next town, but I haven't spoken to her in months. My
husband doesn't like her."

Doctor: "Are you originally from this area?"

Patient: "No, we moved here for my husband's job two years ago. All my family is back in
our hometown."

E. Medical History

Doctor: "Do you have any other medical problems we should know about?"

Patient: "I've been having frequent headaches and stomach aches, but I thought it was just
stress."

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Doctor: "Are you taking any medications?"

Patient: "Just over-the-counter painkillers for the headaches."

Doctor: "Have you ever sought help for anxiety or depression before?"

Patient: "No, I've always been able to handle things on my own before."

IV. Management Plan

A. Express Sympathy

Doctor: "[Patient Name], I'm truly sorry to hear about what you're going through. This
must be incredibly difficult for you. Thank you for having the courage to share this with
me."

B. State Your Point of View

Doctor: "What you've described to me is domestic violence. I want you to know that this is
not okay, and it's not your fault. Domestic violence is wrong, and you don't need to put up
with this. It's actually a crime being committed against you, and you don't deserve this
treatment. Many women go through similar situations, but help is available. You're not
alone in this."

C. Provide Information on Where to Get Help

Doctor: "There are several places where you can get help:

1. The National Domestic Abuse Helpline provides 24/7 confidential advice. Their
number is 0808 2000 247.
2. Women's Aid is a charity specializing in helping women in your situation. They
have a website with lots of information and a live chat service.
3. In an emergency, always call the police on 999. If you can't speak, you can dial 55
after calling 999, and the police will know you need help.
4. If you're ever in immediate danger and can't get to a phone, you can go to any Boots
pharmacy and ask for 'ANI' (which stands for Action Needed Immediately). The
staff will understand you need help and provide you with a safe space.
5. There are also local support services in our area. I can provide you with their
contact information if you'd like."

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D. Explain What You as a Doctor Will Do

Doctor: "I'm going to take several steps to help you:

1. I'm going to prescribe you some sleeping pills to help in the short term. However,
these are not a long-term solution, and we'll need to address the root cause of your
sleep issues.
2. I'd like to refer you to a counsellor who specializes in supporting victims of domestic
abuse. They can provide you with emotional support and practical advice.
3. With your permission, I'd like to refer you to our local domestic violence support
service. They can help you create a safety plan and provide ongoing support.
4. I'm going to give you a thorough physical examination to check for any health issues
related to the stress you're under.
5. We'll arrange regular follow-up appointments to monitor your physical and mental
health.
6. If you're comfortable, I'd like to document the abuse you've disclosed. This can be
important if you decide to take legal action in the future.
7. We won't be suggesting couple counselling, as this isn't appropriate or safe in
situations of domestic violence."

E. Consult with Seniors

Doctor: "I'm going to speak with my senior colleagues about your situation to ensure we're
taking all the necessary steps to help you. This will be done confidentially."

F. Arrange Follow-up

Doctor: "I'd like to see you again in one week to check on your sleep and overall well-being.
After that, we'll arrange regular follow-up appointments. It's very important that you attend
these appointments so we can ensure you're getting the support you need. If anything gets
worse before then, please come back to see me immediately."

V. Safety Planning

Doctor: "I'd like to talk about your immediate safety. Here are some things to consider:

1. Pack an emergency bag with essential items and important documents. Keep it
somewhere safe or with someone you trust.
2. Identify safe places you can go if you need to leave quickly, like a friend's house or a
women's shelter.
3. Memorize important phone numbers in case you can't access your phone.
4. Create a code word to use with friends or family if you need help.

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5. Trust your instincts. If you feel you're in immediate danger, leave as soon as it's safe
to do so and call the police."

Patient-Counsellor Relationship Case

Case Details

Setting

• GP practice

Patient Details

• 35-year-old lady
• Presenting complaint: Wants to change counsellor

I. Initial Approach

Doctor: "How may I help you?"

Patient: "I don't like the counsellor. I just wanted to change the counsellor."

Doctor: "Can you tell me a little bit more? Who is the counsellor? Why are you seeing the
counsellor?"

Patient: "I'm seeing counsellor for my counselling. I've been diagnosed with depression."

Doctor: "Why do you want to change the counsellor? Can I please ask why?"

Patient: "I don't like the counsellor. I saw him with another lady in the supermall. So I
don't feel like seeing him."

Doctor: "Can you please tell me a little more? I'm finding it difficult to understand."

Doctor: "Sometimes some patients come and ask to change their doctors and counsellors if
they are not happy with the service that they receive. Is there anything like that happen? Is
there anything you would like to tell us?"

Patient: (becoming nervous) "I'm not sure, doctor, I should tell you this or not."

Doctor: "Whatever we discuss will remain confidential. Is there anything you would like to
tell us? What is bothering you? Why you want to change the counsellor?"

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II. Encouraging Disclosure

Patient: "Doctor, actually we had a sort of relationship."

Doctor: "I'm finding it difficult to understand. Can you tell me what sort of relationship is
that? How did that start? Was it a romantic relationship you mean?"

Patient: "Yeah, we had a romantic relationship."

Doctor: "May I know his name please? How did that start?"

Patient: "He has become more friendly, become more romantic, started coming, becoming
more close, then started putting his arm around me, then ended up kissing."

Doctor: "I'm sorry to hear about that. How long has this been going on? Have you started
seeing him outside the clinic?"

Doctor: "I'm sorry to ask about this. Was it a sexual relationship?"

Patient: "Yes."

Doctor: "How long have you been in this sexual relationship?"

III. Detailed History Taking

A. Explore the Situation (What, what, what?)

Doctor: "How was the relationship? Was it okay until now? Was everything going okay?"

Doctor: "Has he ever forced you to be in this relationship? Has he ever forced you to be in
a sexual relationship?"

Doctor: "Has he ever threatened you with anything?"

Doctor: "Has he ever been abusive, aggressive?"

Doctor: "Has he ever forced you to do anything?"

B. Actions Taken (What have you done?)

Doctor: "Have you done anything about this now? After seeing him with another lady, I
mean after this incident? Have you spoken to him?"

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Doctor: "Did you speak to anybody? Did you tell anybody about this relationship? Anyone
else knows about this relationship? Any of his friends?"

Doctor: "What has he told you about this relationship? Has he ever asked you not to tell
anybody about this relationship?"

C. Impact Assessment

Doctor: "How is everything affecting you in general? I mean, everything, like how this being
in a relationship has affected. How do you feel about now about this incident? How
everything is affecting your life in general? Has it affected your mood?"

Doctor: "Because of that, would you say that the symptoms have relapsed?"

D. Medical History

Doctor: "Would you like to tell me about your depression? When have you been diagnosed
with it?"

Doctor: "How long have you been on treatment? Do you take any medication?"

Doctor: "How long have you been seeing the psychologist?"

Doctor: "Do you feel low because of this? Any symptoms relapsed?"

Doctor: "Generally, have you ever had, because of the depression or any situation, ever had
any thoughts of harming yourself?"

E. Social History

Doctor: "Who do you live with? Who is at home?"

Doctor: "Do you have any children?"

Doctor: "How are your finances? Were you financially dependent on him? Are you
financially independent?"

Doctor: "Have you had any joint commitment with him?"

Doctor: "Do you smoke, drink alcohol, or use recreational drugs?"

IV. Management Plan

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A. Express Sympathy

Doctor: "I'm so sorry to hear about what has happened to you. I'm really sorry about this
incident."

B. State Your Point of View

Doctor: "This relationship is wrong. It is wrong for him to be in a relationship with you.
We as doctors and healthcare professionals, we are not allowed, we are not permitted to
have this sort of relationship. Our profession is a regulated profession. There are certain
things that we cannot do. We are not allowed to have a relationship with, this sort of
sexual or romantic relationship with our patients. Not only our patients, their relatives too.
We can only have a sort of professional relationship whenever we treat them."

Doctor: "It may not be your fault. It is his fault. He should be aware he shouldn't be having
this sort of relationship."

C. Explain What You as a Doctor Will Do

Doctor: "This will be reported. This is a reportable incident. This will be reported. I'll speak
to my seniors about this."

Doctor: "We can arrange a counsellor for you. I mean, a different counsellor. You don't
need to see the counsellor or the same counsellor. We can arrange a different counsellor."

Patient: "Can I have a female counsellor?"

Doctor: "We can look into it. That may be possible. We can look into it. That should be
fine."

Patient: "Can I get medications now?"

Doctor: "Are you feeling very well? We don't think that you need a medication at the
moment. You can continue with a different counsellor. If you started taking medication,
it's going to be long term. And at the moment, it doesn't seem like you need medication."

D. Consult with Seniors

Doctor: "Before you go, I will speak to seniors regarding it."

E. Arrange Follow-up

Doctor: "We'll follow up in two weeks’ time."

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V. Addressing Patient Concerns

Patient: "I don't want him to get into trouble."

Doctor: "I understand you don't want to get him into trouble. But this is something that I
cannot manage myself. Whenever we come to know one of our colleagues is involving with
the patients in this way, in this manner, I'm supposed to report. This is something that
needs to be reported. This is not something that I can manage myself. Whenever we come
to know our colleagues are involving in a patient or having this sort of relationship, I'm
supposed to report this."

Patient: "Did I make a mistake? Did I make a mistake by telling you this? I think I have
made a mistake."

Doctor: "Please don't feel that way. You haven't done any mistakes. Actually, you have done
very well so far. You have been brave enough to come and talk to us, explain this. This will
help us to find out whether he involves with any other patients as well in this way. You
have done the right thing. And you have been brave enough to come and tell us."

VI. Key Points to Remember

1. Be very supportive and show your empathy.

2. She has been a victim of this.
3. You need to show empathy.
4. You have to be serious and nice and show empathy.
5. Emotions matter in these scenarios.
6. Maintain a non-judgmental approach throughout.
7. Be patient in encouraging disclosure - it may take several attempts.
8. Use the structured approach to history taking once the patient opens up.
9. Be clear about what constitutes inappropriate behaviour from healthcare
professionals.
10. Provide specific information about what will happen next (reporting, changing
counsellor).
11. Always consult with senior colleagues in these cases.
12. Ensure proper follow-up is arranged.
13. Prioritize the patient's mental health and well-being.
14. Be prepared to address the patient's concerns about reporting.
15. Reassure the patient that they've done the right thing by disclosing.

VII. Things to Avoid

1. Don't immediately jump to conclusions.

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2. Don't use the word "confront" when asking if the patient has spoken to the
counsellor.
3. Don't use the word "vulnerable" when describing the patient's actions.
4. Don't jump and say it's illegal.
5. Don't say "I'm going to report" or "Sinead's going to report." Instead, say "This will
be reported."
6. Don't say "definitely" when asked about getting a female counsellor. Instead, say
"We can look into it."
7. Don't rush the patient to disclose - be patient and gentle in your questioning.
8. Avoid using judgmental language or showing shock when the patient discloses the
relationship.
9. Don't tell the patient to talk to the counsellor themselves.
10. Avoid using technical terms - instead, describe the behaviours.
11. Don't forget to consider the impact on the patient's mental health, given their
history of depression.
12. Avoid making promises about outcomes you can't guarantee.
13. Don't suggest couples counselling or mediation - this is inappropriate in this
situation.
14. Avoid pressuring the patient to take any specific action beyond reporting and
changing counsellors.
15. Don't provide unnecessary details about the reporting process to the patient.
16. Avoid ignoring or minimizing the patient's concerns about reporting.
17. Don't ask leading questions.

Workplace Harassment Case (LGBT)

Case Details

Setting

• GP practice (F2 doctor)

Patient Details

• 20-year-old person
• Made an appointment to speak with a doctor

I. Initial Approach

Doctor: "How may I help you? I understand you wanted to speak to doctors, how may I
help you?"

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[Note: The patient may not directly tell you. Be prepared to encourage disclosure.]

Doctor: "I understand that you wanted to speak to us, you're trying to tell something. I'm
finding it difficult to understand. Whatever we discuss will be confidential. Is there
anything particularly you wanted to tell us? Is there anything particularly you would like to
tell us?"

Patient: "Doctor, actually, there are two ladies, they talk about me."

Doctor: "What are they talking? Why does that bother you? What is happening? Would
you like to tell us?"

Patient: "Doctor, I'm lesbian. These two ladies, they just talk about me being lesbian."

Doctor: [Raise eyebrows] "I'm sorry to hear about that."

II. Detailed History Taking

A. Explore the Situation (What, what, what?)

Doctor: "What are they exactly saying?"

Patient: "It is so disgusting. It's so disgusting. I cannot tell."

Doctor: "I'm sorry about that. I'm so sorry about that. But what is their intention? What are
they trying to do to you? Are they trying to hurt you?"

Patient: "They're trying to bully me."

Doctor: "I'm so sorry. Can you tell me what sort of things are going on? Why do they
speak? Do they just speak in front of you or do they just tell things to your face?"

Patient: "They speak behind my back."

Doctor: "How long has this been going on? Why does this happen at your workplace when
you work? Where have you observed this? Does it happen when you are not there? Does it
happen in common places? Have you seen it anywhere else, maybe discussions on social
media and groups?"

Doctor: "Who are these people? How long have you known each other? How long have you
been working with them? Are they senior colleagues, junior colleagues? Do you have some
other colleagues in your workplace? How is their attitude? Are they friendly? Are they nice?
How are your senior colleagues?"

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B. Actions Taken (What have you done?)

Doctor: "Can I please ask you, what have you done about this? Have you done anything?
Have you spoken to those people? Have you spoken to anybody else? Did you report this?"

Doctor: "Why haven't you done anything? Have you thought about doing something? Do
you think that if you report this to your organization, they will take any action, they will
take it seriously? Why haven't you done anything so far?"

C. Impact Assessment

Doctor: "How has this affected you? How is this affecting your general health? Does it cause
any physical symptoms?"

Patient: "Yes, I get some palpitations, racing of the heart."

Doctor: "How long has this been going on? How often do you get it? Around what time do
you get it? What do you do for this racing of the heart?"

Patient: "Whenever I get ready to go to work, I get this."

Doctor: "Do you take any medication? Do you do anything for this?"

Doctor: "Has it affected your mental health? Do you feel low because of this? Is it affecting
your sleep? Do you generally feel safe in your workplace?"

[Note: LGBT individuals usually don't feel safe generally in common places sometimes.]

Doctor: "Because of this incident, would you say that you are losing interest in your work?"

Doctor: "Has this affected your freedom? An individual should have the freedom to do
what they like to do, in a relationship or not in a relationship, workplace, etc."

D. Social History

Doctor: "Who do you live with? Who is at home? Are you in a relationship?"

Patient: "Yeah, I have a partner."

Doctor: "Have you spoken to your partner about this? Why haven't you spoken to your
partner? Is she supportive?"

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Doctor: "Is your family generally supportive? Do they know about your sexual orientation?
Do your family know that you are lesbian?"

[Note: Normally, some people don't tell their families.]

Doctor: "Where do you work? What sort of company is that? Is it a large company? How
many people are working in your company? How long have you been working with them?"

[Note: Large companies usually have full policies. It's easier to sue them.]

Doctor: "Do you have any other stresses in your life?"

Doctor: "Do you smoke, drink alcohol, or use recreational drugs?"

[Note: In this scenario, the patient drinks a bottle of wine every day. Ask: "Because of this
incident, have you started drinking now?"]

Patient: "Yeah, I drink one bottle of wine because of this every day."

E. Medical History

Doctor: "Do you have any other medical problems?"

III. Management Plan

A. Express Sympathy

Doctor: "I'm sorry to hear about what you are experiencing in your workplace. That must
have been very difficult for you."

B. State Your Point of View

Doctor: "This is harassment. Harassment means making other people uncomfortable. It

could be anything - talking about appearance, country, dress, food, culture, sexuality, or
religion. If somebody makes another person uncomfortable, that is harassment."

Doctor: "It seems like you have been harassed based on your sexual orientation, which is
wrong. It is not allowed in our society. You don't need to go through this, you don't need
to put up with this."

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C. Explain What the Patient Can Do

Doctor: "The first thing you can do is make a formal written complaint to your
organization or your company. Write a formal complaint to your managers or supervisors,
and ask them to take proper action against those people and wait."

Doctor: "If they fail to do so, if they don't take action, you can take action by yourself. You
can sue them, you can take them to court, you can take them to employment tribunals.
You can take legal action because they failed to provide you a safe and favourable
environment to work. It is their duty."

Doctor: "There are laws to protect people in your situation. The law is the Equality Act
2010. This Act prevents people from being treated differently because of their sexual
orientation, religion, or other protected characteristics."

Doctor: "In order to take legal action, you might need to find somebody to support you.
Maybe charities can help, like the LGBT Foundation. You can also go and speak to one of
the counsellors there. Sometimes you can get legal aid if you can't afford solicitors."

D. Explain What You as a Doctor Will Do

Doctor: "We can arrange some counselling to help you cope with the stress."

Doctor: "Regarding your alcohol consumption, it seems like you are drinking alcohol a
little bit excessively. This can cause addiction, and in the long run, it will not be helpful.
We advise you to cut it down. Instead, you can do some regular exercise, relaxation
techniques like yoga, meditation, maybe pursuing a hobby, or playing a sport."

E. Consult with Seniors

Doctor: "I will speak to my seniors about this situation."

F. Arrange Follow-up

Doctor: "I'd like to see you again in two weeks to check on your well-being."

IV. Key Points to Remember

1. Be very supportive and show your empathy.

2. The patient has been a victim of harassment.
3. You need to show empathy.
4. You have to be serious and nice and show empathy.

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5. Emotions matter in these scenarios.

6. Maintain a non-judgmental approach throughout.
7. Be patient in encouraging disclosure - it may take several attempts.
8. Use the structured approach to history taking once the patient opens up.
9. Be clear about what constitutes harassment and that it's not acceptable.
10. Provide specific information about what the patient can do (formal complaint, legal
action).
11. Always consult with senior colleagues in these cases.
12. Ensure proper follow-up is arranged.
13. Prioritize the patient's mental and physical health.
14. Be prepared to address any unhealthy coping mechanisms (e.g., excessive alcohol
use).
15. Know about the Equality Act 2010 and its relevance to this situation.
16. Start the management advice well before two minutes are left in the consultation.

V. Things to Avoid

1. Don't jump to conclusions.

2. Don't use the word "confront" when asking if the patient has spoken to the
harassers.
3. Don't ignore signs of physical symptoms (e.g., palpitations).
4. Don't forget to ask about the patient's support system (partner, family).
5. Avoid making promises about outcomes you can't guarantee.
6. Don't suggest the patient should directly confront the harassers.
7. Avoid using technical terms - instead, describe the behaviours.
8. Don't forget to consider the impact on the patient's work performance and interest.
9. Avoid pressuring the patient to take any specific action if they're not ready.
10. Don't provide unnecessary details about the legal process.
11. Avoid ignoring or minimizing the patient's concerns about reporting.
12. Don't ask leading questions.
13. Don't miss any points in the management plan.
14. Don't wait until the last two minutes to start the management advice.

Rape Case Scenario

Case Details

Setting

• GP practice (F2 doctor)

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Patient Details

• 19-year-old boy named George

• Made an appointment

I. Initial Approach

[Note: Patient may be nervous, fidgeting hands, rubbing the floor with feet. Don't
immediately comment on this.]

Doctor: "Hello George. How may I help you?"

Patient: "I need a sick note."

Doctor: "Can I please ask you why you need a sick note?"

Patient: [Possible responses]

• "I have an exam next week/tomorrow, I don't want to go."

• "I need to give an assignment tomorrow, I cannot give."
• "I missed the deadline for assignment, so I need to give a sick note."

Doctor: "Why are you not able to do the exam tomorrow?"

Patient: "I'm not able to concentrate."

Doctor: "Why are you not able to concentrate?"

Patient: "Because of the stress and everything."

[Note: At this point, the patient may appear very nervous and acting weird.]

Doctor: "Is there anything else you would like to tell us? You seem to be a little bit anxious.
Is everything okay? Is there anything you would like to talk to us about?"

Patient: "No, doctor, I'm fine. I just want a sick note."

Doctor: "Look, George, whatever we discuss is going to be confidential. We're a little bit
concerned there may be something bothering you. Is there anything going on? Is there
anything you would like to tell us?"

Patient: "Doctor, actually I got raped."

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Doctor: [Raise eyebrows] "I'm really sorry to hear about this. Would you like to tell us
more?"

II. Detailed History Taking

A. Explore the Situation (What, what, what?)

Doctor: "Can you tell me more about what happened? When did this happen?"

Patient: "I went to a birthday party..."

Doctor: "Whose birthday party was that?"

Patient: "It was my best friend's birthday party."

Doctor: "How did it happen?"

Patient: "My best friend's brother was talking to me, then he invited me to his room. Then
he locked the room, undressed me and raped me."

Doctor: "When did this happen? How long ago?"

Doctor: "Are you familiar with the person, your friend's brother? Do you know him? Are
you friends?"

Doctor: "During this incident, were you under the influence of alcohol? Was the other
person under the influence of alcohol?"

Doctor: "I'm so sorry about the intrusive nature of these questions. We would like to know
exactly what happened. Was there any penetration? Was there any sexual intercourse? Was
there any anal intercourse or anal penetration? Was there any oral intercourse?"

Doctor: "Have you had any injuries during that? Have you experienced any pain during
that?"

Doctor: "Is there anything else that happened during the incident?"

Doctor: "What happened immediately after? Did you go home?"

Doctor: "Did you ask for help during the incident?"

Patient: "I was screaming, but there was a lot of noise and no one helped me."

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Doctor: "I'm sorry to hear about that."

B. Actions Taken (What have you done?)

Doctor: "Have you done anything about it since this incident? Did you report this? Have
you seen any doctors? Have you gone to the hospital? Have you spoken to anybody? Did
you tell anybody about this?"

Doctor: "Why haven't you done anything? Are you afraid of anybody? Has he ever
threatened you with anything?"

Doctor: "Have you thought about doing something? Why haven't you done anything? Is
there anything bothering you about this?"

C. Impact Assessment

Doctor: "How has this affected you? Since this has happened, is it affecting you? Does it
cause any physical symptoms? For example, when you think about the incident, do you
have a racing heart? Are you feeling low?"

Doctor: "Has it affected your mental health? Do you feel low? Has it affected your sleep?"

Doctor: "Do you generally feel safe roaming around?"

D. Social History

Doctor: "Who do you live with? Do you have any siblings or friends?"

Doctor: "Are you in a relationship?"

Doctor: "Can I also please ask you, are you gay or straight?"

Doctor: "Have you ever been sexually active?"

Doctor: "How is your family support? How about friends?"

Doctor: "How are your studies?"

Doctor: "Do you smoke, drink alcohol, or use recreational drugs?"

E. Medical History

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Doctor: "Do you have any medical problems? Are you on any medications? Do you have
any allergies?"

III. Management Plan (S for Zara)

A. Sorry

Doctor: "First of all, I'm really sorry to hear about the incident. It must have been a very
difficult experience for you. We are really sorry about this. Let me see what we can do for
you."

B. Serious Crime

Doctor: "Forcing sex on somebody is a serious crime. You can report this to the police.
Would you like to report this?"

Patient: "No, I don't want to report."

Doctor: "Can I ask you why?"

Patient: "He is my best friend's brother."

Doctor: "If you don't want to report, you don't need to. But please be aware, you can report
this any time later in your life. There is no expiry date."

C. SARK (Sexual Assault Referral Center)

Doctor: "If somebody is affected by sexual violence, we refer them to a specialist centre
called SARK - Sexual Assault Referral Center. It's a specialist clinic for people affected by
sexual violence. They do four main things:

1. It's better to get examined by a forensic expert, preferably within seven days of the
incident.
2. They will check for sexually transmitted infections.
3. They offer counselling.
4. They can help you do a formal report if you choose to.

All these services are given under one roof. We advise you to go there. Even if you go there,
you don't need to do all the things - you can choose what you're comfortable with."

D. Sick Note

Doctor: "We can offer you a sick note."

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Patient: "What are you going to write on the sick note?"

Doctor: "We're going to write that you are not fit to sit in the exam. Your information will
be confidential. We are not going to write about the incident."

Patient: "How long are you going to give a sick note?"

Doctor: "We can give it for two weeks at the moment. Then after that, we will review in
two weeks. If you need further, we can provide."

E. Seniors

Doctor: "I will speak to my seniors about this situation."

F. See You (Follow-up)

Doctor: "We would like to follow up with you in two weeks' time."

IV. Key Points to Remember

1. Be very supportive and show empathy.

2. Maintain a non-judgmental approach throughout.
3. Be patient in encouraging disclosure - it may take several attempts.
4. Use the structured approach to history taking once the patient opens up.
5. Be clear about what constitutes a serious crime.
6. Provide specific information about SARK and its services.
7. Always consult with senior colleagues in these cases.
8. Ensure proper follow-up is arranged.
9. Prioritize the patient's mental and physical health.
10. Be prepared to provide a sick note and explain its contents.
11. Respect the patient's autonomy in decision-making, especially regarding reporting.
12. Remember that this is an adult case (19 years old).
13. Know the difference between adult cases and child cases (e.g., ADHD case is 18
years old, also an adult).
14. Start the management advice well before the last two minutes of the consultation.

V. Things to Avoid

1. Don't immediately comment on the patient's nervous behaviour.

2. Don't use the word "rape" - instead, use terms like "sexual violence" or "this
incident".
3. Don't pressure the patient to report if they're not ready.

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4. Avoid using phrases like "it's a safe place" when offering confidentiality.
5. Don't say "I would really like to see you" for follow-up. Use professional language
like "We would like to follow up with you."
6. Don't ignore signs of physical or psychological distress.
7. Avoid making promises about outcomes you can't guarantee.
8. Don't forget to consider the impact on the patient's studies and daily life.
9. Avoid using technical terms - instead, describe behaviours and symptoms.
10. Don't rush the patient to disclose - be patient and gentle in your questioning.
11. Avoid showing shock or overreacting when the patient discloses the incident.
12. Don't say "Okay" when the patient discloses being raped.
13. Don't forget to raise your eyebrows and express sympathy when the patient
discloses.
14. Don't use the phrase "back passage" - use "anal" instead.
15. Don't forget to ask about the patient's sexual orientation and sexual history.
16. Don't assume the patient's sexual orientation or relationship status.
17. Don't forget to ask about alcohol consumption during the incident.
18. Don't miss any points in the management plan.
19. Don't wait until the last two minutes to start the management advice.

VI. Additional Important Points

1. This scenario is about an adult male (19 years old) being raped.
2. The history taking should follow the structure: what, what, what, what you have
done, how it has affected you, social, medical.
3. The management plan follows the "S for Zara" structure: Sorry, Serious crime,
SARK, Sick note, Seniors, See you (follow-up).
4. Be aware that the patient might not disclose immediately and may need
encouragement.
5. Remember that asking about sexual orientation is normal and not offensive.
6. Be prepared for the patient to ask specific questions about the sick note.
7. Understand the importance of respecting the patient's autonomy in decision-
making.
8. Be aware that the patient may have never been sexually active before this incident.
9. Remember that large companies usually have full policies and are easier to sue
(relevant for workplace scenarios).
10. Be prepared to address any alcohol use that may have started due to the incident.

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Clinical and Ethical Explanation Scenarios

Overview

• These scenarios are called "scenarios that need clinical or ethical explanation"
• There are approximately 18 scenarios in total
• It's likely to encounter at least one scenario from this list in the exam

Types of Scenarios

Scenarios where you typically say "No":

1. Asking for sick note

2. Changing the notes
3. Asking confidential information
4. Head injury (CT scan request)
5. Tonsillectomy
6. Asking for antibiotics (for viral infections)

Scenarios where you promote best interest (say "Yes"):

1. Sigmoidoscopy patient needing colonoscopy

2. DKA patient needing admission

Key Concept

• Saying "No" is not enough

• The explanation is crucial
• Need to "break the deal" by explaining why
• Example: In a viral infection, explain why you can't give antibiotics
• This explanation is the "deal breaker" that can make a difference in performance

Approach: Four Box System

This is not the same as the general four box system, but can be used for learning purposes.

1. Box 1 & 2: General history

2. Box 3: Main interest - Explaining the reason
3. Box 4: Giving the solution

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Example for sick note request:

• Box 3: Explain why you cannot give a sick note

• Box 4: Provide a solution for their problem

Common Mistakes

• Focusing too much on the solution (Box 4) instead of the explanation (Box 3)
• Example: For sick note request, immediately suggesting to speak to the employer
• The exam is not interested in your solution, but in your clinical or ethical
explanation

Important Points

1. Understanding is not enough in PLAB 2

2. Need to reproduce knowledge with proper chunks of information
3. Some scenarios are ethical, some are clinical
4. For "No" scenarios, focus on explaining why not
5. For "Yes" scenarios, explain why they need to do it
6. Don't try to solve every problem of the general public
7. The exam's interest is in listening to your logic

Examples of Explanations

1. Sick note request:

o Incorrect: "Can you speak to your employer?"
o Correct: Explain why you cannot give a sick note, then suggest alternatives
2. Borrowing money (analogy):
o Incorrect: "Can you ask my brother?"
o Correct: "I'm sorry, I cannot give you any money because I spent all on my
holidays. I don't have any money at all at the moment. Alternatively, can you
please ask my brother?"
3. Antibiotic request:
o Focus on explaining why you cannot give antibiotics for a viral infection
4. Tonsillectomy:
o Explain why the tonsillectomy is not done
5. CT scan request:
o Explain why we don't do a CT scan now

Conclusion

• Be fast in your approach

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• Focus on the explanation (Box 3) rather than the solution (Box 4)

• Practice structuring your explanations for each scenario
• Remember: The explanation is what differentiates strong responses

Sick Note Request Scenarios

General Approach for Both Scenarios

1. Use a four-box system:

o Box 1 & 2: General history
o Box 3: Main interest - Explaining the reason
o Box 4: Giving the solution
2. Focus on the explanation (Box 3) rather than the solution (Box 4)
3. Be nice and say sorry when explaining why you can't provide a sick note
4. Learn to say no in a nice way
5. Show empathy for the situation, even if you can't help
6. Don't try to solve every problem of the general public
7. The patient doesn't need to agree with your solutions

Scenario 1: Sick Note for Child's Chickenpox

Setting

• F2 in GP
• 40-year-old lady made an appointment
• Child has been diagnosed with chickenpox yesterday (given in the task)

Initial Approach

Doctor: "How may I help you?" Patient: "Doctor, can you give me a sick note?" Doctor:
"Can I please ask you why?" Patient: "My child has been diagnosed with chickenpox. So I
wanted to stay at home and look after my child. That's why I need a sick note."

Establish Understanding

Doctor: "Let me understand this better. So at the moment your child is having chickenpox,
so you wanted to stay at home to look after your child, and you wanted to give the
employer a sick note for yourself. Is that what you want?" Patient: "Yes, that's correct."

History Taking (Box 1 & 2)

Doctor: "Let me ask you a few questions to understand your circumstances."

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1. About the child: Doctor: "When was your child diagnosed with chickenpox and
how?" Patient: "Yesterday, I brought the child to the GP and the GP diagnosed it."
Doctor: "How is your child doing generally?" Patient: "The child is fine."
2. Childcare: Doctor: "Who usually looks after the child? Are you the only person, or
is there anybody else at home?" [Note: Don't ask where the father or husband is]
3. Other options: Doctor: "What have you tried for this? Have you tried any other
options? Like maybe asking any other family members to look after, or maybe
arranging somebody, hiring somebody, or a childminder?"
4. Employment: Doctor: "Who do you work with? What do you do for a living?"
Patient: "I'm a lecturer in a university." Doctor: "How long have you been working
with them? Is it permanent employment?" Patient: "Yes, it's permanent."
5. Communication with employer: Doctor: "Have you spoken to your employer? Have
you discussed this with them?" Patient: "No, I haven't."
6. Impact: Doctor: "If you don't go to work, how will this impact you?" Patient: "If I
don't go, they will not pay me."
7. Health concerns: Doctor: "Are you concerned about anything? Are you worried that
you may get chickenpox?" Patient: "Yes, I'm worried that I might get chickenpox."
Doctor: "Have you had chickenpox when you were young?" Patient: "Yes, I had
chickenpox in my childhood."

Explanation (Box 3)

Doctor: "I'm really sorry. Unfortunately, we are not able to help you with your request. I
will not be able to give you a sick note because a sick note is given to the particular person
who is sick. In your situation, it is your child who is sick. For your child's sickness, I cannot
give a sick note for you. We are really sorry."

Solution (Box 4)

Doctor: "In this situation, the best people for you to speak to for help is your employer.
You can speak to them, explain to them. They can help you in many ways. Maybe they
might allow you to work from home. Or maybe they can arrange annual holiday. Or, there
is an option, they might give you some compassionate leave, on a compassionate basis. If
that doesn't work, maybe you need to hire somebody. Or maybe you can find help from
family or friends or maybe a childminder."

Things to Avoid

1. Don't diagnose chickenpox again

2. Don't ask where the father or husband is
3. Don't offer parental leave (it's unpaid)
4. Don't suggest self-certification (she's not sick)

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5. Don't focus too much on the solution or try to make the patient agree with your
suggestions

Scenario 2: Sick Note for School Holidays

Setting

• GP setting
• 35-year-old made an appointment

Initial Approach

Doctor: "How can I help you?" Patient: "Doctor, can you give me a sick note?" Doctor: "As a
patient, are you unwell at the moment? Are you feeling unwell?" Patient: "No, but children
are at home. These days, children are at home. So I wanted to stay at home in order to
look after my children. I want a sick note to give my employer."

Establish Understanding

Doctor: "So my understanding is that because of the school holidays, your children are
staying at home. So there is nobody to look after them. So you wanted to stay at home and
you wanted to give a sick note to your employer. Is that correct?" Patient: "Yes, that's right."

History Taking (Box 1 & 2)

1. About the children: Doctor: "Can you tell me a little bit more about the situation?
How many children do you have?" Doctor: "Are they generally okay? Do they have
any special needs or anything?" Patient: "They are generally fine."
2. Childcare: Doctor: "Who usually looks after your children when you're not there?"
Patient: "Usually my husband." Doctor: "Where is your husband?" Patient: "My
husband is on holiday. He's on a vacation fishing in the river."
3. Employment: Doctor: "Who do you work with? What do you do?" Patient: "I'm a
nurse, a palliative nurse." Doctor: "What sort of employment is it? Is it permanent?"
Patient: "Yes, it's permanent employment." Doctor: "Have you taken your annual
holidays?"
4. Communication with employer: Doctor: "Have you spoken to your employer? What
have you tried? Did you explain the situation to them?"
5. Other options: Doctor: "Have you tried any other options? Like maybe arranging
somebody else? Maybe arranging a childminder?"
6. Impact: Doctor: "If you don't go to work, how will this impact you? What are your
main worries about this?"

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7. Past behaviour: Doctor: "Have you done similar things in the past? Have you got any
sick notes from doctors before?"

Explanation (Box 3)

Doctor: "I'm really sorry. I wish we could help you in this situation. Unfortunately, we
cannot help you with your particular request. We offer a sick note when somebody is
having sickness. Tell, in this situation, nobody is sick. So we cannot give a sick note. Sick
note is given when somebody is sick. In this situation, it seems like you need some help
with childcare. We cannot give a sick note for childcare purposes."

Solution (Box 4)

Doctor: "The best people to help you in this situation are your employer. Explain to them
about the situation, they might help you. They may be able to arrange your rotation, or
maybe arrange your annual holidays. Explain to them and get some help. But I'm sorry, we
will not be able to help you with the request. Maybe alternatively, if that doesn't work, you
need to hire somebody. Maybe you can look into your workplace. During the school
holidays, workplaces sometimes arrange some childcare facilities for working mothers. You
may look into it. There may be some other childcare facilities for working mothers. That
may be possible."

If Asked "What Would You Do?"

Doctor: "It can be difficult sometimes. One thing that we can do is we can just pre-plan.
The holiday is better to be pre-planned. It's better to have some emergency funds. If you
have money, it's not a problem. If you have money, you can hire somebody. It's better to
have some emergency funds for emergency situations like this, so you'll be able to hire
somebody. There may be some childcare facilities you can look into. And also, the holidays
are better to be planned. If you have a partner, it's better to be discussed and pre-planned.
These sorts of options can be beneficial in this situation."

Things to Avoid

1. Don't offer compassionate leave (situation is not compassionate)

2. Don't suggest parental leave
3. Don't suggest self-certification
4. Don't focus too much on the solution or try to make the patient agree with your
suggestions

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Additional Important Points

1. The explanation (Box 3) is crucial and should be the focus, not the solution (Box 4)
2. Be aware of the differences between the two scenarios and adjust your explanation
accordingly
3. In the chickenpox scenario, focus on the fact that the child is sick, not the parent
4. In the school holiday scenario, focus on the fact that no one is sick at all
5. Always be nice and sympathetic when explaining why you can't provide a sick note
6. Remember that different employments have different options, so ask about the
patient's job
7. Don't try to solve every problem; focus on explaining why you can't provide a sick
note
8. Be aware that there may be a sick note on the table with a pen, sometimes filled up
9. The scenarios are designed to test if you can think and adjust your response based
on slight changes in the situation
10. Always prioritize the explanation over the solution

Changing Notes Scenarios

General Points

1. Sick note and fit note are the same thing.

2. Government changed the name from sick note to fit note in 2010.
3. In the UK, there is no "medical certificate", only sick note or fit note.
4. It's not "fitness to work" or "fit to work", it's all medical certificate.
5. The change of sick note is very frequent and easy.
6. If you don't do unnecessary stuff, you will be fine.
7. The explanation has to be solid on why you can't change notes.
8. Don't give priority to the solution. Solution is a courtesy.
9. You can pass the scenario without giving a solution.
10. The scenario is not to make the patient accept your solution.
11. The objective is to hear your explanation for why you can't change the notes.

Scenario 1: Ankle Pain

Setting

• F2 in A&E
• 35-year-old lady
• You saw the patient 2 hours ago, assessed her, and sent her for X-ray

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Initial Approach

1. Greet the patient, even though you've seen them before: "Hello, Emily Jones. I am
X, one of the doctors. I am back again."
2. Double-check identity: "I just wanted to double-check that I have the right records
with me. Can you please confirm your age as well once for me, please?"
3. Paraphrase the situation: "Understand we have sent for an X-ray. I have the X-ray
reports. I have the X-rays with me. But you also earlier told me [mention details
from the task]. Apart from that, is there anything you would like to tell us?"

History Taking

1. Ask: "Are you still having the pain?"

2. Ask: "Is the pain getting worse?"
3. Ask: "Any other symptoms?"
4. Ask: "Do you have any other medical problem? Any other ongoing medical
problem?"
5. Ask: "Do you take any regular medication?"
6. Ask about allergies

Explaining X-ray Results

1. Show the patient the X-ray

2. Explain: "These are your bones in your leg. These two long bones are the bones on
your lower leg. These are the bones on your heel. These are your toes. These are the
bones in between your heel and the toes."
3. State: "All the bones are fine. All of them are normal."
4. Diagnose: "You might have sustained an ankle sprain. Ankle sprain is a soft tissue
injury. It is an overstretching of the ligaments, the soft tissue."
5. Mention treatment: Talk about PRICE or RICE "As a treatment, you can take
painkillers, raise the legs, use ice pack, and things like that."

Handling the Request to Change Notes

Patient: "Doctor, can you change my notes?"

Doctor: "Can I please ask you how you want to change your notes? And can I please ask
you why?"

Patient: "Doctor, actually, if you give me a note, if you give me a doctor's note saying that
this happened in my workplace, I can get some compensation. My solicitors, my lawyers
told me that I can get some compensation. So can you please change my notes?"

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Doctor: "I'm so sorry. I will not be able to help you with that. We cannot write something
that did not happen. We cannot write something which is not true. As a doctor, I have to
be honest and I have to maintain my integrity to my profession. It is wrong for me to do
that. It is wrong. I am really sorry."

Patient: "Doctor, you know, I have a child. I am a single mother. If I don't go to work, they
will not pay me. I am going to find it difficult to feed my children. I am going to struggle
financially."

Doctor: "I understand. There may be some financial implications if you don't go to work.
But unfortunately, I will not be able to help you with the request. Alternatively, what you
can do is, you can speak to a local job centre. There is a very good benefit system, or you
can tell there is a very good social security system. Maybe you can speak to local council or
local job centre. You can get some advice from Citizen's Advice Bureau. They can help you,
you know, in order to, tell if you have a child. You may have, you may be entitled to some
state benefits and social security system. Maybe you can speak to them, get some help. Try
looking into some other options, Mrs. Johnson. But unfortunately, I cannot help you the
way that you want."

Patient: "Doctor, you are a junior doctor. You may not be able to help. But can you ask the
seniors? They may be able to help. Can I speak to seniors? Can I speak to your seniors?"

Doctor: "There is no need to speak to seniors. Either seniors or me, no one can actually
help in the particular way that you want. We doctors, we don't do this. We don't change
the notes or alter the notes for anyone to get some financial benefits. It's wrong for us to
do."

Scenario 2: Wrist Pain

Setting

• 19-year-old girl
• Came with wrist pain

Initial Approach and History Taking

[Same as Scenario 1]

Explaining X-ray Results

[Same as Scenario 1, but for wrist instead of ankle]

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Handling the Request to Change Notes

Patient: "Doctor, can you change my notes, please?"

Doctor: "Can you tell me how you want to change your notes? Can I ask you why?"

Patient: "Can you just change it? I just want you to change. Change into something else.
Change. Change. Just change it."

Doctor: "I am finding it difficult to understand why you want to change. Sometimes some
patients ask us to change their notes, in terms of what we write. Because they get benefits
from that. Sometimes some people get some financial benefits from that. Okay, is there
anything? Has anything like this happened? Is there any particular reason that you want to
change?"

Patient: "Doctor, actually my grandma is sick. So I wanted to give a sick note to her. I
cannot go to work actually. My grandma is sick, I cannot go to work. So I wanted to stay
and look after my grandmother. So I wanted to give a sick note saying that this happened
in my workplace, so they can pay me."

Doctor: "I'm sorry, we cannot write something which is not true. It is not right. It is wrong
for me to write something like this."

Key Points to Remember

1. Even if you've seen the patient before, still introduce yourself and check identity.
2. Don't assume you remember everything about the patient. Take a brief history
again.
3. Explain X-ray results clearly to the patient, showing and explaining all parts.
4. When asked to change notes, always ask why and how they want to change.
5. Explain that you can't change notes because it's ethically wrong, not because of fear
of punishment.
6. Be sympathetic but firm in your refusal.
7. Offer alternative solutions if appropriate (like contacting job center or CAB).
8. Don't refer to seniors when asked about changing notes.
9. Learn to say no in a nice way, don't keep a straight face.
10. The focus should be on the ethical explanation, not on the solution.
11. Don't try to solve every problem of the general public.
12. Understanding the difference between ethics and law is crucial.
13. Ethics is about not doing something because it's not right, not because of fear of
punishment.
14. The patient doesn't need to accept your solution or alternatives.

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Things to Avoid

1. Don't skip introducing yourself or checking identity, even if you've seen the patient
before.
2. Don't assume you remember all details about the patient from the previous
encounter.
3. Don't diagnose conditions that have already been diagnosed (like chickenpox in
other scenarios).
4. Don't ask where the father or husband is when discussing childcare.
5. Don't offer parental leave or suggest self-certification when it's not appropriate.
6. Don't say "we are not allowed to write this" - instead, focus on it being wrong or not
right.
7. Don't mention losing your license or being punished as a reason for not changing
notes.
8. Don't keep a straight face when saying no - learn to say no in a nice way.
9. Don't give in to requests to speak to seniors about changing notes.
10. Don't focus too much on solutions - the explanation is more important.
11. Don't ignore the patient's attempts to gain sympathy, but remain firm in your
decision.

Whiplash Injury Scenarios

General Points

1. Whiplash scenarios keep coming recently in studies.

2. There are two types of scenarios: whiplash malingering and real whiplash injury.
3. The whiplash malingering scenario is about asking for a sick note without actual
sickness.
4. The real whiplash injury scenario involves proper history taking and examination.

Scenario 1: Whiplash Malingering

Setting

• F2 in GP
• 40-year-old lady made an appointment

Background Information (Given in the task)

• Patient had a road traffic accident a few days ago

• She hit her car into a tree

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• She was taken to the hospital and examined

• She was fine
• Police checked alcohol content in her breath, which was too high
• She was banned from driving

Initial Approach

Doctor: "How may I help you?"

Patient: "Doctor, can you give me a sick note saying I have whiplash injury?"

Doctor: "Let me ask you some questions to assess you."

History Taking

1. Ask: "Can you tell me what happened? I understand recently you had an accident."
2. Ask: "What sort of injury have you sustained?"
3. Ask about any pain
4. Ask questions related to head injury:
o "Did you hit your head?"
o "Was there any bleeding from the nose or from the ear?"
o "Did you lose your consciousness?"
5. Ask: "Have you had any pain immediately?"
6. Ask: "Have you had any neck pain later on the following days?"
7. Ask: "Do you have any pain at all?"
8. Ask: "Any numbness, weakness in the hand?"
9. Ask: "Any symptoms at all?"
10. Complete the MAP DOSA
11. Ask about occupation

Examination

Doctor: "I would like to examine you." [Examiner will tell you examination is normal]

Explanation

Doctor: "Well, we just assessed you. We have just examined you. At the moment, as you
don't have any whiplash injury, we cannot write something that you don't have. It is wrong
for a doctor to write something that you don't have. We cannot write something like that.
It is wrong for us to do. We don't do something like that. I'm really sorry. We cannot write
something that you don't have."

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Patient Response and Doctor's Reply

Patient: [Mentions having a child, struggling financially, etc.]

Doctor: "You can explain to your employer about the situation, or maybe you can work
from home, or you can find an employment that you can work from home."

[Note: In this scenario, the patient is a medical rep who needs to drive for work. However,
this doesn't change the doctor's response.]

Additional Scenario Variation

Patient: "At least you can write that I'm stressed out."

Doctor: "Are you really stressed out?"

Patient: "No, I'm not stressed out, but you can write that."

Doctor: "I'm sorry, we cannot write something that you actually don't have. It's wrong for
me to write."

Scenario 2: Real Whiplash Injury

Setting

• Patient comes with neck pain

• Equipment on the table: knee hammer, cotton wool, neuro pin

History Taking

1. Ask: "What happened?" Patient: "Yesterday I was driving my car. The car in front of
me put a sudden brake. So I put a sudden brake."
2. Ask: "Did you hit your head?"
3. Ask: "Did you lose your consciousness?"
4. Ask: "Did you faint?"
5. Ask: "Have you had any vomiting?" (head injury questions)
6. Ask: "Any fluids leaking anywhere?"
7. Ask: "Have you had any pain immediately?"
8. Ask: "Any symptoms at all?"
9. Ask: "On the following day, did you wake up with pain?"

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10. Ask: "Where is the pain?"

11. Ask about movements
12. Ask: "Any symptoms in the arm? Numbness, weakness, tingling sensation?"
13. Ask about stiffness
14. Complete the PMAFTOSA

Examination (on a real human being)

1. Look
2. Feel
o Check temperature
o Check tenderness in spinal process and paraspinal process [Note: If there's
tenderness on the midline bone, stop examination, apply neck collar, and do
an X-ray]
3. Move
oAsk patient to look down to the floor, then to the roof
o Ask patient to look side to side
o Ask patient to look over the shoulder on both sides
o Ask patient to try to touch the shoulder with the ear
4. Upper arm neurological examination
o Motor: Check shoulder level, elbow level, wrist level, and finger level
o Sensory: Check dermatomes using neuro pin for pain and cotton wool
o Check reflexes
o Check end nose test (radial nose, median nose, ulnar nose)

Diagnosis

Doctor: "You could have sustained a whiplash injury. Whiplash injury is basically a muscle
spasm due to overstretching of the muscles."

Treatment

1. Prescribe painkillers (NSAID)

2. Advise patient to keep active and keep moving
3. Advise against too much rest
4. If patient asks for neck collar: Doctor: "Neck collar is not recommended. It increases
the stiffness and prolongs the healing. You have to leave the neck freely moving."
5. Advise patient not to drive (no need to inform DVLA)

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Key Points to Remember

1. In malingering cases, focus on explaining why you can't write something that isn't
true
2. For real whiplash cases, conduct a thorough examination
3. Understand the nature of whiplash: overstretching followed by spasm
4. Be aware that symptoms often develop the day after the incident
5. Know the proper examination technique: look, feel, move
6. Be prepared to stop the examination and order an X-ray if there's midline
tenderness
7. Advise against neck collars in whiplash cases
8. Emphasize keeping active rather than resting

Things to Avoid

1. Don't immediately say no to requests for sick notes without assessing the patient
2. Don't write sick notes for conditions the patient doesn't have
3. Don't recommend neck collars for whiplash injuries
4. Don't forget to check for signs of head injury in addition to neck symptoms
5. Don't skip any steps in the examination process
6. Don't forget to advise the patient about driving restrictions

Additional Important Points

1. The whiplash malingering scenario is not about real sickness, unlike previous
scenarios where patients had actual conditions but wanted notes changed.
2. In the real whiplash scenario, the history is short (about three and a half minutes).
3. The nature of whiplash is spasm due to stretching. First overstretching, then that
causes the spasm.
4. There are five or six skin-to-skin physical examinations on a real human being that
need to be studied and practiced:
o Whiplash injury
o Shoulder examination for frozen shoulder
o Parkinson's bradykinesia examination
o Abdominal examination
o Ankle examination for ankle sprain
o Plantar fasciitis examination
5. These are the only real physical examinations required, not cranial nerve or eye
examinations.

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Mini-Mental State Examination (MMSE) Scenario

Setting

• F2 in acute medicine
• 70-year-old man admitted with myocardial infarction
• Patient is being discharged today
• Nurses have noticed he's having some short-term memory loss

Task

Assess the cognitive function of this patient

Room Setup

• Patient is sitting
• Paper and pen on the table

Initial Approach

1. Introduce yourself
2. Check patient details
3. Explain the assessment: Doctor: "Today I've been asked to come and do an
assessment called Mini-Mental State Examination. This is in order to check your
memory and how well you remember events. For the purpose of this assessment, I
might be asking some questions. Sometimes some questions may not make sense to
you. And if you don't know the answer to any of these questions, you don't need to
answer. Okay, simply tell that."
4. Ask preliminary questions: Doctor: "Are you able to read and write?" Doctor: "Do
you have any problem with your vision?" Doctor: "Do you wear glasses?"

Conducting the MMSE

1. Start asking questions immediately (don't discuss myocardial infarction)

2. You need to memorize all 20 questions (not provided on a chart)
3. Ask questions in the correct order
4. Mark answers accurately using tally method (1,2,3,4, diagonal for 5th)

Potential Patient Behaviours and How to Handle Them

1. Patient asks questions back: Patient: "Which year is this, doctor?" Doctor: [Do not
answer]

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2. Patient gives wrong answer: Patient: "It's 1985." Doctor: [Do not correct]
3. Patient makes distractive comments: Patient: "Look, doctor, nice weather." Doctor:
"Yes, it is very nice weather. But can I ask you the next question?"
4. Patient suddenly stands: [Doctor should also stand, then sit when patient sits]
5. Patient comments on doctor's appearance: Patient: "What colour is this? It's a very
nice colour." Doctor: [Acknowledge briefly but redirect to the examination]
6. Patient throws paper: [Pick it up quickly or at the end of the examination] Doctor:
[Smile and continue, don't get angry]

Time Management

• You will not complete the full MMSE in the given time
• Continue until the 6-minute bell

Management (with examiner)

After the 6-minute bell, turn to the examiner and say:

Doctor: "Today I have done a Mini-Mental State Examination for Mr. Johnson, who is a
70-year-old man. So far, I have done up to [mention the section you reached, e.g.,
registration or recall or language]. And so far he scored [mention score]. So he has
significantly lost his points. That shows he has a significant cognitive impairment. So he
may or he might have dementia."

Then discuss management: Doctor: "In terms of his management, we can do all these
investigations [list investigations]. We'll cancel the patient's discharge. We'll refer to
psychiatry. Psychiatrists will further assess, do psychiatric assessment, and patient will be
treated for dementia."

Key Points to Remember

1. This is the only MMSE scenario you need to know

2. Do a genuine work
3. Mark according to the right answers
4. Don't completely ignore patient's distractions, but redirect gently
5. Treat the patient nicely, don't treat him like insane
6. You will never complete the full mini mental state examination
7. Time is not enough and the patient is distractive
8. You need to tell the examiner so far what you have done and the score

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Things to Avoid

1. Don't waste time talking about myocardial infarction or anything else

2. Don't answer patient's questions about the MMSE items
3. Don't correct wrong answers
4. Don't give your marking paper for the folding task
5. Don't ignore the paper if the patient throws it
6. Don't get angry if the patient throws the paper
7. Don't wait for the examiner to initiate the management discussion
8. Don't go into detail of the treatment of dementia

Additional Important Points

1. The scenario is designed to be distractive

2. The patient is trained to distract you
3. You need to memorize the MMSE questions as they won't provide a chart
4. Management discussion is with the examiner in this scenario
5. You need to cancel the patient's discharge due to cognitive impairment
6. Refer to psychiatry for further assessment and treatment

Confidentiality Scenario - Depression

Context

• This is one of three important confidentiality scenarios

• The other two involve contraception for a 15-year-old and a consultant surgeon
asking about a mother's CT scan

Setting

• F2 in GP
• Phone call scenario

Background Information

• Caller: 55-year-old man or woman (mother or father)

• Patient: 22-year-old woman
• Patient visited the practice last week with the other parent
• Patient has been diagnosed with depression
• Started on sertraline or medication

Approach: Use Four-Box System

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Box 1 & 2: History Taking

1. Ask for caller's name and relationship

2. Doctor: "How may I help you?"
3. Caller: "Doctor, yesterday my daughter, Justin, visited your practice with my
husband/wife. I just wanted to know why. Why did she come? Why has she been
seeing the doctors? We wanted to know whether she's okay."
4. Doctor: "May I know why you want to know about why they have visited?"
5. Caller: "I'm just worried she may be having some medical problem. We wanted to
know whether she has any medical problem, whether she's on any medication or
what the doctors are doing for her."
6. Doctor: "Have you spoken to your daughter? Did you ask your daughter?"
7. Caller: "We have been trying to call her and she's not answering. There's no
response."
8. Doctor: "Do you have any other anybody like any common friends? Have you tried
anything to get in touch?"
9. Caller: "No."
10. Doctor: "Have you tried to visit her?"
11. Caller: "She lives far and we are quite old. We are not able to go."
12. Doctor: "It seems like you have tried a few things. Is there anything that concerns
you? Is there anything that worries you regarding your daughter?"
13. Caller: "We are concerned she might do something."
14. Doctor: "What do you mean by she might do something? Would you like to tell us?
Is there anything happened?"
15. Caller: "Doctor, when she was a teenager, when she broke up with her boyfriend,
she took some paracetamol. She took some tablets. So that's why we are worried she
might do something."
16. Doctor: "Now we completely understand why you are concerned about it. Let me
ask you some questions about your daughter for us to have more understanding
about your daughter."
17. Ask about the incident:

• "How long ago did this happen?"

• "Is this the only time that happened?"
• "What happened on that occasion?"
• "Did she receive any treatment after that?"
• "Did she receive any counselling?"

18. Ask about risk factors for suicide and depression:

• Past medical history

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• Any long-term medical problems

• Any mental health problems
• Any medications

19. Social history (all are risk factors):

• Who does she live with?

• Where does she live?
• What does she do for a living?
• Has she got any financial problems?
• Any other stresses in life
• Has she got any children? (Having a child is a less risk factor)
• Has she got a partner?
• Does she have a good circle of friends?
• Has anything significant happened in her life? (losing something - money,
relationship, marriage, partner, family members, job)
• Any problem in the relationship
• Any money issues
• Anything related to jobs
• Family members, children
• Smoking, alcohol, recreational drugs

Box 3: Explanation

Three key words must be in your conversation:

1. Confidentiality
2. Consent
3. Trust and the doctor-patient relationship

Doctor: "I'm so sorry, Mrs. Johnson. I'm really sorry. Our hands are really tight. Our hands
are tied. We will not be able to help you with your particular request because your
daughter's and all of our patients' information is confidential. We keep all of our patients'
information as confidential without their consent. We will not be able to discuss with
other people."

"Confidentiality is the main pillar of the doctor-patient relationship. If we break the

confidentiality, if the patient comes to know that we discuss with other family members or
others about their information, they will lose the trust. They will lose the trust in the
healthcare system and the doctors. So they will not come forward for the treatment."

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"This will damage the doctor-patient relationship. Even if they come forward for the
treatment, they will not tell us everything. They will not give us all the information that we
need to help them. So considering their best interest, we don't discuss with other people.
I'm really sorry."

Box 4: Solution

Doctor: "First of all, thank you very much for letting us know about this. This will help us
to look into it. We will check your records. We'll raise this concern with the seniors
regarding your concern about her suicidal tendencies. We will check whether she has been
properly supported, whether she has been given proper support, whether she needs any
treatment regarding this, any support. If something needs to be done, we will do it. But we
will not be able to discuss with you in terms of what we have been doing. We will do
something about this, but we will not be able to tell you what we are doing. I'm really
sorry."

"Also, what I can explain to you is that when a doctor comes to know somebody has
depression or suicidal tendencies, we do take steps to protect them. We give something
called a crisis card for emergencies for them to call. We do regular follow-ups. We arrange
some counselling. These sorts of arrangements are there."

"Exactly what is going on with your daughter, we will not be able to discuss with you. I'm
really sorry, but don't worry. She will be taken care of. We will look into it."

Key Points to Remember

1. Use the four-box system for all scenarios, even if they don't fit perfectly
2. The phrase "our hands are tied" is only used for confidentiality scenarios
3. In other scenarios (changing notes, sick notes), your hands are not tied; you choose
not to do it because it's wrong
4. Focus on why confidentiality is important, not just that you can't give information
5. Acknowledge the family's concerns and thank them for sharing
6. Provide reassurance that you will look into the matter without breaching
confidentiality
7. Explain general procedures for dealing with depression and suicidal tendencies

Things to Avoid

1. Don't breach patient confidentiality

2. Don't dismiss the caller's concerns
3. Don't provide specific information about the patient's condition or treatment
4. Don't forget to explore risk factors

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5. Don't end the conversation without providing some form of action or reassurance
6. Don't use the phrase "our hands are tied" in non-confidentiality scenarios

Confidentiality Scenario - Contraception for Minor

Context

• This is one of three important confidentiality scenarios

• The scenario is F2 in GP

Setting

• Patricia Jones, 50-year-old lady, made an appointment

• Concerns about her daughter, Emma Johnson, 15 years old
• Emma Jones and her husband, David Jones, are registered patients in your practice
for the last 15 years
• Note: They are telling you they're 15-year customers, be careful, handle it carefully

Initial Approach

Doctor: "How may I help you?"

Patricia: "Doctor, I just wanted to know whether my daughter, she's small, been to this
practice recently."

Doctor: "Can I ask you why?"

Patricia: "Doctor, yesterday I was cleaning her room. I found these contraceptive pills in
her room. So I believe that she must have received it, got it from one of the doctors in this
practice."

Doctor: "I understand now. But did you ask your daughter about this? Did you ask her?"

Patricia: "I did ask my daughter. She initially said it is a friend, Sarah's, and Sarah came last
time, she left it here. And she got angry and she slammed the door and she went out. After
that, she didn't speak to me."

Doctor: "I understand now. May I know how old is your daughter?"

Patricia: "She's 15 years old."

Explanation (Box 3)

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Doctor: "We clearly understand why you are concerned. It is understandable. Usually,
parents get worried when they find out their children are sexually active. That raises
concern, it's understandable. But I'm really sorry, Mrs. Johnson, I will not be able to help
you with this. I will not be able to give you any information about your daughter."

[Note: Say this in a nice way, with extremely friendly body language. Your body language
should be extremely friendly, like you wanted to help. But what comes from your mouth is
pure ethical.]

"I'm really sorry, because your daughter's information is confidential. Every patient
registered in our practice's information is confidential. Without your daughter's consent,
we'll not be able to give you any information. Our hands are really tied in this particular
situation because your daughter's information is confidential."

"Without your daughter's consent, it is not possible for us to give any information to other
family members, because this is the main pillar of the doctor-patient relationship. If we
start talking to other family members about one patient's information to the other, they
will lose the trust, which will damage the doctor-patient relationship. So eventually it is
going to affect the care. I'm really sorry."

"For example, tomorrow, if Mr. Jones comes tomorrow and asks you whether you have
been into this practice today, it will be the same answer. Without your consent, we will not
be able to give any information to Mr. Johnson as well. It is the same situation. I hope you
understand this."

Additional Information (Fraser Guidelines)

Doctor: "But actually, in this situation, I can do you a favour. What I can do for you is I
can explain to you when somebody at MSH, somebody is a younger person, a minor,
somebody, a younger patient at MSH, come and ask for contraception, what do doctors
usually do? It's a normal procedure. Do you want me to explain this to you?"

Patricia: "Go on then."

Doctor: "First thing, when young people come and ask for contraception, we'll ask them to
come with the parents or an adult. When they refuse this, then doctors do an assessment.
In the assessment, we check the understanding, like why they need contraception, how
much they understand about contraception, what will happen if you don't give
contraception, even if you don't give the contraception, will they be sexually involved in the
sexual activities?"

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"We do this assessment. We check the understanding and why they need it, how much
they understand. If you don't give, what will happen? Even if you don't give, what's going to
happen? Will they be in a sexual relationship? Once they finish the assessment, if the
doctor is satisfied, considering their best interest, we tend to offer."

"We do offer, but we offer after an assessment. The assessment is involved in this way. The
benefits are that in this way, we can also prevent teenage pregnancies, prevent from getting
into some other troubles like this. That's how things normally happen."

Addressing Additional Concerns

1. Older partner Patricia: "If she's going out with somebody older than her age now, do
we do anything about it?" Doctor: "Yes, we do check. All the young people, we
check. When young people ask for contraception, we check about their partner as
well. Who are their partners? What is their age? Are they in any abusive
relationship? All this we check. If there is anything, if there is something wrong, we
raise concerns, we report to the right authorities."
2. STIs Patricia: "I'm worried about sexually transmitted infections." Doctor: "Sexually
transmitted infection is a concern for us. So what we do is we advise them to,
whenever possible, practice safe sex and we will tell them to regularly get tested,
screen."
3. Religion Patricia: "Doctor, we are Roman Catholic. It is against our religious beliefs
for someone to be in a sexual relationship before marriage." Doctor: "Well, Mrs.
Johnson, as doctors, we don't really advise our patients on their religious beliefs,
their religious beliefs, our religious beliefs. We don't advise patients on religious
beliefs. That is an individual thing. And maybe parents can talk to the children, but
doctors, we don't do that."
4. Legal concerns Patricia: "Doctor, I think it is illegal for her to be in a sexual
relationship." Doctor: "Well, in the United Kingdom, if somebody is above 13, it is
not illegal for them to be in a sexual relationship. As long as the partner is at almost
the same age and has the same mental maturity, it is not illegal. The number is
technical. As long as they have the same mental maturity, the partner, it is not
illegal."
5. Personal advice Patricia: "Doctor, if this were your daughter, what would you do?
How would you handle this?" Doctor: "What we generally advise, if they wanted to
have some sensitive or difficult discussion with children, is to build up the
relationship. They have to try and improve the relationship, gain the trust. When
you gain the trust and when the relationship is good, younger people will feel the
confidence to talk about their personal issues. They will have the trust to gain the
trust, build up the relationship. This will lead them to have the confidence to talk.
That is the way forward. That is the idea that we give to all the parents, that can be

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including me." "In order to build the relationship, you can do various activities,
maybe spending more time with them, listening to their stories, doing the activities
they like to do together, arranging holidays, that sort of things can help you to build
up the relationship."

Key Points to Remember

1. Use the four-box system for structuring the conversation

2. Maintain confidentiality at all times
3. Explain the importance of confidentiality in doctor-patient relationships
4. Offer to explain the general procedure for providing contraception to minors
(Fraser Guidelines)
5. Address concerns about older partners, STIs, religion, and legal issues
6. Avoid giving personal advice or sharing personal stories
7. Focus on strengthening the system rather than offering personal favours
8. Advise on building trust and relationship with children for better communication
9. The phrase "our hands are tied" is only used for confidentiality scenarios

Things to Avoid

1. Don't breach patient confidentiality

2. Don't give personal opinions or advice
3. Don't discuss religious beliefs
4. Don't ignore the parent's concerns
5. Don't provide specific information about the daughter's medical history or visits
6. Don't use phrases like "I personally would..."
7. Don't offer to do anything that goes against the system or standard procedures
8. Don't use the phrase "our hands are tied" in non-confidentiality scenarios

Confidentiality Scenario - Consultant Surgeon Requesting Information

Setting

• F2 in the surgical department

• Patient: Margaret Williams, 70-year-old lady
• CT scan shows suspicion of colonic cancer
• Son (consultant surgeon) is here to talk

Important Notes

• Scenario doesn't mention consent, which means there is no consent

• If patient's capacity isn't mentioned, assume they have capacity

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• This scenario is related to breaking bad news

Initial Approach

1. Enter the room and assess the situation (standing or sitting)

o If the person is standing, you should stand
o If they're on a couch, stand to keep eye lines at the same level
o Never sit if the other person is standing
2. Introduce yourself: "Hello, I'm Dr. [Your Name], one of the doctors."
o Don't assume they're a consultant surgeon
o Don't introduce yourself with your first name
3. Ask for their name: "May I know your name, please?"
4. Listen to their introduction: Mr. Harris: "I'm Mr. Harris, one of the consultant
surgeons. I'm coming from the next hospital and my mom is admitted here. I
understand that you have done a CT scan. I'm suspecting any cancers. What's going
on? Can you tell me the report?"
5. Offer a seat: "Would you like to have a seat, please, before we discuss further?"
o If they say no, remain standing
o Don't sit until they sit

Gathering Information

1. Express regret for not being able to answer immediately: "I'm so sorry. Can I check
some details before we discuss further?"
2. Verify patient identity: "You mentioned your mother. Can you please tell me your
mother's full name as well? I just wanted to double-check that I have the right
records."
3. Confirm age: "Is it possible to confirm her age as well?"
4. Ask about mother's awareness: "Can I please ask you whether your mother is aware
that you are here to discuss?"
5. Ask about prior knowledge: "Can you tell me how much you have been told so far?
You mentioned a CT scan. How did you come to know about it?"
6. Inquire about previous communications: "Have you ever spoken to any of the
doctors or nurses regarding your mother's condition?"
7. Ask about cancer suspicion: "You mentioned cancer. Why would you say that she
may be having cancer?"
8. Inquire about admission reason: "What was the reason she was brought to the
hospital?"
9. Ask about relationship and next of kin: "Are you the next of kin? Has your mother
appointed anybody as lasting power of attorney?"

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10. Inquire about family structure: "Who are the important other family members? Do
you have any siblings?"
11. Ask about main carer: "Can I please ask you who is the main carer?"
12. Inquire about usual communication: "Who do doctors usually discuss your mother's
condition with?"

Explanation and Refusal

1. Express regret: "I'm so sorry, Mr. Harris. I don't think that I will be able to help you
with your request."
2. Explain lack of information: "At the moment, I don't have much information. I
don't have information regarding how much consent she has given to speak to
family members."
3. Express concern about mistakes: "I'm afraid I don't want to make any mistakes. I
don't want to do anything wrong here because it's important for me to protect her
confidentiality."
4. Offer alternative: "What I can do is, if you give us some time, I'll leave you a
number. After completing this formality and checking with your mother, after
getting the consent or finding out how much consent we have, I can discuss this
with you over the phone. Is that OK with you?"
5. Express understanding and regret: "I understand that you are a little bit concerned,
it is understandable, but I'm really sorry I will not be able to help you with your
request."
6. Explain concerns: "Actually, Mr. Harris, I'm a little concerned this can put us into
trouble because I don't have much information about your mother's consent. I also
don't have much information about her level of capacity, whether she has the
capacity as well."
7. Further explanation: "I'm sure, Mr. Harris, that I'm not very helpful here. I'm really
sorry about the situation because I wanted to make sure that I'm not making any
mistakes here. We are just skipping some steps, and we don't want to skip the steps
because this can put us into trouble."

Key Points to Remember

1. Always verify patient identity and relationship

2. Do not assume the person's role or position
3. Match the physical position of the person you're talking to (standing or sitting)
4. Express regret when unable to provide information
5. Explain the lack of information about consent and capacity
6. Offer alternative solutions (e.g., discussing over phone after getting consent)
7. Be polite but firm in maintaining confidentiality

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8. Don't argue or treat the person differently because of their position

9. The phrase "our hands are tied" is not used in this scenario
10. The conversation is different from other confidentiality scenarios - don't explicitly
mention confidentiality and consent

Things to Avoid

1. Don't provide any patient information without confirming consent

2. Don't assume capacity or lack of capacity without confirmation
3. Don't be argumentative or confrontational
4. Don't skip steps in the verification process
5. Don't sit if the other person is standing
6. Don't use technical terms about confidentiality or consent
7. Don't ignore the person's concerns or rush the conversation
8. Don't treat the consultant surgeon differently because of their position

Next Steps (if asked)

1. Getting the mother's consent

2. Documenting the interaction
3. Discussing with the son after obtaining consent
4. Informing seniors regarding the situation
5. Documentation of all steps taken

Remember, this scenario is designed to test your ability to maintain patient confidentiality
while dealing with a potentially high-pressure situation from a fellow medical professional.
Focus on verifying information, explaining the need for consent, and offering alternative
solutions without breaching patient privacy. The key is to be polite, professional, and firm
in maintaining confidentiality procedures, regardless of the requester's position.

Head Injury Scenarios

General Notes

• Head injury in a child and an adult are opposite scenarios

• Decisions are based on NICE guidelines (to be researched separately)
• Google "NICE guidelines head injury CT requirement criteria" for images and
details
• Criteria questions need to be incorporated into history taking
• Decision must be informed by asking the right questions

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Child Head Injury Scenario

Setting

• F2 in A&E or Paediatrics
• 3-year-old child brought in following a fall
• Child currently playing with nurse (indicates GCS 15/15)
• Small bruise (less than or equal to 5cm)

History Taking

1. Ask: "Can you tell me what happened?" Mother: "I was changing nappy to my
younger child. This child was on sofa, fell down."
2. Ask about mechanism of injury (important criteria)
3. Ask about immediate symptoms:
o Loss of consciousness
o Fits
o Bleeding
o CSF leak
4. Ask about post-injury symptoms:
o Vomiting (Mother will say child vomited once)
o Note: For children, vomiting has to be three or more times to be significant
5. Ask about bruise size (should be less than 5cm in this scenario)
6. Complete MAFTOSA

Assessment

• Child has sustained a minor head injury

Management Plan

1. Explain: "It seems like your child has sustained a minor head injury."
2. Advise: "We would like to observe your child for the next four hours."
3. Mention: "You can give some paracetamol if the child is having pain."
4. Inform: "After that, it should be okay. You can take your child home."

Handling CT Scan Request

Mother: "Why don't you do a CT scan? I brought my child to do a CT scan."

Doctor's Response:

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1. "From our assessment, we are not suspecting any serious or severe head injury."
2. "We take the decision to do a CT scan based on our checklist/criteria."
3. "We have assessed, and nothing at the moment is indicating there is a severe or
major head injury."
4. "Therefore, CT scan is not necessary."
5. "We check important features. For example:
o If a child vomited more than three times
o Losing consciousness
o A larger bruise more than 10cm"
6. "CT scan is basically concentrated x-rays."
7. "It's going to be unnecessary radiation to the brain."
8. "In this situation, it is not necessary."

Adult Head Injury Scenario

Setting

• F2 in A&E
• 40-year-old man brought in by ambulance

History

• Went to restaurant with wife

• Had one pint of beer
• Tripped and fell on way back
• Lost consciousness immediately
• Woke up in ambulance
• Vomited several times
• Experiencing amnesia

History Taking

1. Ask: "Can you tell me what happened?"

2. Ask about before, during, and after the fall:
o How did you sustain this fall?
o Vomiting (note: more than once is significant in adults)
o Fits
o Headache
o Loss of consciousness
o CSF leak
o Amnesia
3. During examination, check for:

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CSF leak from nose or ear (sign of skull base fracture)

o
o Battle sign (bruising behind ear)
o Raccoon eyes or panda eyes (periorbital ecchymosis)
o Bruises on face
o Bruises behind ear
4. Complete MAPTOSA

Assessment

Patient has sustained a major/severe head injury

Management Plan

1. Explain: "Unfortunately, it seems like you've sustained a major head injury, a severe
head injury."
2. Advise: "We will advise you to get admitted."
3. Recommend: "We would like to do a CT scan to confirm."
4. Inform: "If there is any bleeding, we would like to refer you to a neurosurgeon."

Handling CT Scan Refusal

Patient: "Doctor, look at me. I'm perfectly fine. There's nothing wrong with me. I need to
go to work. It is unnecessary. I just fell down, but I'm completely fine now. I don't need a
CT scan."

Doctor's Response:

1. "At the moment you are not experiencing any symptoms, but as the condition
progresses, as the condition gets worse, you may start experiencing symptoms."
2. "At the moment you may have a very small bleeding in your head. That may be the
reason you're not developing any symptoms."
3. "But as the condition gets worse, as the bleeding progresses, you may start
experiencing the symptoms."
4. "When the bleeding gets bigger and bigger, it can increase the pressure in your
head."
5. "You can lose your consciousness. You can collapse. It can impair your breathing."
6. "By the time if you reach the hospital in this situation, it may be more serious than
what you have at the moment."
7. "This can put your life in danger. We may find it more complicated than what you
have at the moment."
8. "Whenever we suspect a severe head injury, it is not safe for you to leave the hospital
unless we have done a CT scan and confirm it."

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9. "Therefore we will advise you to stay in the hospital, do a CT scan. If everything is

fine, you may be able to go home."

Key Points to Remember

1. Child and adult criteria for CT scans are different

2. In children, vomiting 3 or more times is significant; in adults, more than once
3. For children, bruise size matters: more than 10cm is significant
4. Incorporate criteria questions into your history taking
5. Even one finding meeting the criteria can be enough to warrant a CT scan
6. For children, emphasize unnecessary radiation exposure
7. For adults, explain the potential for asymptomatic bleeding that could worsen
8. Always base decisions on established guidelines (NICE in this case)
9. Be prepared to explain your decision-making process to patients/parents

Things to Avoid

1. Don't say "no" to a CT scan without asking the necessary questions

2. Don't ignore the mechanism of injury in your assessment
3. Don't forget to check for signs of skull base fracture in adults
4. Don't dismiss patient concerns without proper explanation
5. Don't use technical terms without explaining them to the patient/parent

Tonsillectomy
Scenario Setup

• Setting: GP consultation (F2 in the GP)

• Patient: 50-year-old mother
• Concern: 15-year-old son (note: transcript mentions 8-year-old as well, be prepared
for either age)
• Situation: Son referred for tonsillectomy, rejected by specialist
• Additional context: There will be a paper in the room with tonsillectomy criteria

Initial Patient Interaction

Anticipate an Angry Patient

Be prepared for the mother to express anger and frustration. Possible statements include:

• "Why did they refuse this?"

• "Why don't they want to do a tonsillectomy for my child?"

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• "How can they refuse?"

• "My son is suffering."
• "Does the NHS want to save money?"
• "Why can't they go for the surgery?"

Handling Angry Patients - Detailed Approach

1. Non-verbal communication:
o Nod your head continuously while the patient is speaking
o Raise your eyebrows to show attentiveness
o Display concern through facial expressions (create wrinkles on your
forehead)
o Maintain consistent eye contact
2. Verbal communication:
o Do not interrupt or cross-talk (speaking while the patient is talking)
o Allow the patient to express themselves fully without interruption
3. After the patient finishes speaking:
o Acknowledge their emotions: "I can see that you're quite upset."
o Express empathy: "I'm really sorry you feel this way."
o Alternative empathy statement: "Anyone in your situation would feel the
same."
o Offer explanation: "I will explain everything about your son's tonsillectomy."
o Ask permission to gather more information: "I would like to ask you some
questions to have a better understanding of the situation. Can I do that?"

Detailed History Taking

Duration and Onset

• "How long has your son been experiencing these tonsillitis symptoms?"
• "For how many years has this been going on?"
• "When did you first notice these issues?"

Frequency and Pattern of Episodes

• "Is the problem continuous, or does it come and goes in episodes?"

• "How many episodes has he had so far?"
• "How often do these episodes occur?"
• "How many days does each episode typically last?"

Symptoms During Episodes

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Start with an open-ended question:

• "What sort of symptoms does your son experience during each episode?"

Follow up with specific, closed-ended questions:

• "Does he develop a sore throat?"

• "Does he experience pain? If yes, where exactly?"
• "Is there any phlegm production?"
• "Does he have a cough? If yes, is it dry or productive?"
• "Does he cough up any phlegm? What colour is it?"
• "Have you noticed any pus in his throat?"
• "Does he experience any wheezing or difficulty breathing?"
• "Does he complain of shortness of breath?"
• "Does he develop a fever? If yes, how high?"
• "Are there any other symptoms you've noticed during these episodes?"

Previous Treatments and Medical Interactions

• "Has your son undergone any tests related to his tonsil problems?"
• "How was he treated during each episode?"
• "Did you need to bring him to the hospital at any point?"
• "Was he prescribed antibiotics? If yes, how often?"
• "What sort of medication did you give him at home?"
• "Has he ever been admitted to the hospital due to tonsillitis?"
• "Have you consulted any specialists about this issue before?"

Impact on Daily Life

• "How are these tonsil problems affecting your son's life in general?"
• "Has there been any impact on his school performance?"
• "How has his school attendance been affected?"
• "Has he had to miss any important events or exams due to these episodes?"
• "How have his extracurricular activities been impacted?"
• "Have you noticed any changes in his mood or behaviour related to this ongoing
issue?"
• "How has this affected your family's daily routine?"

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Explanation of Tonsillectomy

Importance of Tonsils

Explain the following points:

• "Tonsils are important organs in our body."

• "They work in conjunction with our immune system to prevent infections and
complications."
• "Tonsils are an integral part of our body's defence mechanism."
• "It's crucial to understand that if we surgically remove the tonsils, they will not grow
back."
• "Tonsil removal is a permanent procedure, which is why we need to be very careful
in making this decision."

Decision-making Process for Tonsillectomy

Outline the considerations:

• "The decision to remove tonsils is not taken lightly."

• "We only consider tonsillectomy if someone is severely affected by recurring
tonsillitis."
• "The severity is assessed based on the number of infections someone has had in the
previous years."
• "We have specific criteria that help us determine when tonsillectomy is necessary."

Detailed Criteria for Tonsillectomy

Explain the chart in detail:

1. One-year history:
o "If your son has been suffering for just the last year, we would consider
surgery if he's had 7 or more episodes in that year."
2. Two-year history:
o "If the problem has persisted for two years, we look for at least 5 episodes in
each of those years."
3. Three-year history or more:
o "For long-standing cases of three years or more, we consider surgery if there
have been 3 or more episodes in each of those years."

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Explaining the Current Decision

• "Based on the information you've provided, it appears that your son is currently
experiencing fewer infections than these criteria specify."
• "The doctors have assessed his condition as less severe according to these
guidelines."
• "It's important to note that as children grow, their immune system typically becomes
stronger."
• "There's a possibility that your son's condition might improve with age, which is why
it may be premature to perform surgery at this point."
• "We anticipate that he might experience fewer infections in the future as his
immune system matures."
• "I want to assure you that this decision was made with your son's best interests in
mind."
• "I sincerely apologize if you were under the impression that this decision was made
to save money. That's not the case at all."
• "We should have explained these criteria and our decision-making process to you
earlier, and I apologize for that oversight."

Things to Avoid During Consultation

• Don't use phrases like "the infection is not enough" or "which infection is enough"
as these can sound dismissive.
• Avoid giving any impression that the decision is based on cost-saving measures.
• Don't dismiss or minimize the patient's concerns or emotions.
• Avoid medical jargon without explanation.
• Don't rush through the explanation or cut off the patient's questions.

Additional Important Points

• The consultation may involve podiatric history-taking techniques.

• Be prepared to explain the immune system's role and the function of tonsils in
more detail if asked.
• Emphasize the permanent nature of tonsil removal and its long-term implications.
• If the mother remains unsatisfied, offer to review the case again or seek a second
opinion.
• Provide information on managing tonsillitis symptoms at home and when to seek
immediate medical attention.

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Antibiotic Request for Viral Infection

Scenario Setup

• Setting: GP consultation (F2 in the GP)

• Patient: 20-year-old (can be male or female)
• Context: Either a follow-up appointment or a new appointment after a recent visit
• Important note: Nurses have done a swab test, which came back negative

Initial Patient Interaction

Patient's Likely Presentation

Patient may say: "I haven't improved, doctor. My symptoms are getting worse. So, I've come
back."

Initial Response

Respond with empathy: "I'm so sorry to hear that you're not feeling better."

Detailed History Taking

Medical History

1. Initial symptoms:
o Ask: "Can you tell me what sort of symptoms you had initially?"
o Follow-up: "What symptoms did you have when you visited the doctor a few
days ago?"
2. Comprehensive respiratory symptom check:
o Cough: "Do you have a cough? If yes, is it dry or productive?"
o Shortness of breath: "Are you experiencing any difficulty breathing?"
o Fever: "Have you had any fever? If yes, how high?"
o Phlegm: "Are you producing any phlegm? What colour is it?" (Note: Patient
may mention yellow phlegm)
o Rash: "Have you noticed any rashes?"
3. Potential complications:
o Headache: "Are you experiencing any headaches?"
o Ear pain: "Do you have any ear pain or discomfort?"
o Signs of pneumonia: "Have you noticed any chest pain or difficulty
breathing?"
o Signs of otitis media: "Any fullness or pain in your ears?"
o Signs of meningitis: "Have you had any neck stiffness or severe headaches?"

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o Signs of sinusitis: "Any facial pain or nasal congestion?"

4. Current state of symptoms:
o "How are you feeling now compared to your last visit?"
o "Which symptoms have gotten worse?"
o "Are there any new symptoms that have developed?"
5. Previous treatment:
o "What advice were you given at your last visit?"
o "What treatment have you been following so far?"
o "Have you been taking any medications? If so, which ones and how often?"

• Note: Patient is likely to say symptoms are getting worse

• "It sounds like your symptoms have worsened since your last visit. Is that correct?"

• Patient may request: "Can you give me some antibiotics?"

• Ask why they think antibiotics are necessary:

o "Why do you think that an antibiotic is necessary at this point?"
o Patient may respond:
§ If female: "My grandma's birthday party is coming up. It might be her
last, and I want to be able to attend."
§ If male: "I have work to do and can't with these symptoms. I need to
go to work."
o Follow-up: "I understand this is impacting your life. Can you tell me more
about how these symptoms are affecting your daily activities?"

Crucial Examination

• It is critical to examine the patient in this scenario

• Explain: "Before we make any decisions, I'd like to examine you to get a better
understanding of your condition."
• Actions to take:
1. Listen to the lungs: "I'm going to listen to your lungs now. Please take deep
breaths when I ask you to."
2. Check observations: "We'll check your temperature, blood pressure, and
oxygen levels."
3. Any other relevant physical examinations based on symptoms
• Note: Results will likely be normal

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Explanation and Decision

Communicate Test Results

• "We have thoroughly examined you, and all the examination results are normal."
• "We also have the swab results from your previous visit, which came back as
negative."

Explain Likely Diagnosis

• "Based on your symptoms, our examination, and the test results, you are likely
experiencing a viral infection, possibly the flu."

Nature of Flu (Viral Infection)

• Explain the typical course:

o "Viral infections like the flu usually follow a specific pattern."
o "In the first few days, symptoms often get worse."
o "Then they reach a peak and stay there for about two to three days."
o "After that peak, symptoms start to improve."
o "Based on what you've told me, you may be at or near that peak now."
o "This means we expect your symptoms to start improving in the coming
days."

Why Antibiotics Are Not Prescribed

1. Ineffectiveness for viral infections:

o "The flu and most upper respiratory infections are caused by viruses."
o "Antibiotics are designed to fight bacteria, not viruses."
o "This means that antibiotics simply won't work against your viral infection."
o "Taking antibiotics for a viral infection is like using a key that doesn't fit the
lock – it won't solve the problem."
2. Antibiotic Resistance Concerns:
o "There's another important reason why we're cautious about prescribing
antibiotics: antibiotic resistance."
o "Antibiotic resistance occurs when bacteria evolve to resist the effects of
antibiotics."
o "If antibiotics are used too frequently or unnecessarily, bacteria can become
'used to' them."
o "This means that in the future, when you really need antibiotics for a
bacterial infection, they might not work as effectively."

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o "Our decision not to prescribe antibiotics now is actually in your best long-
term interest."
o "We're trying to preserve the effectiveness of antibiotics for when they're truly
necessary and can make a difference."

Treatment Plan

Continue Previous Treatment

• "The treatment plan from your last visit is still the best approach for managing your
symptoms."

Specific Recommendations

1. Paracetamol:
o "You can take paracetamol to help with any pain or fever."
o "The recommended dose is one to two 500mg tablets."
o "You can take this every four to six hours."
o "Very important: Do not take more than four doses (8 tablets) in 24 hours."
2. Hydration:
o "Drinking plenty of fluids is crucial. It helps thin mucus and prevents
dehydration."
o "Aim for at least 8 glasses of water a day, more if you have a fever."
3. Steam Inhalation:
o "Using a steam inhaler or even just inhaling steam from a bowl of hot water
can help relieve congestion."
o "Do this for about 5-10 minutes, 2-3 times a day."
4. Rest:
o "Getting adequate rest is vital for your recovery."
o "Try to get at least 8 hours of sleep at night and rest during the day when you
feel tired."
5. Monitoring:
o "If your symptoms worsen significantly or you develop new, severe symptoms,
please don't hesitate to come back or seek medical attention."

Key Points to Remember

• This scenario is designed to test communication skills and the ability to explain why
antibiotics are not given for viral infections.
• The focus is on articulating the reason for not prescribing antibiotics, not on
actually giving them.

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• Always examine the patient in scenarios like this, angry patient scenarios, hernia
cases, and cerebral palsy cases.
• The examination provides logical support for the decision-making process.
• Emphasize that the decision is made in the patient's best interest.
• Be prepared to explain antibiotic resistance in simple terms.

Consultation Structure (Four Boxes Approach)

1. Box 1: Ask about symptoms and previous treatment

2. Box 2: Perform examination
3. Box 3: Explain findings and reason for not prescribing antibiotics
4. Box 4: Provide treatment plan and advice

Things to Avoid

• Don't dismiss the patient's concerns or symptoms

• Avoid medical jargon without explanation
• Don't rush through the explanation about antibiotics and viral infections
• Avoid giving the impression that you're withholding antibiotics to save money
• Don't skip the examination, as it's crucial for your decision-making process

Final Thoughts

• Remember to maintain a sympathetic and understanding tone throughout the

consultation
• The way you articulate the reasons for not prescribing antibiotics is crucial
• Your communication skills and ability to explain medical concepts clearly are being
assessed
• Always frame decisions in terms of the patient's best interests
• Be prepared to repeat or rephrase information to ensure patient understanding

DKA (Diabetic Ketoacidosis)

Overview of DKA Scenarios in PLAB2

There are three DKA-related scenarios in the entire PLAB2:

1. Acute medicine: Female with UTI, refusing treatment

2. Paediatrics: 9-year-old child, diagnosed yesterday with DKA, mother wants discharge
today for holiday
3. First-time DKA diagnosis, presenting with tiredness and weight loss

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Key points:

• DKA is more common than other scenarios in PLAB2

• Two scenarios involve refusing treatment
• In all DKA scenarios, patients will refuse treatment either from the beginning or at
the end
• The first two scenarios involve refusal from the beginning (already diagnosed)
• The third scenario is a first-time diagnosis but will also involve treatment refusal

Scenario 1: Acute Medicine DKA Case

Patient Profile

• 30-year-old lady
• Presented to A&E with tummy pain and vomiting
• Already diagnosed with DKA
• UTI present (urine dipstick: nitrates positive, leukocytes positive)
• Patient is reluctant to stay in the hospital

Clinical Findings (if provided)

• A, B, C, pH
• Sodium, Potassium, Bicarbonate levels
• Urine dipstick results: nitrates positive, leukocytes positive

Approach to the Consultation (Four Box System)

Box 1: Initial Interaction and History Taking

1. Start with paraphrasing:

o "I understand you've been admitted to the hospital with tummy pain and
vomiting."
o "We've been told that you're not very keen to stay in the hospital today."
o "Can I please ask you why you feel you need to leave?"
2. Patient may give reasons like:
o "I need to pick up my child from school."
o "I have a wedding coming up and need to make arrangements."
3. Respond with empathy:
o "I'm sorry to hear about your situation. It must be stressful for you."
o "I will explain everything about your condition and treatment, but first, I'd
like to understand more about what's happening."
4. Ask about symptoms (DKA symptoms):

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o "What exactly made you come to the hospital today?"

o "Can you tell me more about the tummy pain you're experiencing?"
o "Have you been vomiting? How often?"
o "Are you experiencing any of these symptoms: nausea, dehydration, not
passing much urine or not passing urine at all, headache, or generally feeling
unwell?"
o "When did these symptoms start?"
5. Ask about potential causes of DKA:
o "Have you been unwell recently? Any fever or flu-like symptoms?"
o "Any chest symptoms or urinary problems?"
o "Have you had any diarrhoea recently?"
o "Have you had any recent operations or hospital admissions?"
6. Assess prior knowledge and understanding:
o "What sort of tests have they done for you in the hospital so far?"
o "Has anyone explained to you what's wrong? What did they say?"
o "Did anyone mention DKA or diabetic ketoacidosis? What do you
understand about this condition?"
o "What have you been told about the treatment plan?"

Box 2: General Health and Diabetes History

1. Ask about diabetes history:

o "How long have you been diagnosed with diabetes?"
o "What type of diabetes do you have?"
o "What sort of treatment do you usually take for your diabetes?"
o "How long have you been on insulin?"
2. Assess compliance:
o "Do you take your diabetes medication regularly?"
o "Have you been taking your insulin as prescribed?"
o If not compliant, ask why: "Can you tell me more about why you haven't
been taking your medication/insulin regularly?"
3. Complete MAPTOSA

Box 3: Explanation and Education

1. Briefly explain test results:

o "We've done some tests, and they show that your blood has become more
acidic than normal."
o "We've also found signs of a urinary tract infection in your urine test."
2. Explain DKA:
o "You have a condition called diabetic ketoacidosis, or DKA for short."

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o "DKA is a serious complication of diabetes that occurs when there isn't

enough insulin in your body."
o "Without insulin, your body can't use sugar for energy. As a result, your
blood sugar levels keep increasing."
o "To find an alternative source of energy, your body starts breaking down fats
in the liver."
o "This process produces substances called ketones. When ketone levels get too
high, they become toxic to your body."
o "These high ketone levels are responsible for your symptoms like tummy pain
and vomiting."
o "DKA also causes dehydration, which is why you might be feeling very thirsty
or not passing much urine."
3. Explain treatment:
o "The treatment for DKA involves several steps, all of which need to be done
in the hospital:"
o "First, we need to give you fluids through a vein in your arm. This helps with
the dehydration."
o "We also need to give you insulin through the vein. This helps your body
start using sugar for energy again and stops the production of ketones."
o "We need to regularly monitor your blood sugar and salt levels, adjusting the
treatment as needed."
o "For your urinary tract infection, we'll need to give you antibiotics through
the vein as well."
4. Explain need for hospital admission:
o "All of these treatments can only be given safely in the hospital setting."
o "You need to be under constant medical supervision to make sure the
treatments are working and to adjust them if needed."
o "This kind of close monitoring isn't possible if you go home."
5. Explain consequences of not receiving treatment:
o "If you don't receive the proper treatment for DKA right away, it can become
very serious very quickly."
o "Without treatment, DKA can lead to more severe complications:"
o "Your other organs might start to fail, which we call multi-organ failure."
o "You could go into a coma."
o "In the most severe cases, DKA can be life-threatening."
o "That's why it's crucial that you stay in the hospital to receive the proper
treatment."

Box 4: Solutions and Addressing Concerns

1. Offer solutions for patient's concerns:

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oFor child pickup: "I understand you're worried about your child. We can ask
social services to speak to the school and arrange for your child to be picked
up and cared for."
o For wedding arrangements: "I know you have important plans. Perhaps we
can help you contact a family member or friend who could handle some of
the arrangements while you're here?"
o "We can also look into arranging some temporary assistance or support for
your responsibilities outside the hospital."
2. Emphasize risks of leaving:
o "I understand you want to leave, but it's really not safe for you to do so right
now."
o "If you go home without proper treatment, your condition will likely get
worse very quickly."
o "You might need to come back to the hospital within just a few hours, and by
then, your condition could be much more serious and harder to treat."
3. Address requests for home treatment:
o If patient asks to take insulin and go home: "I understand you want to go
home, but taking insulin at home isn't enough to treat DKA."
o "DKA requires very careful monitoring and adjustment of your fluids,
insulin, and electrolytes. This can only be done safely in the hospital."
o "If you leave now and your condition worsens, it could become much more
difficult to treat when you return."
4. Continual reinforcement:
o Keep explaining the consequences and risks
o "I know staying in the hospital is inconvenient, but it's really crucial for your
health and safety."
o "DKA is a serious condition that needs immediate and thorough treatment.
Going home now could put your life at risk."

Key Points to Remember

• Focus on checking the patient's prior knowledge and understanding of their

condition
• Tailor your approach based on whether it's a new diagnosis or an already diagnosed
case
• Always examine the patient, even if the diagnosis is already made
• Emphasize the seriousness of DKA and the need for immediate treatment
• Be prepared to explain DKA, its treatment, and consequences clearly and repeatedly
• Offer practical solutions to address the patient's concerns about staying in the
hospital

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• Never call seniors to handle patient refusal; it's your responsibility to convince the
patient
• The way you articulate the reasons for not allowing the patient to leave is crucial
• Your communication skills and ability to explain medical concepts clearly are being
assessed
• Always frame decisions in terms of the patient's best interests

Things to Avoid

• Don't waste time re-diagnosing an already diagnosed condition

• Avoid calling seniors for "babysitting" or to convince the patient
• Don't dismiss the patient's concerns or reasons for wanting to leave
• Avoid using medical jargon without explanation
• Don't give up easily; be prepared to explain and convince repeatedly
• Don't skip the examination, as it's crucial for your decision-making process
• Avoid giving the impression that you're keeping the patient in the hospital to save
money
• Don't rush through the explanation about DKA and its treatment

Scenario 2: Paediatric DKA Case

Scenario Overview

• Paediatric case: 9-year-old child

• Admitted yesterday with first-time DKA
• Test results are usually provided with this scenario
• Mother wants to speak to a doctor about discharge
• Family plans to go on holiday

Detailed Consultation Approach

Initial Interaction

• Start with: "I understand you wanted to speak to one of the doctors. Is there
anything in particular you would like to discuss?"
• Mother's likely response: "I wanted to discharge my son."
• Follow-up question: "Can I ask you why?"
• Expected answer: "Because we are going on a holiday."

Gathering Information (Box 1)

1. Ask about holiday plans:

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o "When are you planning to go on holiday?"

o "Where are you going?" Note: The impact may differ based on destination.
For example:
o Small holiday: "Are you going somewhere nearby, like Spain?"
o Big holiday: "Is it a longer trip, perhaps somewhere like Mauritius?"
2. Inquire about the child's initial symptoms:
o "What made you bring your child to the hospital in the first place?"
o Ask about DKA symptoms:
§ "Was your child experiencing nausea or vomiting?"
§ "Did you notice any abdominal pain?"
§ "Were there signs of dehydration, like excessive thirst or decreased
urination?"
o Inquire about potential causes:
§ "Has your child been sick recently?"
§ "Any recent episodes of diarrhoea?"
§ "Has there been any fever?"
§ "Any other infections you're aware of?"
3. Assess mother's understanding:
o "What have you been told about your child's condition?"
o Note: She may only know the child is sick, not specifics about DKA
o "Did the doctors mention anything about diabetes or DKA?"
4. Ask about treatment information:
o "What have you been told about your child's treatment so far?"
o "Do you know what medications or fluids your child is receiving?"

Medical History (Box 2)

1. Past medical history:

o Note: This is likely the first diabetes diagnosis, so no prior history of diabetes
o "Has your child ever been diagnosed with any medical conditions before
this?"
2. Recent symptoms:
o "Did your child have any unusual symptoms before this admission?"
o Ask about possible diabetes symptoms:
§ "Did you notice your child drinking more water than usual?"
§ "Was there any increase in frequency of urination?"
§ "Has your child lost weight recently?"
§ "Did you notice any increased hunger or appetite changes?"
3. Complete MAP-DOSA (Medical history, Assessment, Plan, Desires, Options,
Strengths, Assessments)
4. Optional paediatric history elements:

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General health status: "How has your child's overall health been before this
o
incident?"
o Note: Detailed pregnancy, birth, and developmental history may not be
necessary for a 9-year-old unless there are specific concerns
o If needed: "Were there any complications during pregnancy or birth?"
o "Has your child met all their developmental milestones?"
5. Immunization and general development:
o "Is your child up to date with their immunizations?"
o "How has their growth been?"

Explanation and Education (Box 3)

1. Explain DKA briefly:

o "Your child has a condition called diabetic ketoacidosis, or DKA for short."
o "It's a serious complication related to diabetes, which we've just discovered
your child has."
o "DKA occurs when the body doesn't have enough insulin to use sugar for
energy, so it starts breaking down fat instead, producing harmful substances
called ketones."
2. Describe treatment:
o "DKA requires careful treatment with fluids and insulin given through an
IV."
o "We need to closely monitor your child's blood sugar, electrolyte levels, and
overall condition."
o "This treatment helps rehydrate your child, lower their blood sugar, and stop
the production of ketones."
3. Emphasize need for hospital admission:
o "This treatment can only be safely given in the hospital setting."
o "Your child needs to be under constant medical supervision to ensure the
treatment is working and to adjust it if needed."
o "We need to monitor your child very closely to prevent any complications."
4. Explain potential consequences if untreated:
o "If DKA isn't treated properly and promptly, it can lead to very serious
complications."
o "These complications can include severe dehydration, electrolyte imbalances,
and in severe cases, brain swelling."
o "In the most serious situations, untreated DKA can be life-threatening."

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Addressing Concerns and Providing Solutions (Box 4)

1. Clearly state the situation:

o "I understand you want to go on your holiday, but I'm afraid it's not safe for
your child to travel at this time."
o "Your child is not fit to travel in his current condition."
2. Explain risks:
o "If he's not treated appropriately and completely, he could develop further
complications while traveling."
o "These complications could become very serious very quickly, especially if
you're in a place without immediate access to appropriate medical care."
o "This situation could put your child's life in danger."
3. Offer alternatives:
o "I understand this is disappointing and disruptive to your plans, but your
child's health must come first."
o "Perhaps you could speak to your travel agency about changing the dates of
your trip."
o "You might be able to get a refund or reschedule for when your child is fully
recovered."
o "If you have travel insurance, you might be able to make a claim for the
cancelled trip."
4. Reinforce medical necessity:
o "This condition cannot be treated outside the hospital."
o "Your child needs to be under constant medical supervision."
o "It's not possible to provide the same level of treatment at home or while
traveling."
o "The treatment involves careful monitoring and adjustment of fluids, insulin,
and electrolytes, which can only be done safely in a hospital setting."
5. If mother refuses:
o Repeat the explanation about the risks and necessity of treatment
o "I know this is difficult, but leaving the hospital now could have very serious
consequences for your child."
o "Without proper treatment, DKA can worsen rapidly and could be life-
threatening."
o "Your child's safety is our primary concern, and we strongly advise against
leaving the hospital at this time."

Key Points to Remember

• Do not call senior doctors to convince the patient; it's your responsibility to handle
the situation

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• Avoid weak statements like "his health is our utmost priority" - be more specific
about the medical necessity and risks
• Be clear and firm about the need for hospital treatment and the dangers of leaving
• Repeat explanations if necessary, focusing on the medical reasons and potential life-
threatening complications
• Maintain a balance between empathy for the family's situation and clarity about the
medical urgency
• This scenario is designed to test communication skills and the ability to explain why
immediate hospital treatment is necessary
• The focus is on articulating the reason for not discharging the patient, not on
actually allowing the discharge

Things to Avoid

• Don't use vague statements about priorities (e.g., "Health is our utmost priority")
• Avoid calling seniors for support in convincing the family (no "babysitting")
• Don't downplay the seriousness of the situation
• Avoid medical jargon without explanation
• Don't give up easily if the family initially refuses; be prepared to explain repeatedly
• Don't negotiate as if it's a minor issue (this is a life-or-death situation, not like
choosing between football and tuition)
• Don't use weak arguments like "Health is our priority" - be more specific about the
medical necessities and risks

Hypoglycaemia

Scenario Overview

• Setting: F2 in acute medicine

• Patient: Young man, around 28 years old
• Admitted following a fit (seizure)
• Developed fits twice during admission
• Blood sugar dropped to 2.1 twice
• Patient is reluctant to stay in the hospital
• Task: Talk to him about his admission (convince him to stay)

Detailed Consultation Approach

Initial Interaction and History Taking (Box 1)

1. Greet the patient and start with:

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o "I understand you've been brought to the hospital. Can you tell me what
happened?"
2. Patient's likely response:
o "I developed fits at home."
3. Follow-up questions about the fit:
o "When did you develop the fits?"
o "How did you develop them?"
o "How did you come to the hospital?" (Note: He was brought by an
ambulance)
o "What happened during the fit?"
o "What happened after the fit?"
4. Assess patient's prior knowledge:
o "What have you been told so far about the reason for your admission?"
o "What have you been told about how they're planning to treat you?"
o "Has anyone told you about the reason for your fit?"
o "During your stay, did anyone tell you that you developed fits in the
hospital?"
o "Did anyone mention that your sugar levels dropped?" Note: The patient
likely doesn't know about the fits and sugar drops in the hospital.
5. Explore patient's reluctance to stay:
o "I understand you're not keen on staying in the hospital. Can you tell me
why?" Note: This point will likely reveal that the patient wants to work.

Medical History and Cause Assessment (Box 2)

1. Ask about medical history:

o "Do you have any long-term medical problems?" Expected response: "I have
diabetes."
2. Inquire about diabetes treatment:
o "What treatment do you take for your diabetes?" Expected response:
"Insulin."
3. Determine diabetes type:
o "Do you know if you have Type 1 or Type 2 diabetes?"
4. Investigate reason for hypoglycaemia (focus on four main causes): a. Excessive
insulin:
o "Is there any possibility you could have taken too much insulin?" b. Normal
insulin but missed meal:
o "Did you take your normal insulin dose?"
o "Did you skip any meals recently?"
o "Did you forget to eat after taking insulin?" c. Vigorous exercise:

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o "Have you done any intense physical activity recently?" d. Alcohol

consumption:
o "Do you drink alcohol?"
o "Have you consumed any alcohol recently?"
5. Identify the cause: Note: In this scenario, the patient took normal insulin but forgot
to eat because he was busy.
6. Complete MAFTOSA

Explanation and Education (Box 3)

1. Explain the cause of fits:

o "You developed fits due to your blood sugar level dropping too low. We call
this hypoglycaemia."
2. Describe what happened in the hospital:
o "After you were admitted this morning, your sugar level dropped to a very
low level of 2.1 twice."
o "Unfortunately, you also developed fits twice during your stay here."
3. Explain the current situation:
o "At the moment, your condition is not stable."
o "Your sugar levels are fluctuating dangerously low."
o "There's a real possibility your sugar levels could drop again, and you might
develop more fits."
4. Justify the need for hospitalization:
o "We need to continuously monitor you until your condition stabilizes."
o "When someone develops repeated fits like you have, we may need to arrange
a CT scan of the brain."
o "The CT scan results would need to be reviewed by a specialist."
5. Discuss treatment adjustments:
o "Your insulin regimen and dose may need to be readjusted."
o "This needs to be done by diabetic specialist nurses who will review your
treatment."
o "We need to find out why your sugar levels are dropping so low and adjust
your treatment to prevent this from happening again."
6. Recommend hospital stay:
o "Given all of this, we strongly advise you to stay in the hospital for at least a
day or two until your condition becomes stable."

Addressing Concerns and Providing Solutions (Box 4)

1. Address the patient's main concern about work:

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o "I understand that you're concerned about your work. That's a valid
concern."
2. Offer solutions:
o "Maybe we can find a way for you to work from here in the hospital."
o "You could bring your computer or laptop and work from your hospital bed
if you feel well enough."
o "We can ensure you have access to Wi-Fi and any other necessities for your
work."
3. Explain risks of leaving:
o "If you go home now, you're at high risk of developing more fits."
o "Your girlfriend, who called the ambulance when you had fits at home,
might not be able to manage if you have another fit."
o "If you have a fit while alone, it could be extremely dangerous."
4. Emphasize safety concerns:
o "It's really not safe for you to go home right now."
o "You're not stable at the moment, and your sugar levels could drop again at
any time."
o "If you develop fits at home, it can sometimes become life-threatening."
o "This situation can put your life in serious danger."
5. Reinforce the need for hospital care:
o "Here in the hospital, we can monitor you closely and respond immediately if
your sugar drops again."
o "We can also make sure we adjust your diabetes treatment to prevent this
from happening in the future."

Key Points to Remember

• This scenario is designed to test communication skills and the ability to explain why
immediate hospital treatment is necessary.
• The focus is on articulating the reason for admission, not on actually allowing the
patient to leave.
• Be clear about the recurrent nature of the hypoglycaemic episodes and fits in the
hospital.
• Emphasize the instability of the patient's condition and the need for monitoring
and treatment adjustments.
• Highlight the risks of leaving the hospital prematurely, including the potential for
life-threatening complications.
• Offer practical solutions to address the patient's work concerns while remaining in
the hospital.
• The way you articulate these reasons is crucial, and your communication skills are
being assessed.

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Things to Avoid

• Don't dismiss the patient's desire to work; instead, offer solutions.

• Avoid medical jargon without explanation.
• Don't minimize the seriousness of repeated hypoglycaemic episodes and fits.
• Avoid being vague about the reasons for hospital admission.
• Don't suggest calling in senior doctors to convince the patient; it's your
responsibility to handle the situation.

Colonoscopy/Sigmoidoscopy Case
Scenario Overview

• Setting: F2 in GP
• Patient: 65-year-old lady
• Patient made an appointment
• Patient had a sigmoidoscopy where polyps with dysplastic changes were found and
removed
• Specialist wants to do a colonoscopy
• Patient wants to speak to the doctor (likely to refuse the colonoscopy)

Detailed Consultation Approach

Initial Interaction (Box 1)

1. Start with paraphrasing:

o "I understand you had a procedure recently, a camera test."
o "I've been told that you wanted to speak to one of the doctors."
o "How can I help you?" or "What can I do for you?"
2. Patient's likely response:
o "Doctor, they want to do another procedure. I don't want to do another
procedure."
3. Ask why:
o "Can I please ask you why you don't want to do the procedure?"
4. Patient's likely reasons:
o "It was very uncomfortable."
o "Last time they didn't put me to sleep, then they put me to sleep later."
o "They said everything is benign and nothing to worry, so why do I need to do
it again?"
5. Reassure and set expectations:
o "I will explain everything about your procedure and why it needs to be done."

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o "To help me understand better, I'd like to ask you some questions first."
6. Assess prior knowledge:
o "What is your understanding about sigmoidoscopy? Do you know what it is?"
o "What do you understand about colonoscopy?"
o "Do you know the difference between these two procedures?"
o "What did they tell you about the polyps? Do you understand what a polyp
is?"
o "What do you understand about your previous treatment?"

Medical History and Risk Assessment (Box 2)

1. Ask about initial symptoms:

o "What made you have the first test (sigmoidoscopy) in the first place?"
Expected answer: Bleeding
2. Follow-up on symptoms:
o "How long did you have the bleeding?"
o "Do you still have the bleeding?" (Likely answer: Bleeding has completely
gone)
o "Any other symptoms?" (Don't specifically ask about colonic cancer
symptoms)
3. Ask about risk factors:
o "Have you had any bowel problems in the past?"
o "Have you had any polyps in the past?"
o "I'm sorry to ask, but has anyone in your family had any polyps?"
o "Has anyone in your family had bowel cancer?"
4. Lifestyle factors:
o "What's your diet like? Do you eat a lot of red meat?"
o "Do you eat much fibre?"
o "How much exercise do you do?"
o "Do you smoke?"
5. Complete MAFTOSA

Explanation and Education (Box 3)

1. Explain sigmoidoscopy:
o "Sigmoidoscopy is a camera test, as you're aware."
o "In sigmoidoscopy, they only checked a very few centimetres, a small area
from your back passage."
o "They found some polyps during this test and removed them."
2. Explain colonoscopy:

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o "What they are planning to do now is check the remaining part of your large
bowel."
o "Colonoscopy is a camera test for the remaining part of your large bowel."
3. Justify the need for colonoscopy:
o "Because you had polyps in the area checked by sigmoidoscopy, there's a
possibility you may have similar polyps in other parts of your large bowel."
o "If there are any polyps in the rest of your bowel, we need to find them and
remove them."
4. Explain the importance of removing polyps:
o "These polyps have the potential to turn into cancer."
o "They have the ability or chances of becoming cancer."
o "Polyps are not cancers, but they are abnormal growths."
5. Clarify the procedure's purpose:
o "We've checked one region and found polyps, which we removed."
o "Now, as you had polyps in this region, we want to check the remaining part
of your large bowel for any more polyps."
o "If we find any more polyps, we want to remove them."
o "That's the reason they want to do this procedure."
6. Apologize for lack of earlier explanation:
o "I'm sorry we should have explained this to you earlier."

Addressing Concerns and Providing Solutions (Box 4)

1. Offer solutions for discomfort:

o "We can give you some painkillers."
o "We can put some numbing agent before they insert the tube."
o "They can put you to sleep so you won't have the same uncomfortable
experience."
o "Would that be okay?"
2. Address potential questions: Patient may ask: "Why didn't they do the colonoscopy
in the first place?" Response:
o "Colonoscopy is a more extensive procedure and needs a lot of preparation."
o "Sigmoidoscopy is easier to perform and needs less preparation."
o "When someone has bleeding from the back passage, we usually start with
sigmoidoscopy."
o "The common place for someone to have bleeding is in the sigmoid colon,
which is the last part of the large bowel."
o "Sigmoidoscopy is easy to perform, doesn't need much preparation, and
checks the most common area for bleeding."
o "If we find something during sigmoidoscopy, then we go for further testing,
like colonoscopy."

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Key Points to Remember

• This scenario is designed to test communication skills and the ability to explain why
the colonoscopy is necessary.
• The focus is on articulating the reasons for the colonoscopy, not on actually
performing the procedure.
• Be clear about the difference between sigmoidoscopy and colonoscopy.
• Emphasize the potential for polyps to become cancerous to justify the need for the
procedure.
• Be prepared to explain why sigmoidoscopy was done first.
• Offer solutions to address the patient's concerns about discomfort.
• The way you articulate the reasons for the colonoscopy is crucial, and your
communication skills are being assessed.

Things to Avoid

• Don't use medical jargon without explanation (e.g., avoid using "gut" instead of
"large bowel").
• Don't dismiss the patient's concerns about discomfort during the previous
procedure.
• Avoid being vague about the reasons for the colonoscopy.
• Don't rush through the explanation about polyps and their potential to become
cancerous.
• Avoid saying "colonic cancer" when asking about symptoms; instead, ask about
general symptoms.
• Don't use weak explanations like "health is our priority" - be specific about the
medical necessity.

Sample Dialogue

Doctor: "I understand you had a procedure recently, a camera test, and that you wanted to
speak to one of the doctors. How can I help you?"

Patient: "Doctor, they want to do another procedure. I don't want to do it."

Doctor: "Can I please ask you why you don't want to do the procedure?"

Patient: "It was very uncomfortable last time. They didn't put me to sleep at first, and then
they did later. Plus, they said everything was benign, so why do I need to do it again?"

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Doctor: "I understand your concerns. I will explain everything about the procedure and
why it needs to be done. But first, to help me understand better, I'd like to ask you some
questions. Is that okay?"

Patient: "Alright."

Doctor: "What do you understand about the sigmoidoscopy you had?"

Patient: "They put a camera in to look at my bowels."

Doctor: "That's right. And do you know what they found?"

Patient: "They said they found some polyps and removed them."

Doctor: "Correct. Now, can you tell me what made you have the first test?"

Patient: "I had some bleeding."

Doctor: "I see. And how long did you have the bleeding?"

Patient: "A few weeks."

Doctor: "Is the bleeding still there now?"

Patient: "No, it's completely gone."

Doctor: "That's good. Have you had any other symptoms?"

Patient: "No, not really."

Doctor: "Okay. Now, let me explain why they want to do another procedure. The
sigmoidoscopy you had only looked at a small part of your large bowel, just a few
centimetres from your back passage. They found polyps there and removed them. What
they want to do now is check the rest of your large bowel with a colonoscopy. This is
because if you had polyps in one area, you might have them in other areas too. It's
important to find and remove any polyps because, although they're not cancer, they have
the potential to turn into cancer if left alone. Does that make sense?"

Patient: "I guess so, but why didn't they just do the colonoscopy in the first place?"

Doctor: "That's a good question. Sigmoidoscopy is quicker and easier to do, and it doesn't
need as much preparation. When someone has bleeding from their back passage, we
usually start with a sigmoidoscopy because the most common place for bleeding is in the

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last part of the large bowel, which is what the sigmoidoscopy checks. If we find something
during the sigmoidoscopy, like we did with you, then we go on to do a full colonoscopy to
check the rest of the bowel."

Patient: "I see. But it was so uncomfortable last time."

Doctor: "I understand, and I'm sorry about that. This time, we can make sure you're more
comfortable. We can give you painkillers, use a numbing agent, and make sure you're
properly sedated for the procedure. Would that help address your concerns?"

Patient: "Yes, I think that would be better."

Doctor: "I'm glad. It's really important that we check your entire bowel to make sure there
are no more polyps. This is the best way to prevent any potential problems in the future.
Do you have any other questions or concerns?"

Refusing Breast Cancer Treatment

Scenario Setup

• Setting: F2 in the GP
• Consultation method: Over the telephone
• Patient: Female, around 40 years old
• Diagnosis: Breast cancer (DCIS - Ductal Carcinoma In Situ)
• Note: This scenario is different from breaking bad news

Initial Contact and Patient's Statement

1. Patient has made an appointment to speak with you.

2. Begin the conversation: You: "Hello, I understand you wanted to speak to one of
the doctors. How can I help you?" Patient: "Doctor, I don't want to go for the
treatment." You: "Can I ask you what treatment you don't want to go for?" Patient: "I
don't want to have any breast cancer treatment."
3. Express empathy: You: "I'm sorry to hear that you have been diagnosed with breast
cancer. I'm sorry about that. Can I ask you why you don't want to have the
treatment?"

Listening Phase

• The patient will now talk continuously until the last 6 minutes of the consultation.
• Never interrupt the patient.
• Listen carefully to reflect and act upon what they're saying later.

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Anticipated Patient Concerns and Statements

During this phase, the patient may express the following concerns:

1. "Everyone dies with cancer anyway."

2. "They convinced my friend to have treatment, but she died anyway."
3. "Even celebrities and important people die from cancer."
4. "I read a lot on the internet and social media. I follow people with cancers, and
everyone with cancer dies."
5. "When they do the surgery, they're going to remove my breast."
6. "I'm going to lose my hair."
7. "When I think about the doctor, I cannot sleep."
8. Expressions of psychological distress

Questions to Ask (if opportunity arises)

If the patient gives you an opportunity to ask questions, you may ask up to three of the
following:

1. "What have you been told in terms of the stages of your cancer?"
2. "What have you been told about how well they can treat your cancer and the
outcome of the treatment?"
3. "How has this new diagnosis been affecting your life?"
4. "Who do you live with, and have you spoken about this with your husband?"

Note: The patient may not allow time to ask these questions. If they do, only ask two or
three.

Promoting Treatment (Carrot Approach)

After listening to the patient's concerns, use the "carrot approach" to promote the best
interest of the patient. Focus on the benefits and positive outcomes of treatment.

You: "Let me explain to you, Mrs. Johnson. According to the reports, it says DCIS, which is
an early stage of cancer. You are quite young, therefore there is a good chance they can
treat your cancer very well. Breast cancer treatment is well advanced now and very well
developed. There is a good chance that you can become cancer free. There is a possibility
that your cancer can be treated very well. You can live longer, you can spend time with
your children. As it's an early stage cancer, they can cure your cancer. 'Cure' means survive
for five years or more."

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Providing Solutions

1. Cognitive Behavioural Therapy (CBT)

You: "It seems like you're not feeling very good about this. You may be feeling low. We can
arrange some talking therapy for you. After speaking to counsellors, you will feel better."
Note: Always mention CBT first in this scenario.

2. Address social media concerns

You: "We advise you not to follow social media for information about cancer. Everything
written on social media is not reliable. We will give you some credible information to read
about breast cancer and treatment."

3. Discuss side-effects

You: "I understand you're worried about losing your hair. Losing hair is temporary. Hair
will grow again. In the meantime, you can wear wigs. You're also worried about losing the
breast. After the surgery, the surgeons can reconstruct and remodel the breast. We have a
solution for that."

4. Support groups

You: "There are also some support groups available. We can refer you to Macmillan Cancer
Support. They offer various support and advice for people newly diagnosed with cancer."

5. Family support

You: "We advise you to speak to your husband about this. I'm sure he will have the same
opinion as me."

Concluding the Conversation

You: "Mrs. Johnson, we will advise you to go for the treatment. Given that this is an early
stage cancer and you're young, there's a very good chance of successful treatment. Modern
breast cancer treatments are advanced and have high success rates. We'll provide you with
credible information sources about breast cancer and its treatment. I encourage you to
discuss your concerns with your family, especially your husband. Remember, we're here to
support you through this process."

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Things to Avoid

1. Don't interrupt the patient when they are speaking

2. Avoid using the "stick approach" (emphasizing negative consequences of refusing
treatment)
3. Don't provide a lot of history if the patient is speaking continuously
4. Avoid starting responses with phrases like "Certainly!", "Of course!", "Absolutely!",
"Great!", "Sure!", etc.

Additional Important Notes

• The consultant has already discussed treatment options (mastectomy,

chemotherapy, radiotherapy) with the patient
• If the patient doesn't speak much, you can ask about their prior knowledge of
cancer, treatment, and social history
• When promoting treatment, use "we" language: "We will advise you to go for the
treatment."
• Always address the patient's concerns one by one
• Emphasize that this is an early stage cancer with good treatment possibilities
• Reassure the patient that modern breast cancer treatments are advanced and
successful
• Offer to provide credible information sources about breast cancer and its treatment
• Encourage the patient to discuss their concerns with their family, especially their
husband

Ectopic Pregnancy
Setting

• Location: Hospital
• Patient: 21-year-old female (note: previously 18 in older scenarios)
• Presenting complaint: Tummy pain
• Initial diagnosis: Positive pregnancy test, suspected ectopic pregnancy

Initial Approach

1. Begin the conversation: You: "Hello, I understand you've been asked to talk to me.
What have you been told, and what made you come to the hospital?"
2. Ask about symptoms: You: "Can you tell me more about the tummy pain you're
experiencing?"

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3. Inquire about risk factors: You: "Have you had any previous infections or
procedures? What contraceptive methods have you been using, especially any
devices?"

Diagnosis and Explanation

You: "Based on your symptoms and the initial tests, you could be having a condition called
ectopic pregnancy. Ectopic pregnancy means the pregnancy is developing outside the
womb. Unfortunately, this type of pregnancy will not survive. It's important to understand
that ectopic pregnancy is a medical emergency."

Management Plan

You: "The first thing we need to do is arrange a scan to confirm the diagnosis. The nurses
have decided to do a morning scan, as that's when it's available. Until it's confirmed, we
strongly advise you to stay in the hospital."

Addressing Patient Reluctance

Patient: "I can't stay in the hospital."

You: "I understand you're reluctant to stay. Can you tell me why?"

Patient: [Gives reason - e.g., "My parents will not be happy," "They'll find out about this"]

You: "I understand your concerns, but let me explain why it's important to stay. Ectopic
pregnancy can burst or break at any time, causing internal bleeding. This can happen
suddenly and without warning. If it does, you'll need emergency treatment immediately."

Patient: "If there's any bleeding, I'll come back. I just live nearby."

You: "I appreciate that you're willing to come back if you notice bleeding, but there's a
serious risk we need to consider. You can have a sudden, profuse bleeding at any time. You
could lose a large amount of blood within a very short period. In that situation, you may
collapse or go into shock. If someone brings you in in that condition, it may be difficult for
us to treat or resuscitate you. This can cause various complications in your body and put
your life in danger."

Providing Solutions

You: "I understand your concerns about your parents finding out. We are not going to tell
your parents without your permission. Our primary concern is your health and safety.

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Staying in the hospital allows us to monitor you closely and respond immediately if any
complications arise."

Pre-eclampsia

Setting

• Location: Antenatal clinic

• Patient: Typically 36 weeks pregnant (note: can occur as early as 24 weeks, but 24-
week cases usually don't require admission if blood pressure is controlled)
• Reason for visit: Routine antenatal check-up
• Findings: High blood pressure (e.g., 160/90 mmHg), protein in urine

Initial Approach

1. Begin the conversation: You: "Hello, I understand you've come for your follow-up.
How have you been feeling?"
2. Ask about symptoms: You: "Have you been experiencing any headaches, blurry
vision, tummy pain, vomiting, or leg swelling?"
3. Inquire about pregnancy history: You: "Is this your first pregnancy? Have you had
any problems in previous pregnancies?"

Diagnosis and Explanation

You: "The nurses have done some tests, and they found that your blood pressure is high.
We also found some protein in your urine. These findings suggest you might have a
condition called pre-eclampsia. Let me explain what that means.

Pre-eclampsia is a complication that can occur in late pregnancy. It's when someone at a
late stage of pregnancy, like yourself, develops high blood pressure. Due to this high blood
pressure, the kidneys may not filter the blood properly, which is why we see protein in the
urine. When we see these features together - high blood pressure and protein in the urine -
we call it pre-eclampsia."

Management Plan

You: "Pre-eclampsia at this stage needs regular monitoring. We advise you to get admitted
to the hospital. As part of the treatment, we need to regularly monitor your blood pressure
and give you medication called labetalol to control it. We also need to monitor your baby's
heartbeat regularly. Are you okay with that?"

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Addressing Patient Reluctance

Patient: "No, I don't want to get admitted. I can't get admitted."

You: "Can I ask why you feel you can't be admitted?"

Patient: [Gives reason - e.g., maternity leave not ready, planned baby shower, barbecue
party at home]

You: "I understand your concerns, but let me explain why it's important to be admitted. If
pre-eclampsia is not treated properly, the high blood pressure can continue to increase.
This can lead to a more serious condition called eclampsia, where you might develop fits
due to the effects of high blood pressure on your brain.

If you were to develop fits, we would need to give you a medication called magnesium
sulphate through a drip, and we might need to arrange an emergency c-section. The only
definitive treatment for pre-eclampsia is delivery of the baby."

Patient: "What about having a water birth?"

You: "I'm sorry, but water birth is not recommended in cases of pre-eclampsia. Here's why:

1. We need to regularly monitor your blood pressure and your baby's heart rate, which
is difficult to do in water.
2. You have a potential to develop fits, and in that case, we would need to arrange an
emergency c-section.
3. Water birth would make it difficult for us to respond quickly if any complications
arise.

Our primary concern is the safety of both you and your baby, which is why we recommend
a more controlled delivery environment."

Concluding the Conversation

You: "I know this isn't what you had planned, and I understand it's disappointing. But
your health and your baby's health are our top priorities. By staying in the hospital, we can
ensure you receive the best care possible and respond quickly to any changes in your
condition. We'll do our best to make your stay as comfortable as possible. Do you have any
other questions or concerns I can address?"

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Important Notes for Both Scenarios

1. Listen attentively to the patient's concerns without interrupting.

2. Address each concern individually and thoroughly.
3. Explain the seriousness of the situation clearly but compassionately.
4. Offer solutions to practical concerns (e.g., confidentiality, comfort during hospital
stay).
5. Use "we" language to emphasize team-based care.
6. Be prepared to negotiate, but always prioritize patient safety.
7. Avoid starting responses with phrases like "Certainly!", "Of course!", "Absolutely!",
"Great!", "Sure!", etc.
8. Focus on giving solid explanations for why the recommended course of action is
necessary.
9. In the pre-eclampsia scenario, emphasize that delivery is the only definitive
treatment.
10. For both scenarios, clearly explain the potential life-threatening complications if left
untreated.

Additional Notes

• These scenarios frequently appear in exams. Sometimes two or three scenarios from
this list may be included.
• The key to success in these scenarios is providing solid explanations for why the
recommended course of action is necessary.
• Practice explaining the seriousness of the situation in a way that the patient can
understand.
• Be prepared to address various reasons for refusal, including concerns about privacy,
family obligations, or planned events.
• Remember that the goal is not just to diagnose, but to effectively communicate the
need for immediate medical intervention.

Colleague-Related Scenarios
List of Scenarios

1. Student coming late

2. Social media-related scenarios:

a. Twitter scenario: Dr. A wanted to speak to you about Dr. B

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b. Nurse Teresa wanted to speak to you about Dr. Paul (adding people on
Facebook and receiving gifts)

c. F1 has written about a patient on Facebook

3. Medical student taking drugs

4. Chronic alcohol problem: F2 smelling of alcohol, coming late, being clumsy with
patients
5. F1 smelling of alcohol (drinking for last two weeks only)
6. Chronic alcohol problem presented as a third-person situation (Dr. A speaking
about Dr. B) - less common variation

Note: These scenarios are related to good medical practice and are serious problems.

Five-Box System for Addressing Colleague-Related Issues

Box 1: Build Rapport

• Introduce yourself professionally

• Establish a limited, professional rapport
• Don't act like you've known them for 20 years, but they're not complete strangers
either
• Be professionally friendly

Examples of building rapport:

• "Are you David?"

• "Hello David, I'm X, one of the F2s."
• "We have briefly met before."
• "I understand you're one of the F1s. You've been working with us for some time."

Ice-breakers:

• "How are you today?"

• "How is your rotation?"
• "How is the work?"
• "Is it a busy rotation?"
• "What's your next rotation?"
• "Do you like it here?"
• "Are you enjoying the rotation?"

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For medical students:

• "How is school?"
• "How are your studies?"
• "You're in fifth year, how is that going?"
• "You're graduating next year, how do you feel about that?"
• "What do you do in your free time?"
• "How are your exams?"

Remember: Rapport is an effort. You need to build it up, but keep it professional.

Box 2: Introduce the Topic

Go straight to the point after building rapport.

If they wanted to speak to you:

• "I understand you wanted to speak to me. Is there anything in particular you'd like
to discuss?"

If you're initiating (e.g., smelling alcohol):

• "Actually, I've been getting some smell of alcohol from you. I just wanted to check
whether you've had any alcohol at all."

Box 3: Take Relevant History

Gather information related to the specific issue. Base your questions on the implications of
the issue (why it's wrong).

Box 4: Discuss Implications

This is the core part of the conversation. Explain why the behaviour or situation is
problematic.

Example for social media breach:

• Implication: Breach of confidentiality

Your history-taking and solutions should be based on these implications.

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Box 5: Provide Solutions

Offer appropriate solutions based on the specific issue and its implications.

Example for social media breach:

• Solution: Deleting the post, seeking knowledge about proper conduct

Key Points to Remember

1. These scenarios are testing your understanding of good medical practice

2. Treat all issues as serious, not trivial
3. The implications (why the behaviour is wrong) should guide your approach
4. These scenarios are ultimately about your own conduct and understanding, not just
about handling colleagues
5. Be prepared to explain clearly why certain behaviours are inappropriate in a medical
setting

Examples of implications to understand:

• Why shouldn't we come late?

• Why shouldn't we smell of alcohol?
• Why shouldn't we treat patients under the influence of alcohol?
• Why can't we take drugs at all in our life?
• Why shouldn't we have sexual relationships with patients?
• Why shouldn't we write anything about patients on social media?

Remember: These scenarios are about you, not just about the colleagues mentioned.
They're giving you a heads up before you start practicing.

Things to Avoid

1. Don't act overly familiar with colleagues

2. Don't assume they know who you are
3. Don't treat these issues as simple or trivial
4. Don't say things like "Oh, can you just come early now?" for serious issues

Sample Dialogue

You: "Hello, are you David?" David: "Yes, that's me." You: "Hi David, I'm X, one of the F2s.
We've briefly met before. How are you today?" David: "I'm doing alright, thanks." You:
"That's good to hear. How's your rotation going? Finding it busy?" David: "It's been pretty

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hectic, yeah." You: "I can imagine. Listen, David, I hope you don't mind me mentioning
this, but I've noticed a smell of alcohol. I just wanted to check if you've had any alcohol
recently?" David: "Oh... well, yes, I had a drink last night." You: "I see. Can you tell me a bit
more about your drinking habits? How often do you drink?" David: "Well, I've been
drinking more lately, to be honest. It's been a stressful time." You: "I understand that things
can get stressful. However, it's important to discuss why coming to work under the
influence of alcohol is problematic. It can affect patient safety and your professional
conduct. Have you considered the potential implications of this?" David: "I... I hadn't really
thought about it that way." You: "I understand. There are support services available that
can help with stress management and alcohol-related issues. Would you be open to
speaking with occupational health? They can provide confidential support and guidance."

Medical Student Coming Late

Setting

• You are an F2 in surgery

• You need to speak to David, a fifth-year medical student
• David has been coming late by one hour
• Fifth-year medical students have a GMC number
• No one has asked you to speak to David; it's your own initiative due to ethical
concerns

Approach

1. Build Rapport

• Introduce yourself professionally

• Example: "Are you David? Hello David, I'm X, one of the F2s."
• Acknowledge your working relationship: "I understand you're a fifth-year medical
student. We have briefly met and I've seen you doing the rotation with us for some
time."
• Ask ice-breaker questions:
o "How are you today?"
o "How is your rotation?"
o "How is medical school?"
o "How are your studies?"
o "Is everything fine?"
o "How is your fifth year going?"
o "You're graduating next year, how do you feel about that?"
o "What do you do in your free time?"

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o "How are your exams?"

Remember: Be friendly and nice, but maintain professionalism. Don't act like you've
known them for 20 years, but they're not complete strangers either.

2. Introduce the Topic

• Approach the topic sensitively

• Example: "David, actually, recently, I have been noticing that you are coming a bit
late." (Show all your teeth while saying this, indicating it's difficult for you to say)
• Follow up with: "I just want to know, is everything okay? What is the reason that
you are not able to make it on time?"

3. Handle Potential Denial

If the student denies being late:

• "Well, the nursing staff also mentioned to me, and other people have noticed that
you have been coming late by one hour."
• If they say they're only late by 5 minutes: "I'm afraid even if you're late by five
minutes, it's still late. What is the reason you are not able to make it on time? Is
everything okay?"

4. Gather Information

• Ask about possible reasons for lateness:

o "Are you struggling with anything?"
o "Are you traveling from far?"
o "Do you live nearby?"
o "How do you come to the hospital?"
o "What time do you get up?"
o "What time do you go to bed?"
o "What do you do until late at night?"
• If they mention video games:
o "How often do you play video games?"
o "How many hours do you spend playing?"
o "What time do you start playing?"
o "What do you do in the video games?"
o "Do you make any income or participate in tournaments?"
o "Are you a professional video game player?"
• If they mention social media:
o "What sort of social media do you use?"

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o "What do you do on social media?"

o "Do you run any page?"
o "Are you an influencer?"
o "How much time do you spend on social media?"
o "How often do you use it?"
o "What sort of activities do you do on social media?"
o "Do you just watch social media for fun?"
• Ask about studies and exams:
o "How are your exams?"
o "How are your studies?"
o "Are you passing exams?"
• Ask about free time activities:
o "What do you do in your free time?"
o "Do you drink alcohol?"
o "How often do you drink alcohol?"
o "Do you drink on weekdays as well?"
o "What are your hobbies?"
o "Do you hang out with friends?"

Remember: Always approach these questions positively and naively, as if you don't already
know the answers.

5. Explain Implications

Start with: "Let me explain to you why coming late can be problematic."

Key points to cover:

1. It's unprofessional
o "Coming late is unprofessional. There are certain expectations for our
profession."
o "As doctors and medical students, we all have the same requirements in
terms of punctuality."
2. It affects team dynamics
o "If someone comes late, it creates negativity in the environment."
o "It affects the team's morale and productivity."
o "The team cannot work together effectively if people are coming in on their
own time."
o "It creates a sort of negativity in the team and the environment."
3. It affects learning
o "If you come late, you might miss important teaching sessions or interesting
cases during ward rounds."

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o "You might miss demonstrations of examinations or interesting clinical

findings."
o "Seniors might think you're not very keen to learn if you keep missing
sessions."
o "They will not have any interest to teach if you keep missing classes."
4. It affects references and portfolio
o "Our profession requires references throughout our career."
o "It's difficult to get a good reference if you consistently come late."
o "It can affect your e-portfolio, which consultants need to fill out after each
rotation."
o "E-portfolio is the new logbook, it's all online now."

6. Provide Solutions

1. For lateness due to sleep schedule:

o "My simple advice is to go to bed early and get up early to come on time."
2. For social media or video game use:
o "Social media and video games can waste our time without us realizing it."
o "They can be addictive and you might spend a lot of time without noticing."
o "You could use that time to maybe learn a new skill or study something."
o "You can invest that time for your future."
3. Encourage speaking to seniors:
o "I would advise you to speak to one of the seniors as well, maybe your
educational supervisor or the ward consultant, to discuss this issue."
o "Seniors are there to help and support us. They have more experience."

7. Address Potential Concerns

If the student asks if you're going to tell the seniors:

• "I might consider it. If I get a chance to speak to the consultant, I will discuss it."
• "But the discussion would be about what we have discussed today and what we have
agreed upon."
• "It's not about reporting, but about discussing what we've talked about."
• "Meanwhile, I would advise you to speak to one of the seniors yourself to get some
help."

Important Points to Remember

1. Don't act superior or like you're the boss.

2. Maintain a positive and supportive attitude throughout the conversation.
3. Don't make conditional offers (e.g., "If you come late again, I'll tell the seniors").

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4. Always present seniors as part of the same team, there to support and help.
5. Be transparent; don't suggest covering up the issue.
6. Focus on the main issue (lateness) rather than getting distracted by smaller issues.
7. If the student seems disinterested or not engaging, continue to be nice and
supportive.
8. Remember, your energy and approach are crucial in handling this scenario
effectively.
9. Don't assume they know who you are; always introduce yourself.
10. Avoid saying things like "Oh, can you just come early now?" for serious issues.
11. Don't say "If the seniors come to know, they will be upset" or suggest it's better to
hear from you before others.
12. Never try to cover up or suggest sorting it out before others know.
13. Don't use phrases like "Certainly!", "Of course!", "Absolutely!", "Great!", or "Sure!" to
start responses.

Sample Dialogue

You: "Hello, are you David?" David: "Yes, that's me." You: "Hi David, I'm X, one of the F2s.
We've briefly met before. How are you today?" David: "I'm doing alright, thanks." You:
"That's good to hear. How's your rotation going? Finding it busy?" David: "It's been pretty
hectic, yeah." You: "I can imagine. Listen, David, I hope you don't mind me mentioning
this, but I've noticed that you've been coming a bit late recently. Is everything okay? What's
the reason you're not able to make it on time?" David: "Oh... I didn't realize it was
noticeable. I've just been having trouble waking up." You: "I see. Can you tell me a bit more
about that? What time do you usually go to bed?" David: "Well, I've been going to bed
pretty late, around 3 or 4 AM." You: "I see. And what do you do until that time?" David:
"Mostly playing video games or browsing social media." You: "I understand. How often do
you play video games? And how much time do you spend on social media?" David: "I play
games most nights, and I'm always checking social media." You: "I see. Let me explain why
coming late can be problematic. It's considered unprofessional, and it can affect the team's
dynamics and your learning opportunities. It might also impact your references and e-
portfolio. Have you considered how this might affect your future career?" David: "I hadn't
really thought about it that way." You: "I understand. My advice would be to try going to
bed earlier and waking up earlier. Also, maybe try to limit your time on video games and
social media. They can be quite addictive and time-consuming without us realizing it. What
do you think about speaking to one of the seniors about this? They might have some good
advice." David: "Are you going to tell them about this?" You: "If I get a chance to speak to
the consultant, I might discuss what we've talked about today and what we've agreed upon.
But I'd really encourage you to speak to a senior yourself. They're here to support us and
help us improve. Do you have any other concerns about this?"

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Twitter Posts

Setting

• You are an F2 in the surgical department

• Alex Thompson (F2) wants to speak to you about concerns regarding Dr. Patel (F1)
• Sometimes the scenario might mention Dr. Goodwill instead of Dr. Patel

Approach

1. Build Rapport

• Greet Alex without using full name: "Are you Alex?"

• Don't say "Are you Alex Thompson?" as it might make them think they're in trouble
• Acknowledge his position: "I understand you're one of the F2s, yes."
• If you make a mistake (e.g., saying F1 instead of F2), correct yourself politely
• Ask brief questions: "How are you, Alex? How's your rotation? Is this your first
rotation? How long have you been working here?"
• Don't act overly familiar or as if you've been going to dinner together

2. Initiate the Conversation

• "I understand you wanted to have a discussion with me. What can I do for you,
Alex?"
• "You mentioned you wanted to speak to me about something. What is this about?"

3. Gather Information

When Alex mentions Dr. Patel's tweets:

• "What has he written about the patient?"

• Alex might say: "He wrote that the patient was smelly today."
• Respond: "Oh, that is not very nice."
• "You mentioned a video. What's in the video?"
• Alex might say: "Nurses are washing a patient."
• "Is the patient's face visible in the video?"
• "What part of the body are they washing?"
• "Is there any personal information mentioned, like the patient's name or medical
condition?"
• "What has he written about the consultant?"
• Alex might say: "He wrote that the consultant's classes are boring and it takes too
long to do ward rounds."

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• Respond: "That is not very nice."

• "When did you see these tweets?"
• "Are they still there?"
• "How are other people reacting to his tweets? Are people discussing or sharing
them?"
• "Have you spoken to Dr. Patel about this?"
• If not, ask: "Why haven't you spoken to him?"
• Alex might say: "I don't want to speak to him because it can affect our relationship."

4. Explain Implications

Start with: "Let me explain why this situation is problematic."

Key points to cover:

1. Unprofessionalism:
o "Writing about patients or consultants and putting pictures online is
unprofessional behaviour."
2. Breach of Confidentiality:
o "Writing about patients' details, discussing them, or posting pictures can be a
breach of confidentiality."
o Note: Don't say it "is" a breach, but "can be" a breach.
3. Reputation and Trust:
o "When people see these posts, they might think we're not serious about our
profession."
o "They will think we are not serious about our occupation."
o "We are joking around."
o "It can damage our reputation and affect the doctor-patient relationship."
o "People might lose trust in us."
4. Good Medical Practice:
o "This behaviour doesn't adhere to good medical practice."
o "It doesn't go with good medical practice."
o "We have guidelines about how to handle social media as medical
professionals."

Don't mention:

• Hospital policies (hospitals don't typically have policies on personal social media
use)
• That it's illegal (breaching confidentiality isn't illegal in this context)

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5. Provide Solutions

Use three key words: Delete, Talk, and Read.

• "We need to advise Dr. Patel to delete these posts."

• "It's better if you tell him. You're actually doing him a favour by preventing him
from getting into trouble."
• "I'm sure Dr. Patel will appreciate it."
• "We should advise him to talk to one of the seniors about this."
• "We can also speak to seniors and have a discussion about this. All the seniors are
here to help us."
• "We need to advise Dr. Patel to read about how to handle social media properly."
• "The GMC has good medical practice guidance that he should read."
• "It seems he's quite active on social media, but we have some regulations for that.
He may not be aware of it, so it's better to get educated on that."

6. Address Potential Concerns

If Alex asks if Dr. Patel is in trouble:

• "This may cause trouble because when we write something on social media, it can
sometimes cause issues. It has the potential to cause significant problems."
• "It's difficult to say how far it can go or what problems it might cause."
• "We hope that if he deletes this, everything should be okay."

If Alex asks to keep this anonymous:

• "I understand your concern. Explain to Dr. Patel that by talking to him, you're
actually helping to build a relationship and preventing him from getting into
trouble."

Important Points to Remember

1. Don't use full names when addressing colleagues

2. Maintain a professional tone throughout the conversation
3. Focus on gathering information and explaining the implications
4. Don't turn this into Alex's problem; the issue is with Dr. Patel's behaviour
5. Avoid "tuk-tuk management" (saying you'll handle it without taking proper action)
6. Don't mention hospital policies; focus on professional standards and good medical
practice
7. Avoid using the word "illegal" when discussing confidentiality breaches
8. Don't assume Dr. Patel will refuse to delete the posts or act unreasonably

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9. Avoid using "if" clauses that suggest extreme scenarios (e.g., "If Dr. Patel refuses to
delete...")
10. Remember that Dr. Patel is a qualified professional who likely made a mistake due
to lack of understanding, not malice
11. Good Medical Practice is not a book, but a set of PDF pages with guidelines

Sample Dialogue

You: "Hello, are you Alex?"

Alex: "Yes, that's me."

You: "Hi Alex, I understand you're one of the F2s and you wanted to speak with me. How's
your rotation going? Is this your first rotation?"

Alex: "It's my first rotation, been here for about two months now."

You: "That's great. So, you mentioned you wanted to speak to me about something. What
is this about?"

Alex: "I wanted to talk to you about Dr. Patel. I've seen some tweets from his account."

You: "I see. What has he written in these tweets?"

Alex: "He wrote that a patient was smelly today. And there's a video of nurses washing a
patient."

You: "Oh, that is not very nice. Can you tell me more about the video? Is the patient's face
visible?"

Alex: "Yes, you can see the patient's face clearly."

You: "I see. Has he written anything about any of the consultants?"

Alex: "Yes, he wrote that the consultant's classes are boring and it takes too long to do ward
rounds."

You: "That's not very appropriate either. Have you spoken to Dr. Patel about this?"

Alex: "No, I don't want to speak to him because it can affect our relationship."

You: "I understand your concern. Let me explain why this situation is problematic. Writing
about patients or consultants and putting pictures online is unprofessional behavior. It can

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be a breach of confidentiality. When people see these posts, they might think we're not
serious about our profession. It can damage our reputation and affect the doctor-patient
relationship. This behaviour doesn't adhere to good medical practice guidelines.

We need to advise Dr. Patel to delete these posts. It would be better if you tell him, as
you're actually doing him a favour by preventing him from getting into trouble. We should
also advise him to talk to one of the seniors about this and to read about proper social
media use for medical professionals.

Don't worry about affecting your relationship. By talking to him, you're helping to build a
positive relationship and potentially saving him from serious issues in the future."

Alex: "Is Dr. Patel in trouble?"

You: "This may cause trouble because when we write something on social media, it can
sometimes lead to significant problems. It's difficult to say how far it can go, but we hope
that if he deletes this, everything should be okay. The important thing now is to address it
promptly and ensure Dr. Patel understands the implications of his actions."

Alex: "Can you keep this anonymous?"

You: "I understand your concern, but explaining to Dr. Patel that you noticed this and are
bringing it to his attention is actually helping him. You're preventing him from potentially
getting into more serious trouble. I'm sure he'll appreciate your looking out for him."

Facebook Activities Scenario

Setting

• You are speaking with Teresa, a nurse in your department

• Teresa has requested to speak with you about Dr. Paul, an F1 doctor

Approach

1. Build Rapport

• Introduce yourself and acknowledge Teresa's role

• Example: "Hello Teresa, I understand you're one of our staff nurses. How are you?
How is everything going? How is your rotation?"
• Keep it simple and straightforward, don't overdo the friendliness
• Avoid phrases like "I haven't heard from you in a long time" or "Nice to hear from
you"

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• Don't act like you know her very well if you don't

2. Initiate the Conversation

• Start with: "I understand you wanted to speak to me. Is there anything in particular
you'd like to discuss?"

3. Gather Information

When Teresa mentions Dr. Paul, gather detailed information:

• Clarify Dr. Paul's position: "Dr. Paul is one of our F1s, correct?"
• Ask for more details: "Can you tell me more about what you've been noticing?
What's happening on Facebook?"
• Specific questions to ask:
o "Are they patients he's adding, or relatives as well?"
o "How did you come to know about this? Are you on his Facebook friend
list?"
o "How many people has he added? Is it a lot of people?"
o "What seems to be his intention? Why is he trying to add people?"
o "Is he just being friendly, or is he showing interest in specific people?"
o "Is he giving any medical advice or discussing their medical conditions and
treatments?"
o "Is he receiving gifts? What kind of gifts? How often?"
o "Have you noticed any expensive gifts?"
o "Do you know if he's receiving sweets from patients?"
• Ask about Dr. Paul's general behaviour:
o "Apart from Facebook, how is he generally as a doctor?"
o "How is his patient care? Is he taking good care of patients?"
o "Have you noticed any other activities, like seeing patients in cafes or
somewhere else?"

4. Explain Implications

Start with: "Let me explain why this situation can be problematic."

Key points to cover:

1. Unprofessionalism:
o "Adding patients to our personal Facebook accounts is unprofessional."
o "We are not allowed to have this kind of relationship with patients."
o "We can't attend patients' personal events like weddings or birthday parties."

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oExample: "If a patient invites you to their daughter's wedding, you need to
politely refuse."
2. Regulated profession:
o "Our profession is a regulated profession."
o "There are certain things we cannot do as medical professionals."
3. Impact on reputation and trust:
o "When others find out, they might think we're not serious professionals."
o "It can affect our reputation and the doctor-patient relationship."
o "It's not good medical practice."
4. Regarding gifts:
o "Receiving gifts isn't completely wrong, but there are guidelines."
o "We can receive small gifts as tokens of appreciation on behalf of the team."
o "Small gifts are okay because they motivate the team."
o "Gifts should be received on behalf of the team and shared."
o "The value of gifts is important. We should avoid receiving expensive gifts."
o "Any gift over £50 needs to be recorded."
o "It's better to have a record of all gifts received."
o "Records can be kept with Patient Advisory Liaison Service (PALS)."
o "Different hospitals have different policies on gift reception. We should
follow our hospital's policy."
o "He can keep records of gifts in his appraisal or portfolio."

5. Provide Solutions

• Advise Dr. Paul to unfriend patients on Facebook

• Suggest he reads about good medical practice and how to manage social media
• Recommend he familiarize himself with hospital policies on receiving gifts
• Offer to speak to Dr. Paul yourself

6. Address Potential Concerns

If Teresa is reluctant to discuss this with Dr. Paul:

• Ask: "Can I ask why you don't want to discuss this with him?"
• Offer to take responsibility: "I can speak to Dr. Paul. I'll take the responsibility."
• Explain: "It's better for you to let me handle this. You're trying to help him, and he
should appreciate that."

Important Points to Remember

1. Maintain a professional tone throughout the conversation

2. Focus on the main issues: unprofessional social media use and gift reception

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3. Emphasize the importance of maintaining proper doctor-patient relationships

4. Highlight the regulated nature of the medical profession
5. Provide clear guidelines on gift reception and recording
6. Offer support in addressing the issue with Dr. Paul
7. Do not suggest speaking to patients about this issue in social media-related scenarios
8. If Dr. Paul's patient care is good, acknowledge it as it can be important for overall
support
9. Remember that patient care is crucial - if it's good, people will be more supportive
even if mistakes are made

Sample Dialogue

You: "Hello Teresa, I understand you're one of our staff nurses. How are you today? How is
everything going with your rotation?"

Teresa: "Hello, I'm doing alright. I wanted to speak to you about Dr. Paul."

You: "I see. Dr. Paul is one of our F1s, correct? Can you tell me more about what's
concerning you?"

Teresa: "Well, he's been adding a lot of people on Facebook, and most of them are his
patients."

You: "I see. How did you come to know about this? Are you connected with him on
Facebook?"

Teresa: "Yes, I am. I've noticed he's added many patients recently."

You: "Do you know if he's adding just patients or relatives as well? And what seems to be
his intention? Is he just being friendly, or is there more to it?"

Teresa: "It seems to be mostly patients. I'm not sure about his intentions, but he's
interacting with them quite a bit."

You: "Has he been giving any medical advice or discussing their conditions on Facebook?"

Teresa: "Not that I've seen directly, but patients have been writing things like 'Doctor,
please accept my sweets' or mentioning gifts."

You: "That's concerning. Do you know what kind of gifts he's receiving or how often? Have
you noticed any expensive gifts?"

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Teresa: "It seems to be mostly sweets, but I'm not sure about the frequency or value."

You: "I see. Apart from Facebook, how is Dr. Paul generally as a doctor? How's his patient
care?"

Teresa: "His patient care is generally okay. I haven't noticed anything else unusual."

You: "Thank you for bringing this to my attention, Teresa. Let me explain why this
situation can be problematic. Adding patients on Facebook is unprofessional and goes
against good medical practice. Our profession is regulated, and there are certain things we
cannot do. This kind of interaction can affect the doctor-patient relationship and our
reputation.

Regarding gifts, while small tokens of appreciation are okay, we need to be careful. Gifts
should be received on behalf of the team and shared. Any gift over £50 needs to be
recorded, and it's better to keep a record of all gifts. Our hospital has policies on this that
Dr. Paul should be aware of.

I'll speak to Dr. Paul about unfriending patients on Facebook and advise him to read up
on our social media policies and gift guidelines. Is there anything else you think I should
know?"

Teresa: "No, that covers everything. But I'm not comfortable discussing this with Dr. Paul
directly."

You: "I understand. Can I ask why you don't want to discuss this with him?"

Teresa: "I just don't want to create any tension in the workplace."

You: "I appreciate your concern. Don't worry, I can speak to Dr. Paul myself. I'll take
responsibility for addressing this issue. It's better this way, as we're trying to help him, and
he should appreciate that. Thank you again for bringing this to our attention, Teresa. It's
important that we maintain professional standards in all our interactions with patients."

Doctor Posting About Patient on Facebook

Setting

• You are in the emergency department

• You need to speak to David, an F1 doctor
• You have seen some of David's posts on Facebook about a patient
• The patient was described as having schizophrenic behaviour

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• David wrote that the patient claimed to be the Queen of England, coming from the
palace
• David also mentioned the patient was "insane" and used "haha" in the post

Approach

1. Build Rapport

• Introduce yourself: "Hello David, I'm one of the F2s."

• Ask about his wellbeing: "How are you?"
• Inquire about his work: "How is your rotation? How is your work?"
• Be prepared for an enthusiastic response: David might talk about his personal life,
recent outings, etc.
• Listen politely but don't engage too deeply in personal conversation
• Don't act like you know him very well if you don't

2. Introduce the Topic

• Transition to the main issue: "Actually David, I want to talk to you today about
something that I have noticed on your Facebook."
• Clarify: "I wanted to talk to you about something in private."
• Note: The scenario is already set in a private setting. Don't suggest moving to
another location.

3. Gather Information

Ask specific questions about the post:

• "I've seen that you've written about somebody who seems to be one of our patients.
Can I ask you a few questions about that?"
• If David laughs or thinks it's funny, maintain a serious demeanour. Don't laugh
along.

Ask about the patient:

• "Who was that patient?"

• "Where is the patient at the moment?"
• "What condition are we treating them for?"
• "Was it your patient? Who was the consultant?"
• "Have you treated this patient previously?"
• "Do you know how the patient looks? Have you met this patient before?"
• "Was the patient accompanied by anybody or alone?"

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• "Do you know where the patient is coming from? Maybe from a nursing home?"
• "Did the patient have capacity?"

Ask about his social media use:

• "Can I ask you a few questions about social media?"

• "Do you identify yourself as a registered doctor on Facebook?"
• Explain: "I'm asking because I had a very quick look at your Facebook, but I didn't
get much time to check thoroughly."
• "When you post something, who can see it? Is it public or limited to friends?"
• "Can everyone share your posts? Do you control that?"
• "What about commenting? Do you allow everyone to comment, or do you restrict
that?"
• "After you posted this, did you check how other people are reacting to it? Have you
seen any comments or reactions?"

4. Explain Implications

Start with: "I'm a little bit concerned because this could be a breach of confidentiality."

Key points to cover:

1. Confidentiality breach:
o "It's wrong to share patient information, even with friends."
o "Whatever happens between you and your patient is confidential, including
information about their capacity."
2. Loss of privacy on social media:
o "Once you put something on social media, it's not private anymore."
o "People can easily share it or take screenshots."
o "It's difficult to control once you've put something on social media."
o "Even if it's your private account, sharing with friends is still wrong."
3. Unprofessional conduct:
o Mention that this behaviour is unprofessional
o It affects reputation and goes against good medical practice
o Using terms like "insane" and "haha" when referring to patients is
inappropriate

5. Provide Solutions

• Advise David to remove the post immediately

• Suggest he reads about proper social media use for medical professionals and good
medical practice

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6. Address Potential Concerns

If David asks if he's in trouble:

• "It's difficult to say because once you put something on social media, it's hard to
know how far it can go or what problems it might cause."
• "We hope that if you delete this post, everything should be okay."
• "But it's important to understand that writing about a patient you're treating can get
you into serious trouble."
• "It's not easy to fix once it's out there. If someone has already taken a screenshot, for
example, you can't do anything about that."
• "This is a very good lesson for you about the importance of confidentiality and
professional conduct on social media."

Important Points to Remember

1. Maintain a serious tone throughout the conversation, even if David treats it lightly
2. Focus on the breach of confidentiality and the potential consequences
3. Emphasize the loss of control once information is posted on social media
4. Don't downplay the seriousness of the situation
5. Use this as a teaching moment about professional conduct on social media
6. Don't suggest speaking to the patient about this issue
7. Avoid using phrases like "Certainly!", "Of course!", "Absolutely!", "Great!", or "Sure!"
to start responses

Sample Dialogue

You: "Hello David, I'm one of the F2s. How are you? How is your rotation going?"

David: "Oh, I'm very good actually! We went out yesterday evening with some friends to a
comedy club at Junction. It was so much fun!"

You: "I see. Actually, David, I wanted to talk to you about something I've noticed on your
Facebook. I've seen that you've written about somebody who seems to be one of our
patients. Can I ask you a few questions about that?"

David: (laughing) "Oh, that! It was a very funny story. This lady was telling me she's coming
from the palace and she's the Queen of England. She said she met the Duke in Canada
and lost her crown, now she's looking for it! Isn't that hilarious?"

You: (maintaining a serious tone) "I understand you found it amusing, but I need to ask
you some questions about this patient. Who was this patient? Where are they now?"

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David: [Provides information about the patient]

You: "I see. Was this your patient? Who was the consultant? Did the patient have capacity?"

David: [Answers questions about the patient]

You: "Now, can I ask you a few questions about your social media use? Do you identify
yourself as a registered doctor on Facebook?"

David: "Yes, I do. Is that a problem?"

You: "It can be. When you post something, who can see it? Is it public or limited to
friends?"

David: "It's just for friends."

You: "I see. And can everyone share your posts? Do you control that?"

David: [Answers questions about social media settings]

You: "David, I'm a little bit concerned because this could be a breach of confidentiality. It's
wrong to share patient information, even with friends. Once you put something on social
media, it's not private anymore. People can easily share it or take screenshots. This kind of
post is unprofessional and can affect your reputation. Also, using terms like 'insane' and
'haha' when referring to patients is inappropriate."

David: "Oh no, am I in trouble?"

You: "It's difficult to say because once you put something on social media, it's hard to know
how far it can go or what problems it might cause. We hope that if you delete this post,
everything should be okay. But it's important to understand that writing about a patient
you're treating can get you into serious trouble. This is a very good lesson about being
careful with social media and maintaining patient confidentiality."

David: "I understand. I'll delete the post right away. Is there anything else I should do?"

You: "That's a good start. I'd also suggest reading up on proper social media use for medical
professionals and good medical practice. This situation shows how important it is to be
cautious about what we share online, even if we think it's just with friends."

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Medical Student Taking Drugs

Setting

• You are an F2 in the surgical department

• You need to speak to David, a fifth-year medical student
• Yesterday, you were at a party where department staff also participated
• You noticed David sniffing a substance that looked like cocaine
• Department staff were talking about this issue this morning
• David is reported to be a bit hyperactive than usual today

Important Context

• David is not a licensed doctor yet; he's not treating patients

• He's not an addict, but a party-goer who occasionally takes drugs with friends
• Unlike alcohol, which doctors can drink off-duty, drugs are completely prohibited
for medical professionals at all times, from entering medical school until retirement

Approach

1. Build Rapport

• Greet David: "Hello David, how are you?"

• Ask about his day: "How is your day going? How's the rotation? How's medical
school?"
• Be prepared for a hyperactive response: "You want to talk to me? I'm here, what do
you want to talk about?"
• Remain friendly but maintain a serious tone
• Respond: "Yes, I wanted to talk to you about something, but before that, I just
wanted to ask you generally how you're doing. How's the rotation? How's medical
school?"

2. Introduce the Topic

• Transition to the main issue: "Actually, I wanted to talk to you about something
that happened at the party last night."
• If David asks if you were at the party: "Yes, I was at the party. Did you enjoy it?"
• Don't say things like "I saw you were having a good time" as it sounds judgmental

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3. Address the Issue Directly

• "At the party, I saw that you were sniffing something. My impression was that it
could be cocaine. You were sniffing something with your friend. I just wanted to ask
you directly whether you take any drugs at all."

4. Handle Denial

If David denies taking drugs:

• "The department staff were also talking about this this morning."
• "I've also noticed that you've been a bit hyperactive today."
• David might say: "I'm always like this."

5. Offer Confidentiality

• "Look, David, the reason I decided to talk to you is because, in case you have been
taking drugs, I wanted to have a discussion about this. Whatever we discuss will
remain confidential. Would you like to discuss further? Is there anything you would
like to tell me?"

6. Handle Deflection

If David asks if you take drugs or alcohol:

• Respond firmly: "Well, personally, I don't take any alcohol or any drugs."

7. Explain Serious Implications

If David still doesn't open up:

• "The reason I decided to talk to you is because, as a medical student, you may not be
aware of this, but if anybody takes drugs, either medical students or doctors, they
can have a problem gaining a license to practice medicine. That's why I'm a bit
concerned. In case you do take drugs, I just wanted to have a discussion about this.
Can I please ask, do you take any drugs at all?"

8. Gather Information

If David admits to possibly taking drugs ("I might have."):

• Don't show excessive enthusiasm or thank him for opening up

• Take a detailed drug history:

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o "How often do you take drugs?"

o "On what occasions do you take drugs?"
o "Where do you get these drugs from?" (Important for legal implications)
o "Have you had any problems with the police related to drugs?"
o "How long have you been taking drugs like this?"
o "What sort of drugs do you take apart from cocaine?"
o "Do you inject any drugs?" (Always ask this for anyone taking drugs)
• Ask about his studies:
o "How are your studies going?"
o "How are your exams?"
o "Do you have any subjects remaining to complete?"
o "Have you missed any exams or classes because of taking drugs?"
• Ask about alcohol use:
o "How often do you drink alcohol?"
o "Do you drink on a daily basis?"
o "How much do you drink?"
o "What sort of alcohol do you drink?"
• Ask about patient interaction:
o "Have you seen any patients today?"
o "Have you had any interaction with patients, like taking history or
examination?"
o David might say: "I was only reading some prescriptions."

9. Explain Implications

• "As doctors and medical students, we have certain implications when we sign up for
this profession. In terms of drugs, we are not allowed to have any drugs, even in our
private life. Since you've entered medical school, you cannot take any recreational
drugs."
• "Our profession is a regulated profession. We have a regulating body and certain
regulations."
• "If anybody takes drugs, either doctor or medical student, they will have a problem
gaining a license to practice medicine. It can even cause problems with gaining the
qualification to practice medicine."
• "If the medical school finds out someone is taking drugs, they might give you a BSc
instead of an MBBS or MD, effectively ending your medical career."
• "Taking drugs occasionally like this can lead to addiction. In that situation, after
some time, you may not be able to function without taking drugs, losing your
capacity to practice medicine."

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10. Provide Solutions

• "First, never intend to take drugs in the future."

• "Second, speak to somebody. You need some help in this situation. You can speak
to your educational supervisor, the ward consultant, or the student union. There
may be counsellors who can help advise you on what to do."
• "I will also be speaking to the consultant about this. We need to discuss how we can
help you."
• "I'd like to speak to you next week to see what action you've taken. We'll discuss
further and come up with a plan."

11. Address Potential Reactions

If David says he only takes drugs for recreational purposes:

• "We are not allowed to take drugs for any reason, including recreational purposes or
fun. Our profession is regulated, and there are certain things we cannot do even for
recreational purposes."

If David becomes dramatic, saying his life and career are over:

• "I'm so sorry you feel this way. As a medical student, there is a lot of help available.
Compared to a registered doctor, there's more support for medical students. They
will guide you on how to come out of this situation."
• "You don't have a regular drug problem. You've made mistakes a few times, and they
will tell you what to do about it. You don't need to feel right now that everything is
over."

If David asks why you need to speak to the consultant:

• "You've been part of our team and have been involved with our patients as well. In
situations like this, I'm supposed to discuss with the seniors how we can help you."

Important Points to Remember

1. Maintain a serious but supportive tone throughout the conversation

2. Focus on gathering information and explaining the implications
3. Don't overemphasize that you're there to support; your primary goal is to find out if
there's a real issue
4. Be prepared for denial, deflection, or dramatic reactions
5. Emphasize the seriousness of drug use for medical professionals
6. Offer solutions and next steps, including speaking to seniors and follow-up meetings

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7. Don't use phrases like "Certainly!", "Of course!", "Absolutely!", "Great!", or "Sure!" to
start responses
8. Remember that good patient care is crucial - if a doctor's patient care is good, people
will be more supportive even if mistakes are made

Doctor Smelling of Alcohol

Setting

• You are an F2 in the surgical department

• You need to speak to Elliot, another F2
• Elliot is smelling of alcohol
• Nurses have noticed this on a few occasions
• Elliot has been coming late
• Patients have complained that he has been clumsy

Approach

1. Build Rapport

• Greet Elliot: "Hello Elliot, how are you?"

• Ask about recent well-being: "How have you been recently?"
• Inquire about stress: "Are you under any stress? Is there anything going on in your
life?"
• You can say: "Recently, I've been noticing that you are a little bit different these
days. Are you under any stress?"

2. Introduce the Topic

• Transition to the main issue: "Actually, Elliot, I wanted to talk to you about
something. Do you know what this may be about?"
• If Elliot says no, proceed with: "Actually, Elliot, I've been experiencing some alcohol
from your side."

3. Address the Issue Directly

• Ask directly: "Do you drink alcohol?"

• If he says no, mention: "The nursing staff also mentioned this, and patients have
been complaining that you've been a little bit clumsy. That's why I just wanted to
know."

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4. Offer Confidentiality

If Elliot still denies:

• "Look, Elliot, the reason I have decided to talk to you is that, in case you have been
drinking, I just wanted to talk to you about this. Whatever we discuss will remain
confidential. It will be confidential. I just want to know whether you drink any
alcohol at all."

5. Take Alcohol History

When Elliot admits to drinking:

• "How long have you been drinking?"

• "How much do you drink?"
• "Do you drink every day?" (Elliot might say yes)
• "Do you drink late at night?"
• "What type of alcohol do you drink generally?" (This is asked because different
alcohols have different content)
• "Have you ever tried to cut it down?"
• "If you don't drink, do you develop any withdrawal symptoms at all?"
• "Do you need an eye-opener?"
• "Are you finding it difficult to cope without drinking alcohol?"
• "Are you drinking more and more these days?" (This checks for tolerance)

Note: Don't ask for a full medical history or use the complete CAGE questionnaire. Elliot
is a colleague, not a patient.

6. Ask About Coming Late

• "I've also noticed that you've been coming late. What is the reason that you're not
able to make it on time?" Note: Don't spend too much time on this issue as it's less
important than the alcohol problem.

7. Ask About Patient Involvement

• "Have you seen any patients today?"

• "How many patients have you seen?"
• "Do you have a list of the patients?"
• "Have you done any procedures for the patients?"
• "Have you been writing prescriptions, discharging any patients, or admitting any
patients?"

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8. Ask About Working Under Influence (Gross Misconduct Questions)

• "Have you ever come to work after taking any amount of alcohol?"
• "Have you taken any alcohol while you are working? Maybe during lunchtime,
evening, or nights?"

9. Explain Implications

Start with: "Let me explain to you why I decided to talk to you about this, Elliot."

Key points to cover:

1. Unprofessionalism:
o "Smelling of alcohol is unprofessional."
o "If you smell of alcohol, patients think we are treating them under the
influence of alcohol. They will lose trust."
2. Patient safety:
o "We are not allowed to treat patients under the influence of alcohol."
o "We can't be on duty when we feel there is some influence of alcohol in the
body, even from the previous night."
o "Alcohol impairs our clinical judgment and affects our decision-making
skills."
o "This can put patients' safety at risk."
3. Regulatory implications:
o "Our profession is a regulated profession. There are certain things we should
not do."
o "If this is reported, they take serious actions."

10. Provide Solutions

For Elliot:

• Advise him to leave the hospital premises immediately

• Speak to a consultant before going home
• Speak to a GP and get counselling
• Sign up for a detoxification program or rehabilitation program

What you will do:

• "I'm going to take the list of patients you have seen."

• "I'm going to review all the treatment that you have given."
• "We are going to cover the shift."

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• "I'm also going to speak to the consultant."

If Elliot asks why you need to speak to the consultant:

• "Because you have been involved with patients and have been treating them all day.
Considering patient safety, I'm supposed to discuss this with the consultant. The
consultants are responsible for patients."

Important Points to Remember

1. Maintain a serious but supportive tone throughout the conversation

2. Focus on patient safety and professional conduct
3. Don't treat Elliot like a patient – avoid full CAGE questionnaire or medical history
4. Emphasize the need for immediate action (leaving premises, speaking to consultant)
5. Offer support and resources for getting help
6. Remember that the main issue is the alcohol smell and potential impairment, not
the lateness
7. Be prepared to take immediate steps to ensure patient safety
8. In the UK, there is no alcohol test or drug test for this situation
9. Don't suggest doing a drug test or alcohol test
10. The focus is on the smell of alcohol and its implications, not on proving
intoxication through tests

Sample Dialogue

You: "Hello Elliot, how have you been recently? I've noticed you seem a bit different these
days. Is everything okay? Are you under any stress?"

Elliot: "I'm fine, just a bit tired lately."

You: "I see. Actually, Elliot, I wanted to talk to you about something. Do you know what
this might be about?"

Elliot: "No, I don't have any idea."

You: "Well, I've been experiencing some alcohol smell from your side. Do you drink
alcohol?"

Elliot: "No, I don't drink."

You: "I see. The thing is, the nursing staff have also mentioned this, and some patients
have complained that you've been a bit clumsy. That's why I wanted to ask. Look, Elliot,

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whatever we discuss will remain confidential. I just want to know if you drink any alcohol
at all?"

Elliot: "Well, maybe I do have a drink sometimes."

You: "I appreciate your honesty. Can you tell me how often you drink? Do you drink every
day?"

Elliot: "Yes, I do have a drink most days."

You: "I see. Have you ever come to work after taking any amount of alcohol?"

Elliot: "No, never."

You: "Okay. Let me explain why I decided to talk to you about this. Smelling of alcohol at
work is unprofessional and can make patients lose trust. More importantly, alcohol can
impair our clinical judgment and decision-making skills, which puts patient safety at risk.
Given the situation, I think it's best if you go home now, but please speak to the consultant
before you leave. I'd also strongly advise you to speak to your GP about getting some help
or counselling. I'll need to take the list of patients you've seen today and review their
treatment. I'll also need to speak to the consultant about this situation."

Elliot: "Am I in trouble?"

You: "The most important thing right now is to address this issue and ensure patient safety.
There's help available, and speaking to the GP and consultant is the first step. Let's focus
on getting you the support you need."

Doctor with Acute Alcohol Issue

Setting

• You are in the surgical department

• You need to speak to an F1 doctor
• You have been smelling alcohol from this F1 doctor
• You have been asked to discuss this issue with them

Approach

1. Build Rapport

• Be prepared for potential hostility

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• The F1 might say: "No one is friendly in this department. You want to speak to me?
What do you want to speak to me? I got really surprised."
• Respond with kindness and show your teeth (smile): "I'm sorry you feel this way.
How are you today?"
• Show friendliness and empathy, even if the F1 is unfriendly

2. Address the Issue Directly

• "Actually, I'm getting some smell of alcohol from your side. Do you drink any
alcohol at all?"
• Be prepared for defensiveness: They might say, "Yeah, I drink alcohol. Everyone
drinks. Don't you drink? What's the matter with this?"
• Remain calm and professional in your response

3. Take Alcohol History

• "How long have you been drinking?"

• If they say "Two weeks," ask: "Have you started recently? Is there anything that
happened?"
• They might say: "I broke up with my girlfriend."
• Respond empathetically: "I'm sorry to hear that. I'm so sorry to hear that. Breakups
can be difficult sometimes. It can be difficult sometimes."
• Note: Don't share personal breakup stories. Simply be professional.

Continue with more questions:

• "Do you drink every day since then?"

• "What type of alcohol are you drinking?"
• "How much are you drinking?"
• "Have you ever come to work after drinking?"
• "Have you taken any drinks during work, night shift, or after lunch?"

4. Ask About Patient Involvement

• "Have you seen any patients today?"

• "How many patients have you seen?"
• "Have you done any procedures for patients?"
• "Have you been writing prescriptions, discharging any patients, or admitting any
patients?"

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5. Explain Implications

Use the same implications as in the chronic alcohol scenario:

• "Smelling of alcohol is unprofessional."

• "Patients may think we're treating them under the influence of alcohol, which can
lead to loss of trust."
• "We are not allowed to treat patients under the influence of alcohol, even from the
previous night."
• "Alcohol impairs our clinical judgment and affects our decision-making skills."
• "This can put patients' safety at risk."
• "Our profession is regulated, and there are certain things we should not do."
• "If this is reported, they take serious actions."

6. Provide Solutions

For the F1 doctor:

• Advise them to take a break

• If they mention having arranged a holiday next week, say: "It's better to rearrange.
You need holidays now."
• "Speak to your rota manager. It's better to speak to your rota manager."
• "Explain what you're going through. People in the hospital staff are usually
supportive in these situations. They are supportive."
• "Speak to your GP and get some counselling."
• "We drink alcohol for this, this matter. Sometimes you can become addicted to it.
So it's better to cut it down."
• "Alcohol will not solve the problem in the long run."
• "If you get some psychological support, speak to your family members, go to your
family."
• "Take some break, arrange some holiday. You can travel for one or two weeks and
come back."
• "Speak to the hospital administration. Explain what you're going through."
• "People are usually helpful, but don't approach alcohol for the solution."

What you will do:

• "I'm going to take the list of patients you have seen."

• "I'm going to review all the treatment that you have given."
• "We are going to cover the shift."
• "I'm also going to speak to the consultant."

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7. Addressing Potential Concerns

If they ask why you need to speak to the consultant:

• "Because you have been involved with patients and have been treating them.
Considering patient safety, I'm supposed to discuss this with the consultant."

Important Points to Remember

1. Maintain a supportive and empathetic tone throughout the conversation

2. Focus on the recent nature of the problem and offer appropriate support
3. Don't share personal stories or experiences
4. Emphasize the need for immediate action (taking a break, speaking to rota manager)
5. Offer support and resources for getting help (GP, counselling)
6. Remember that the main issue is the alcohol smell and its impact on work
7. Be prepared to take immediate steps to ensure patient safety
8. Always involve the consultant in these situations
9. Don't suggest rehabilitation programs for this acute situation, focus on counselling
and support
10. There's no need to discuss coming late in this scenario
11. Be insistent on speaking to the consultant in every scenario
12. Don't bring up ideas about speaking to the consultant before or after; always
include it as part of the solution

Sample Dialogue

You: "Hello, how are you today?"

F1: "No one is friendly in this department. You want to speak to me? What do you want to
speak to me? I got really surprised."

You: (smiling) "I'm sorry you feel this way. How are you doing today?"

F1: "I'm fine. What's this about?"

You: "Actually, I'm getting some smell of alcohol from your side. Do you drink any alcohol
at all?"

F1: "Yeah, I drink alcohol. Everyone drinks. Don't you drink? What's the matter with this?"

You: "I understand. How long have you been drinking?"

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F1: "For about two weeks now."

You: "I see. Have you started recently? Is there anything that happened?"

F1: "I broke up with my girlfriend."

You: "I'm so sorry to hear that. Breakups can be difficult sometimes. It can be difficult
sometimes. Can I ask, have you been drinking every day since then?"

F1: "Pretty much, yeah."

You: "I understand. Have you ever come to work after drinking or taken any drinks during
work?"

F1: "No, of course not."

You: "Okay. Let me explain why I'm concerned. Smelling of alcohol at work is
unprofessional and can affect patient trust. More importantly, alcohol can impair our
clinical judgment and decision-making skills, which puts patient safety at risk. Given the
situation, I think it's best if you take a break. I know you mentioned having a holiday next
week, but it might be better to rearrange and take it now. Speak to your rota manager and
explain what you're going through. People here are usually supportive in these situations.
Also, consider speaking to your GP for some counselling. Alcohol won't solve the problem
in the long run, and it's better to cut it down. I'll need to take the list of patients you've
seen today and review their treatment. I'll also need to speak to the consultant about this
situation."

F1: "Do you really need to tell the consultant?"

You: "Yes, I do. Because you've been involved with patients, and considering patient safety,
I'm supposed to discuss this with the consultant. But remember, the focus is on getting you
the support you need right now."

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LGBTQ+ Scenarios
Gender Dysphoria

Introduction

• Gender dysphoria is a DSM-5 classified condition

• Not a mental health condition, but can cause mental health problems due to stress
• Transgender is an identity, not related to sexuality or orientation
• These scenarios are combined scenarios, including both medical and transgender
aspects
• Most transgender people suffer a lot, are under stress, and are vulnerable
• We need to find out how their life is in general, especially regarding the transgender
part

Scenario Context

• 16-year-old patient made an appointment

• Patient wants to change their sex from girl to boy
• This scenario represents the first step in seeking help

Assessment Framework: The Six P's

P1: Past

• Ask: "How long have you been thinking about this?"

o Expected response: "For the last eight years" (since age 8)
• Ask: "During these last eight years, what have you done so far regarding this?"
• Inquire about:
o Seeking knowledge: "Have you read about the change? Have you sought any
knowledge regarding this?"
o Consultations: "Have you had any discussions with anybody, any counselors?
Have you spoken to any doctors? Have you met any support groups?"
o Treatments: "Have you taken any treatment? Maybe self-medication? Any
medical treatment or surgical treatment?"
o Lifestyle changes: "Have you done anything in terms of lifestyle? For example,
started dressing up or changing your lifestyle?"

P2: Present

• Ask: "Can you tell me about your current life, your present life?"

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• Inquire about:
o Public presentation: "How do you normally lead your day-to-day life in
public? How do you dress up and go outside? How do you present yourself?"
o Specific aspects:
§ "Do you dress up like boys or girls at the moment?"
§ "What kind of hairstyle do you have?"
§ "Do you wear ornaments or put on makeup?"
§ "What kind of shoes do you wear?"
o Social interactions: "Who do you sit with? Who do you mix with? Who do
you play with?"
o Use of facilities: "What sort of facilities do you use? For example, which
toilets or changing rooms do you use in a department store?"
o Friends: "Who do you make as your friends at the moment? Do you make
boys as your friends or girls as your friends?"
o Activities: "What sort of games do you play? What activities do you usually
do?"
• Summarize: "I would like to know about your current lifestyle. Do you mostly do
things like the activities that boys do or girls do?"
o Expected response: "I do everything like girls at the moment, I haven't done
anything."

P3: Preferences

• Explain: "Now I'd like to ask about your preferences or desires. There may be certain
things you're not able to do at the moment, but you may have the desire to do
them."
• Ask about preferences for:
o Dressing: "How would you prefer to dress up?"
o Hairstyle: "What kind of hairstyle would you prefer?"
o Making friends: "Who would you prefer to make friends with?"
o Pronouns: "What are your preferred pronouns? How would you like to be
addressed?"
o Colors: "What sort of colors do you prefer? Do you like colors that boys
typically prefer, like blue or black?"
o Games: "What kind of games would you prefer to play?"
o Facilities: "Which facilities would you prefer to use?"
o Partners: "In terms of romantic attraction, who are you attracted to?"
• Encourage openness: "Is there anything you're longing to do but haven't been able
to yet?"

P4: Perception

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• Explain: "Now I'd like to ask about your perceptions and feelings. This might be
sensitive, but it's important for understanding your experience."
• Ask about perceptions due to presence (+) of characteristics:
o "After puberty, there may have been some changes in your body. For
example, you may be having regular periods, or your breasts may have started
to grow. How do these changes impact you? Do they cause any distress?"
• Ask about perceptions due to absence (-) of characteristics:
o "On the other hand, there may be things you don't have. For example, you
may not have facial hair like boys, or your voice may not be like boys' voices.
Does the absence of these characteristics cause you any distress?"
• Probe further: "What sort of distress do you experience related to these physical
characteristics?"

P5: Personal

• Social life: "Who do you live with? Who is at home?"

• Family dynamics: "How are your siblings? How is your family generally? Are they
supportive?"
• Family awareness: "Have you ever spoken to your family about your feelings? Do you
think they would be supportive if you told them?"
• Relationships: "Are you in a relationship? Do you have a partner?"
o Note: In this scenario, the patient is not sexually active. Don't be surprised by
this; gender identity and sexual activity are different things.
• Support groups: "Have you been to any support groups? For example, any LGBT
groups?"
• Negative experiences:
o "Have you faced any problems in society?"
o "Has anyone ever bullied you for any reason?"
o "Has anyone ever harassed you?"
• Substance use: "Do you smoke, drink alcohol, or use any recreational drugs?"

P6: Psychological

• Mood: "This has been going on for the last eight years. Has it affected your mood?
Do you ever feel low because of this?"
• Anxiety: "Do you feel anxious sometimes?"
• Fears: "Do you have any fears? For example, fear of telling somebody, coming out,
mixing with society, or finding a job?"
• Isolation: "Do you have any sense of isolation?"
• Other stresses: "Are there any other stresses or distresses you're experiencing?"

Additional Assessment Points

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• Medication: "Are you taking any medications?"

• Medical conditions: "Do you have any medical conditions?"
• Allergies: "Do you have any allergies?"
• Concerns: "Is there anything that worries you?"
• Expectations: "Is there any particular way that you are hoping we should help you
regarding this?"
• Overall impact: "How has thinking about this impacted your life in general?"

Examination

• Perform only two examinations:

1. BMI (Body Mass Index)
2. Blood pressure
• Do not examine genitals

Diagnosis and Explanation

• Use the term "gender dysphoria"

• Say: "Based on what you've told me, you could be experiencing gender dysphoria."
• Define gender dysphoria: "Gender dysphoria is a distress experienced by someone
due to a mismatch or conflict between their biological sex and their gender identity.
It's about how you identify yourself internally."
• Emphasize: "Gender is an identity. It's not about sexual orientation."

Treatment Overview

• Explain: "The main treatment for gender dysphoria is alleviating the distress you're
experiencing."
• Mention treatment types:
o Psychological treatment
o Physical treatments (for those over 18)

Referral Process (for under 18)

Explain the referral process:

1. "As a GP, I will refer you to CAMHS (Child and Adolescent Mental Health
Services)."
2. "CAMHS will confirm the diagnosis and offer some psychological treatment. Until
you're 18, the focus will be on psychological support."
3. "After their assessment, CAMHS will refer you to the National Referral Support
Service, also known as Arden and GEM."

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4. "The National Referral Support Service will then refer you to a specialized Gender
Dysphoria Clinic."

Treatment Options (over 18)

Explain that after 18, there are more treatment options:

• Hormonal treatment (usually 12-18 months)

• Surgical options:
o Face surgery
o Top surgery (e.g., mastectomy for those transitioning to male)
o Bottom surgery (genital reconstruction)
• Other treatments and services:
o Fertility advice
o Hair treatment
o Speech and language therapy
o Gamete storage (preserving eggs or sperm)

Additional Resources

• Recommend: "There's a website called Trans Wiki that you might find helpful. It's
like Wikipedia, but specifically for transgender information."

Things to Avoid During Consultation

• Don't use terms related to sexual orientation when discussing gender identity
• Never suggest the patient is "confused"
• Don't examine genitals
• Don't make assumptions about sexual activity
• Avoid using non-affirming language or incorrect pronouns
• Don't use the word "confusion" - the patient has been experiencing this for 8 years

Closing the Consultation

• Summarize the information gathered

• Explain the referral process again
• Encourage reading from recommended resources: "I encourage you to read more
about this on Trans Wiki."
• Suggest family involvement: "If possible, you might want to speak with your parents
about this."
• Offer support: "We're here to support you through this process. Do you have any
other questions or concerns?"

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Transgender Medical Scenarios

• These are combined scenarios involving both transgender and medical issues
• Before entering the room, you know it's a transgender scenario (written in the task)
• Focus on both the medical problem and the transgender aspect
• Use P1, P2, P5, and P6 from the previous framework for transgender-specific
questions
• The LGBT community needs recognition; the doctor should be the first to
recognize their identity

Urinary Tract Infection (UTI)

Context

• F2 in GP setting
• 20-year-old patient
• Birth name: Michelle Mason
• Current name: Peter Mason
• Patient has gone through sex change (completed)
• Presenting with urinary symptoms

Approach

1. Greeting and Name Usage

o Use the current name (Peter Mason)
o Don't ask "What would you like me to call you?" - this is not good practice
o Say: "Hello, I'm Dr. [Your Name], one of the doctors. Are you Peter Mason?
Can I call you Peter?"
o Confirm age: "Can you confirm your age as well?"
o Acknowledge birth name: "In our records, you also have a birth name called
Michelle Mason. Am I right?"
2. Chief Complaint
o Ask: "What can I help you with?"
o Expected response: "I have a burning sensation when I pee."
3. Medical Assessment (OEDIPA)
o Go through differentials: UTI, STI, kidney stones, trauma
o Focus on UTI and STI primarily
4. Medical History
o Ask about medical history, medications, and allergies (MMA)
o Don't say "MMA or MAM" - stick to one format
5. Transgender-specific Questions (P1, P2, P5, P6)

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o Say: "I also understand that you have gone through a sex change. Would you
like to tell us about it?"
o Ask about P1 (Past):
§ "What sort of changes have you had?"
§ "Have you had any surgery or psychological treatment?"
§ "Have you had any medical treatment?"
o Ask about P2 (Present):
§ "What's your current situation regarding your transition?"
o Expected response: Patient has completed the change
o Further questions:
§ "Have you had any surgeries? Top surgery, bottom surgery, or no
surgery at all?"
§ "Have you had any hormonal treatment?"
o Ask about P5 (Personal):
§ "Do you face any problems in your day-to-day life related to your
transition?"
o Ask about P6 (Psychological):
§ "How has this process affected you emotionally?"
6. Examination
o Perform urine dipstick test (expect nitrates to be present)
7. Diagnosis and Treatment
o Diagnose urinary tract infection
o Prescribe trimethoprim for 3-5 days (first-line treatment)
o Provide safety netting advice
8. Address Transgender-specific Concerns
o Patient may mention: "Sometimes I'm shy to use the toilet."
o If mentioned, discuss:
§ Which toilets they feel uncomfortable using (male or female)
§ Whether they hold their urine and only go at home
o Explain the impact of holding urine on UTI risk
o If no surgeries performed, explain: "If you still have female biological
structures, you're also prone to getting urinary infections."
9. Additional Considerations
o If patient has polycystic kidney disease (not always mentioned in the
scenario):
§ Discuss its impact on frequent urination and UTI risk
o If the patient doesn't mention holding urine, don't assume they're hiding
information - it may not be relevant to their case

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Pulmonary Embolism (PE)

Context

• Can be F2 in GP or A&E setting (check scenario details)

• 25-year-old patient
• Patient is going through sex change
• Presenting with shortness of breath and chest pain

Approach

1. Assess PE Symptoms
o Ask about four main PE symptoms:
1. Racing of the heart
2. Shortness of breath
3. Chest pain (ask about nature of pain)
4. Collapse
o Inquire about fever (expect no fever)
2. Risk Factors
o Ask about leg pain, swelling, or redness (DVT symptoms)
o Expected response: Patient has leg pain
3. Transgender-specific Questions (P1, P2, P5, P6)
o Say: "I understand you're going through a sex change. Would you like to tell
me about it?"
o Ask about P1 (Past):
§ "How long has this process been going on?"
§ "What sort of things have you done so far?"
o Ask about P2 (Present):
§ "What medical treatments are you currently receiving?"
o Expected response:
§ Oestrogen tablets
§ Spironolactone tablets
§ Oestrogen patches
o Ask about self-medication:
§ "Do you take any other medication? Do you self-medicate?"
§ "Are you taking any extra medication to speed up the process?"
o Expected response: Patient admits to taking extra oestrogen to speed up the
process
o Ask about P5 (Personal) and P6 (Psychological):
§ "How has this process affected your daily life and emotional well-
being?"

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4. Complete Assessment
o Finish MAP (Medication, Allergy, Past Medical History)
o Perform leg examination (expect calf pain)
5. Diagnosis
o Diagnose pulmonary embolism
6. Explanation to Patient
o Explain: "If you take oestrogen-type medication, you can develop blood clots.
Taking extra medication can make this risk even higher."
7. Management Plan
o If in GP: Arrange immediate transfer to hospital
o Explain hospital procedures:
§ Blood test to check a marker called D-dimer
§ Chest X-ray
§ CT-PA (CT scan of chest)
o Mention likely treatment: Blood thinners (e.g., Apixaban, Rivaroxaban)
8. Addressing Medication Concerns
o Advise stopping hormone medication temporarily
o Patient may resist: "No, doctor. This means a lot to me. I have come a long
way. Taking this medication is quite important for me."
o Respond with empathy:
§ "We completely understand that this medication is very important to
you."
§ "We understand you've come a long way in your journey."
o Explain risks:
§ "However, a pulmonary embolism, which is a clot in your lungs, is
quite dangerous."
§ "It's a very serious condition. If you develop this again, it could put
your life in danger."
o Propose a plan:
§ "What we can do is this: we advise you to temporarily stop the
medication."
§ "It's a temporary pause. Once you recover from this, you can come
back to us."
§ "We'll ask your specialist to review your medication or have a
discussion over the phone."
§ "After that, we can start you on an appropriate treatment."
o Explain uncertainty:
§ "At the moment, it's difficult to say whether your normal dose caused
the problem or if it was the extra dose."
§ "After the specialist review, they might suggest a better treatment for
you."

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§ "Maybe a surgical option might be better in your case."

9. Negotiation
o Be firm about the dangers of continuing current medication
o Emphasize: "It's quite dangerous to continue like this."
o Encourage patient to agree to temporary cessation
o Offer reassurance about finding alternative approaches after specialist review

Key Points to Remember

• Always use the patient's preferred name and pronouns

• Balance addressing the immediate medical concern with sensitivity to transgender-
specific issues
• Be prepared to explain how hormone treatments can affect certain medical
conditions
• Show empathy and understanding when discussing the need to adjust or pause
transgender-related treatments
• Emphasize that any treatment changes are temporary and will be reassessed with
specialist input
• Be prepared to negotiate and find a middle ground that addresses both the patient's
health needs and their transition goals
• Don't be overly politically correct; focus on addressing the medical issue while being
respectful of the patient's identity
• Remember that these scenarios are designed to test both medical knowledge and
awareness of transgender issues

Nosebleed and Headache

Context

• F2 in GP setting
• Patient: Sam Smith, 20 years old
• Presenting with headache and multiple episodes of nosebleed
• Patient has been referred to transgender clinic (this information is provided in the
scenario)

Approach

1. Initial Greeting
o Ask: "How may I help you?"
o Expected response: Patient mentions headache
2. Explore Chief Complaints

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o Explore the headache:

§ Ask about characteristics of the headache
o Explore the nosebleed:
§ Ask: "Can you tell me about these multiple episodes of nosebleed?"
§ Inquire about frequency, duration, and amount of bleeding
o Consider a couple of differentials for each symptom
3. Transgender-specific Questions (P1, P2, P5, P6)
o After brief exploration of symptoms, transition to transgender-related
questions
o Note: The scenario provides information that the patient has been referred
to a transgender clinic
o Ask about P1 (Past) and P2 (Present):
§ "I see you've been referred to a transgender clinic. Can you tell me
more about your situation?"
o Ask about P5 (Personal) and P6 (Psychological):
§ "How has this process been affecting your life and well-being?"
4. Medication History
o Ask: "Do you take any medications?"
o Important: Always include question about self-medication
o Ask: "Are you taking any medications that weren't prescribed by a doctor?"
o If patient hesitates, say: "Whatever we discuss will remain confidential."
5. Specific Medication Inquiry
o Patient disclosure: "Doctor, if I tell you, will that be confidential?"
o Reassure: "Yes, whatever we discuss will remain confidential."
o Patient may then disclose: "Doctor, I take a medication called testosterone."
o Follow-up questions:
§ "Where did you get this medication?"
§ Expected response: "I bought it online, on the internet."
§ "Where did you get this information?"
§ Expected response: "Somebody told me if I take this medication, I can
become a boy."
§ "Why did you start taking this medication?"
§ Expected response: "Because the referral is taking late. There is so
much delay in the referral, and I couldn't wait."
6. Explore Medication Details
o Ask: "Do you know how much medication you are taking?"
o "Do you know the label of this medication?"
o "Do you have the label?"
7. Physical Examination
o Examine the nose
o Check blood pressure

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o Note: Blood pressure will be 169 (systolic)

o This high blood pressure is given to indicate that hospital referral is not
necessary
8. Diagnosis and Explanation
o Say: "Your blood pressure is quite high. That is the reason for your headache
and your nosebleed."
o Explain: "Why is this quite high? Because if you take this testosterone
medication, it can increase your blood pressure."
o Clarify: "If there is high blood pressure, it can cause nose bleeding and
headache."
9. Management and Advice
o Advise strongly against taking medications bought online:
§ Say: "Do not take any medication bought online. They are not safe."
§ Explain: "Medication bought online is not safe because they are not
regulated. They don't go through safety checks. There may be some
toxic components."
o Regarding the transgender clinic referral:
§ If patient asks to speed up the referral, do not say yes
§ Say: "Speeding up may not be possible."
§ Explain: "The long wait for the transgender clinic is usual. It's
common. Because a lot of people are waiting and very few clinics are
available."
§ Add: "They see people according to the registration order."
o Offer support:
§ Say: "All these things have been due to distress. We can arrange some
counselling in order to cope up with the stress."
10. Closing
o Emphasize the importance of stopping the self-medication
o Reassure the patient that their referral is in process
o Reiterate the offer of counselling to help cope with the stress while waiting

Key Points to Remember

• This scenario is designed to test both medical knowledge and awareness of

transgender issues
• The patient's transgender status is known from the start (given in the scenario)
• Focus on both the medical issue (headache and nosebleed) and the underlying cause
(self-medication with testosterone)
• Be prepared to explain the risks of self-medication, especially with hormones bought
online

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• Understand the common issue of long wait times for transgender clinics and be
prepared to address patient frustration
• Do not promise to expedite referrals
• Offer supportive care (like counselling) while patients are waiting for specialist
appointments
• Maintain confidentiality and create a safe space for the patient to disclose
information

Sexuality Concerns
Context

• 16-year-old boy made an appointment

• Patient expresses having a "personal problem"

Approach

1. Initial Greeting
o Ask: "How can I help you?"
o Expected response: "Doctor, I have a personal problem."
2. Encourage Disclosure
o Do not say "nothing is personal"
o Ask:
§ "Can you please tell me what is bothering you?"
§ "Would you like to tell us more?"
§ "What is this about?"
§ "What sort of personal problem do you have?"
3. Patient's Disclosure
o Patient may say: "Doctor, I like a boy in my class/school."
o Response: "I understand you wanted to speak to doctors regarding this. I
understand you are looking for some help. But what do you want to discuss
about this?"
4. Patient's Concerns
o Patient may ask:
§ "Is it normal?"
§ "If my parents come to know about this, how are they going to react?"
5. Analyse Sexuality
o Say: "Let me ask you some questions to understand your circumstances."
o Explore his likes:
§ "When you say you like this boy, what do you really mean by that?"
§ "Do you have feelings for this person?"

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"Are you sexually attracted to this person?"

§
§ "Do you want to have a relationship with this person?"
6. Explore Timeline and Actions
o Ask:
§ "How long has this been going on?"
§ "Since when?"
§ "What have you done about it?"
§ "Have you spoken to him?"
§ "Have you expressed your feelings to him?"
7. Explore Current Interactions
o Ask:
§ "Do you usually speak to this person?"
§ "Are you friends?"
§ "Have you gone out with him?"
§ "Do you usually chat?"
§ "Do you communicate on a daily basis?"
§ "Have you checked his intention? Is he friendly?"
8. Inquire About the Other Person
o Ask:
§ "Can you tell me about the other person?"
§ "How are you related to him?"
§ "Is he your classmate?"
§ "How long have you known each other?"
§ "How much do you know about that person?"
§ "Do you know his age?" (Important due to patient's age of 16)
§ "Do you know about his sexual orientation? Is he gay or straight?"
§ "Do you know if he's in a relationship or has a partner?"

Note: If the other person is a classmate, the scenario may lead to bisexuality. If the other
person is a senior, it may lead to homosexuality.

9. Explore Patient's Past Relationships

o Ask:
§ "Can I please ask you about your past relationships?"
§ "Have you had any previous relationships?"
§ "When was your last relationship?"
§ "Was it with a girl or boy?"
§ "Was it a sexual relationship?"
§ "How was the relationship? Were you enjoying it? Were you happy in
it?"
§ "How long did that relationship last?"

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"What was the reason for ending that relationship?"

§
§ "Apart from that, have you had any other relationships in the past?"
§ "In the past, have you ever been attracted to or romantically involved
with any other male person?"
10. Explore Future Attractions
o Ask:
§ "At the moment, are you still attracted to girls?"
§ "Do you think in the future you'll still be attracted to girls?"
§ "Would you say that you will still be attracted to girls in the future?"

Patient response possibilities:

o For bisexuality: "I don't mind" or "I'm not sure"

o For homosexuality: "No, doctor. I want to live like a gay person"
11. Family Dynamics
o Ask:
§ "Can you tell me about your family? Who is in the family?"
§ "Do you have any siblings?" (Expected response: two sisters)
§ "Is your family generally supportive?"
§ "Do you usually discuss relationships with your family members?"
§ "In your family, do they discuss your siblings' relationships or people's
personal relationships?"
§ "Do you discuss this sort of relationship with your siblings?"
§ "Has anyone in your family openly expressed any opinion about same-
sex couples?"
§ Expected response: "His father laughs at gay boys"
12. Social Aspects
o Ask about:
§ Preferences
§ School and studies
§ Alcohol, smoking, recreational drugs
13. Medical History
o Ask about medication and medical conditions
14. Diagnosis and Explanation
o Based on the information, determine if the patient could be gay or bisexual
o For bisexuality:
§ Say: "You could be bisexual. There is a possibility you could be
bisexual."
§ "Bisexual means someone attracted to both sexes, males and females."
§ "It is normal to be bisexual and it is okay to be bisexual."

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"In the UK, 1.3% of the population identify themselves as bisexual.

§
That's more than half a million people out of 65 million, so you are
not alone."
o For homosexuality:
§ Say: "You could be homosexual or gay. The word 'gay' is official, it's
not a bad word. You see, LGBT uses 'gay'."
§ "Having an attraction to the same sex is normal, nothing to be
worried about."
§ "In the UK, 1.5% of the population identify themselves as
homosexual (gay and lesbian). That's almost a million people."
o Explain: "Identify means they came out, they said 'I'm gay'. There are people
who didn't identify outside but inside they are gay."
15. Addressing Parental Concerns
o Assure confidentiality: "Your information is confidential even though you
are younger. We are not going to discuss anything with your parents."
o Advise on disclosure: "This is your personal life. If you feel this can cause
conflicts or distress in the family, you don't need to disclose. You can keep it
to yourself."
o Encourage family communication: "We always advise young people to talk to
their family about their relationships whenever it is suitable."
o Suggest approach: "The best way is to build up a very good relationship with
your family. When you gain their trust, the confidence will build up. In that
situation, you will be able to talk to your family."
o Emphasize patience: "When you feel comfortable, when you have
confidence, you can talk to your family. There is no rush."
16. Closing
o Reassure the patient that their feelings are normal and valid
o Offer support and follow-up if needed

Key Points to Remember

• Be non-judgmental and create a safe space for the patient to express themselves
• Use neutral language when discussing sexuality
• Be prepared to provide statistics on LGBT population in the UK
• Emphasize normalcy and acceptance of different sexual orientations
• Balance encouraging family communication with respecting the patient's privacy
and safety
• Be aware of age-related concerns, especially if the person of interest is significantly
older
• Do not push for immediate disclosure to family if the patient is not ready

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• The scenario can end up with the patient being either gay or bisexual, depending on
the details provided
• Remember to be very political when discussing family disclosure
• Treat this as a department voice scenario and memorize the key points

Follow-up Consultations
Introduction

• Follow-up is the doctor's plan, not the patient's

• If you invite someone for follow-up, you need to have a plan
• You cannot ask "How may I help you?" in a follow-up consultation
• Main objective: Check if the treatment is working or not
• How to check: Compare symptoms before and after treatment
• Follow-up typically occurs after diagnosis and treatment initiation
• Also check for medication side effects and complications of the condition

Six-Step Structure

1. Paraphrase

• Acknowledge the follow-up: "I understand you're here for follow-up."

• Acknowledge the condition: "I understand you've been recently diagnosed with
[condition]" or "You have a long-term medical problem."
• Example: "I understand you're here for follow-up. I also understand that you have
been recently diagnosed with this condition."

2. Check and Explain

• Ask about patient's understanding: "What is your understanding about the

condition that you have?"
• Ask what they've been told: "What have you been told about the reason for your
admission?"
• If patient lacks understanding, say: "Did anyone explain to you what this condition
is about?"
• Ask: "Do you know how this condition affects someone's body?"
• Provide explanation if needed
• Check understanding after explanation: "Do you understand?"
• If needed, offer to draw something to aid explanation

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3. Treatment

• Ask: "Can you please tell me what sort of treatment they have given to you?"
• Inquire about medication details:
o "Do you know the name of the medication?"
o "Do you know the dose?"
o "How much medication do you take?"
o "How often do you take it?"
o "Do you take it regularly?"
• If patient stopped taking medication, ask: "May I know why you had to stop taking
it?"
• If patient mentions side effects (e.g., cough), ask:
o "Are you still having the cough?"
o "Has the cough stopped?"
o "When you're taking it, did it stop?"
o "While having cough, have you had any other symptoms?"

4. Symptom-related Check

• Symptom discrimination (before and after treatment):

o "Before you started on this medication, what sort of symptoms did you have?
What were you feeling?"
o "After the medication, what sort of changes have happened?"
o "What sort of symptoms do you have now?"
o "Is there any difference? Has the medication made any difference?"
o "Are you still the same?"
• Ask about complications of the condition:
o For polymyalgia rheumatica: Ask about GCA, headaches, blurry vision
o For epilepsy: Ask about head injuries, traumas, biting the tongue
o For diabetes: Ask about diabetic complications
o For hypertension: Ask about hypertension complications
• Inquire about medication side effects:
o Know common side effects of prescribed medications (e.g., steroids, insulin,
apixaban)
o Ask specific questions rather than general "Do you have any side effects?"
o Example questions:
§ "Do you have any headache?"
§ "Do you have any tummy pain?"
§ "Do you have any hair loss?"
§ "Do you have any weight gain?"

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5. MAFTOSA

• The 'S' in MEFTOSA is particularly important, often relating to social history which
can have significant impact in scenarios.

6. Fix the Issue

Three possible scenarios:

1. Find an issue and fix it (mostly related to medication)

2. Discuss a given plan
3. Diagnose and treat a new condition discovered during follow-up

Example: If you discover B12 deficiency during follow-up, discuss what needs to be done
and how to treat it.

Sample Scenario: Polymyalgia Rheumatica

• 80-year-old patient
• Diagnosed 3 weeks ago
• Started on prednisolone 50mg
• Blood test done this week (ESR and CRP results given)
• Plan: Blood test in 3 weeks, add two new medications
• Task: Talk to the patient and address concerns about the medications

Apply the six-step structure to this scenario:

1. Paraphrase: Acknowledge follow-up and recent diagnosis

2. Check and Explain: Ensure patient understands polymyalgia rheumatica
3. Treatment: Discuss prednisolone usage
4. Symptom Check: Compare symptoms before and after treatment, check for GCA
symptoms, ask about steroid side effects
5. MAFTOSA: Go through general health checks
6. Fix the Issue: Discuss blood test results, plan for next blood test, and introduction
of new medications

Key Points to Remember

• Study this structure religiously before consultations

• This structure can be applied to any follow-up scenario
• Don't ask "How may I help you?" in a follow-up consultation
• Know the side effects of common medications; it's the doctor's job, not the patient's

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• Be specific when asking about side effects

• The social history aspect of MAFTOSA is often important in scenarios
• Practice this structure to be confident in follow-up consultations
• This structure allows you to "walk into the room like a hero" without needing to
remember a specific script

Scenario 1: Polymyalgia Rheumatica Follow-up Consultation

Background

• 80-year-old man
• Initially presented with shoulder pain and hip pain
• Diagnosed with polymyalgia rheumatica
• Currently on follow-up

Consultation Structure (Using 6-step approach)

1. Paraphrase

• "I understand you're here for a follow-up."

• "I also understand you've been diagnosed with a condition."
• "What have you been told about your condition?"

2. Check and Explain

• Ask: "What is your understanding about the condition you've been diagnosed with?"
• If patient lacks understanding: "Did anyone explain to you what polymyalgia
rheumatica is?"
• If no explanation given, provide one:
o "Polymyalgia rheumatica is a condition that affects the large joints like the
shoulder and hip joints."
o "It's basically inflammation of these large joints and also affects the muscles
surrounding them."
o "It's an autoimmune condition, which means our defence against infection
in the body mistakenly attacks our own tissue, damaging it."
• Check understanding: "Do you understand? Is it clear now?"
• Emphasize: "It's better to have an understanding about the condition when you have
it."

3. Treatment

• Ask about medication:

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o "How have you been given treatment?"

o "Do you know the name of the medication?" (Expected: Prednisolone)
o "Do you know how much medication you've been asked to take?" (Expected:
15 milligrams)
o "Do you take it regularly?"
o "Do you take it every day in the morning?"

4. Symptom-related Check

• Compare initial and current symptoms:

o "Can you tell me what sort of symptoms you had initially when you were
diagnosed?"
o "Did you have any shoulder pain, hip pain, any stiffness?"
o "Any redness, any swelling, problem with walking?"
o "How are you feeling now? Is it any better?"
o "How much have you improved?"
o "Do you have any other symptoms at all?"
• Expected response: "Doctor, I'm much better now."
• Your response: "I'm glad to hear that."
• Check for complications (Giant Cell Arteritis - GCA):
o "Do you have any problem with vision, any blurry vision?"
o "Any headache, any tenderness on your scalp, any tenderness when you
comb?"
o "Do you have any pain when you chew your food or bite something?"
• Ask about medication side effects:
o "Have you had any side effects from this medication?"
o "Has anyone told you anything about side effects?"
o Focus on acute side effects (patient only on medication for 3 weeks):
§ "Any tummy problems, tummy pain, bloating, indigestion?"
§ "Any recent weight gain?"
§ "Any changes in your sugar level?"
§ "Any changes in your blood pressure?"
§ "Any throat infections? Any sore throat?"
§ "Any recent fever, flu, feeling unwell?"

5. MAFTOSA

• Medical history:
o "Do you have any other medical problems?"
o Expected: Patient has high blood pressure
o Ask: "How long have you been diagnosed with it?"

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o "Do you take any medication for it?" (Expected: Amlodipine)

o "Is it controlled?"
• Ask about other conditions:
o Expected: Patient has diabetes
o "Do you take any medication for diabetes?" (Expected: Diet-controlled)
• Ask about allergies
• Social history:
o "Who do you live with?"
o "How are you managing your day-to-day activities?"
o "Do you need any help?"
o "Has this new condition affected your life in general?"
• Ask about concerns: "Do you have any concerns?"
o Patient may say: "I want to know about the side effects."

6. Fix the Issue (Management)

• Discuss reducing medication:

o "As your symptoms have improved, we can start reducing your medication."
o "We're going to reduce your Prednisolone to the next required dose, which is
12.5 milligrams. This means you'll take two and a half tablets."
• Plan for follow-up:
o "We're going to do a blood test in three weeks’ time."
o "On the fourth week, we'll do a review. If your symptoms continue to
improve, we can further reduce the dose."
• Introduce new medications:
1. Alendronic acid: "If you take steroids, it can cause a condition called osteoporosis.
To prevent that, we're going to give you a medication called alendronic acid."
2. Lansoprazole: "Steroids can also cause stomach ulcers. To prevent that, we're going
to give you a medication called lansoprazole."
• Explain steroid side effects:
o "It can cause stomach ulcers, but we're giving you medication to prevent
that."
o "It can cause osteoporosis, but we're giving you medication for that too."
o "It can increase your weight. You can manage this with lifestyle changes."
o "It can increase your sugar level. We'll monitor this regularly and can give
you medication if needed."
o "It can increase the chance of developing infections as it affects your
immunity. We'll do regular blood checks for this."
o Mention other side effects if remembered (e.g., cataracts)

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Important Points to Address

Stopping Steroids

If patient asks, "Can I stop taking steroids, doctor?":

• "It's not advisable to stop taking steroids."

• Explain: "When you start taking steroids from outside the body, your body stops
producing its natural steroids. If you suddenly stop taking steroids, the steroid levels
in your body can drop."
• "This can cause various complications in the body."
• "If someone is developing side effects from steroids, we usually treat those side
effects rather than stopping the medication."

Comparison with Bodybuilder Steroids

If patient asks, "Is it the same steroids that bodybuilders take? The guys in the gym?":

• "No, they are not the same. They are different."

• "What they use is called anabolic steroids."
• "These are basically hormones. They are taking testosterone hormone."
• "They are different from the steroids you're taking, which are for medical purposes."

Key Reminders

• Always maintain a structure in the consultation

• If patient asks about side effects at the beginning, say: "You've come for a follow-up.
There are certain things we need to do, but I will explain everything about your side
effects after checking a few things with you. Is that okay?"
• When discussing steroid side effects, always mention the remedy or management
strategy
• Know the guidelines for managing polymyalgia rheumatica, including dose
reduction and additional medications
• Don't refer to the BNF in scenarios except for prescriptions
• Remember the "Reduce, Repeat, and Add" approach for managing the condition
• If you want to examine the patient (e.g., eyes, joints, blood pressure), it's okay to do
so, but it's not problematic if you don't
• Avoid asking about osteoporosis symptoms (like bone pain) after only three weeks
of steroid use

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Scenario 2: Follow-up with Elevated ESR and CRP

Key Differences

• ESR and CRP levels are elevated (55 and 43 respectively, compared to 10 and 5 in
Scenario 1)
• Patient reports symptomatic improvement
• Biochemistry (ESR, CRP) hasn't improved

Approach

• Follow the same structure as Scenario 1

• Key difference in management:
o Do not reduce the steroid dose
o Leave the current dose as it is
o Review after the current period

Scenario 3: Patient-Initiated Contact

Background

• 80-year-old man
• Presented to GP three weeks ago
• Diagnosed with polymyalgia rheumatica
• Placed on Prednisolone 50mg
• Patient has made an appointment (not a scheduled follow-up)
• This scenario usually comes as a telephone consultation

Approach

1. Initial Greeting
o "How may I help you?"
o If you want to paraphrase: "I understand you've recently been diagnosed with
a condition, but I also understand that you wanted to speak to one of the
doctors. Is there anything particular you'd like to speak about?"
2. Patient's Concern
o Expected response: "Doctor, I'm having side effects. I'm having tummy pain.
Can I stop taking steroids?"
3. History Taking
o Say: "Let me see what we can do for you. Let me ask you some questions to
understand your situation better."

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o Ask: "Can you tell me what sort of symptoms you have?"

o Take a history for the symptoms using OEDIPA:
§ "What sort of symptoms are you experiencing?"
§ "When did that start?"
§ "Is it getting better or getting worse?"
§ "Is there anything that makes it worse?"
§ "What about eating and drinking? Does that make it worse or better?"
§ "Does alcohol make it worse?"
o Ask about dietary habits: "Do you drink alcohol? Do you eat spicy food?"
o After present complaint, ask: "Have you had any other symptoms?"
o Ask about all GIT symptoms:
§ Nausea, vomiting, diarrhoea, bloating
§ "Are you passing any dark colour poo?"
o Ask about other side effects of steroids (short-term):
§ Weight gain
§ Throat infection
§ Blood pressure changes
4. Medication Review
o "I understand you have been given treatment with steroids. Do you take it
regularly?"
o Expected response: "I'm still taking it. Yeah, I still take it."
o "What is the dose?"
5. Polymyalgia Rheumatica Symptoms
o "How are you in terms of your symptoms?"
o Compare initial symptoms with current symptoms
6. MAFTOSA
o Include lifestyle factors: alcohol consumption, eating spicy food, exercise
o Ask about things that aggravate the symptoms
7. Management (Fix the Issue)
o Address the patient's desire to stop taking steroids
o Explain: "As you are aware, you are developing symptoms as side effects of
steroids. But it is not advisable to suddenly stop the steroids."
o Reason: "If you suddenly stop, it can cause various complications in the
body. The body will go into steroid crisis because when you take steroids
from the outside, the body naturally stops producing it."
o Emphasize: "You just started the medication three weeks ago, so the
symptoms can relapse. The symptoms can come back."
o Explain importance: "Mainly this medication is given to protect your eye.
This condition can affect your eye."
o Propose treatment for side effects:
§ "We can give you some medications for the side effects."

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"We'll give you a medication called Lansoprazole."

§
§ "We also can add another medication called Alendronic acid in order
to prevent some other side effects like osteoporosis."
o Suggest lifestyle changes:
§ "By making some changes in your lifestyle, you can control the
symptoms."
§ "Avoid things that irritate the stomach, like eating spicy food,
drinking alcohol, and eating late at night."
§ "Instead, you can have frequent small meals and do regular exercise."

Key Points to Remember

• This scenario is more like a history-taking scenario than a formal follow-up

• It's patient-initiated, so the approach is slightly different
• Even though it's taught under follow-up, it's not a scheduled follow-up
• This scenario often comes as a telephone consultation
• Focus on addressing the patient's immediate concerns (side effects) while ensuring
they understand the importance of continuing the medication
• Emphasize treating side effects rather than stopping the medication
• Provide both medicinal and lifestyle interventions to manage side effects

Epilepsy Follow-up Consultation

Scenario Context

• F2 in the outpatient medical department (neurology)

• Patient: Sanjit Singh (formerly Sandeep Singh), 20-year-old man
• Recently diagnosed with epilepsy
• Prescribed sodium valproate 600mg BD
• Task: Review the patient and explain idiopathic epilepsy

Consultation Structure

1. Paraphrase

• "I understand you're here for a follow-up."

• "I also understand that you've been recently diagnosed with a new medical
condition."

2. Check and Explain

• Ask: "What have you been told about your condition?"

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• Expected response: "I know I have epilepsy."

• Explore recent events: "Can you tell me what happened?"
• Expected response: "Six weeks ago, I was developing fits. I was taken to the hospital
where they diagnosed me with epilepsy."
• Ask: "Did anyone explain to you what epilepsy is?"
• If not explained, provide explanation:
o "Epilepsy is a condition of the brain."
o "In the brain, sometimes there will be some abnormal electrical impulses or
electrical activity that causes fits or jerky movements in the body."
o "When the cause is not known, we call this idiopathic epilepsy. That is the
condition you have been having."
• Check understanding: "Do you understand? Is it clear?"

3. Treatment

• Ask: "You have been given a medication. Do you know the name of the
medication?"
• Expected response: "Sodium valproate"
• Ask: "Do you take it regularly?"
• Expected response: "Yes, I do take it regularly."
• Important: Ask specifically, "How many times do you take it?"
• Expected response: "I take it only once in the morning."
• Follow-up: "Did anyone explain to you how many times you need to take this
medication?"
• Expected response: "Yeah, they explained to me so many things, but I didn't
understand."
• Your response: "I'm sorry about that."
• Note: Do not correct medication usage at this point

4. Symptom Check

• Focus on the difference between pre- and post-treatment:

o "After you've been started on treatment, are you still developing fits?"
o "Is there any difference?"
• Expected response: "No, I still develop fits."
• Your response: "I'm sorry to hear that."
• Further questions:
o "How often do you develop fits? Is it the same frequency as before you started
treatment?"
o "Is it the same intensity or worse than in the past?"
o "On what occasions do you develop fits?"

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o "What were you doing when you developed fits?"

o "What happened after each fit? Were you taken to the hospital?"
• Expected response: "If I develop fits, I take medication, after that I'm fine."

5. Complications

• Ask: "During any of the fits, have you had any injuries?"
o Inquire about head injuries, bleeding from the ear, biting tongue or nose,
fractures

6. Side Effects

• Ask about sodium valproate side effects

• Note: It's important to know 4-5 specific side effects of sodium valproate
• One known side effect: hair loss and thinning hair
• If not asked here, be prepared to explain side effects in the management section

7. MAFTOSA (focusing on social aspects)

Five important areas to cover:

1. General social history:

o Ask: "Who do you live with? What do you do?" Expected responses:
o Lives alone in university campus
o University student studying computer science Follow-up: "What do you
study?" Expected response: Computer science
2. Alcohol consumption:
o Ask about alcohol intake Expected response: He drinks alcohol
3. Epilepsy triggers:
o Ask about activities with flashing lights (clubbing, watching TV, musical
festivals)
o Inquire about sleep patterns: "Do you sleep on time? Do you get enough
sleep?"
o Ask about eating habits: "Do you eat on time?"
o Inquire about screen time: "Do you spend a lot of time watching TV, playing
video games, or using electronic screens?"
4. Dangerous activities:
o Ask: "Are you into any dangerous activities or extreme sporting activities?"
o Examples: horse riding, mountain climbing, rock climbing, bungee jumping,
scuba diving, activities at height Expected response: Planning to go to Kenya
for mountain climbing
5. Driving:

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o Ask: "Do you drive?" Expected response: "I'm learning to drive."

Management (Fix the Issue)

1. Explain why patient is still having fits:

o "According to your notes, your medication should be taken twice a day. You
are taking it only once at the moment."
o "I'm sorry, this must have been explained to you earlier."
o "You need to have a certain amount of medication in your system always. If
the medication level drops, you can easily develop fits."
o "The medication level is not enough to prevent the fits."
2. Advise on correct medication usage:
o "We will advise you to take it twice a day."
3. Discuss triggers:
o "There are certain things that can trigger your fits."
o Mention alcohol consumption
o Discuss flashing lights and computer use: "You mentioned you're studying
computer science. If you're using computers, have some breaks every half
hour, maybe close your eyes and take a break."
o Suggest: "You can have a very good screen protector. If possible, print out
notes and read rather than using electronic screens."
4. Address dangerous activities:
o "There are certain activities that can be dangerous for you because if you
develop fits while doing these activities, it can cause severe injuries."
o "You mentioned you're planning to go to Kenya for mountain activities. We
would advise you to postpone that."
5. Driving:
o "Regarding driving, we would advise you to put a pause on driving."
o "I'm afraid we need to put a temporary pause on taking classes."
o If asked about future driving: "You need to be free from fits for two years.
After that, with specialist advice, you may start driving."
6. Explain medication side effects if not discussed earlier

Key Points to Remember

• Explain idiopathic epilepsy even in follow-up

• Be thorough in asking about medication usage
• Focus on comparing pre- and post-treatment symptoms
• Know specific side effects of sodium valproate (homework: search and study 4-5
proper side effects)

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• Address all five key social aspects (living situation, alcohol, triggers, dangerous
activities, driving)
• Provide specific advice on managing triggers and lifestyle adjustments
• Be prepared to explain why immediate driving is not advised
• Don't try to fix issues immediately when discovered; wait for the management
section
• If examination is desired, checking head and neck is acceptable but may not make a
difference in this scenario
• If side effects are not asked about during the consultation, be prepared to explain
them in the management section

Scenario 2: Non-Compliant Patient

Context

• Patient with English name (e.g., John Peters)

• Not taking medication at all (unlike Sandeep who was taking it once daily)
• Developing fits
• Enjoying social life, partying with girlfriend

Scenario 3: Annual Review in GP

Context

• GP setting
• 23-year-old man
• Diagnosed with epilepsy 6 years ago
• Started on sodium valproate
• Coming for annual review

Key Points

• No fits for 2 years, DVLA gave license 3 years ago

• Currently driving
• Last 2-3 weeks: on and off medication due to being busy, forgot to take it
• Developed fits a few days ago
• Occupation: Scaffolder (works at heights)

Approach

1. Follow-up structure
2. Ask about compliance and medication

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3. Identify recent fits and occupation as key issues

Management

1. Explain importance of regular medication

o "When medication level drops, it's not enough to prevent fits"
2. Advise to stop driving
o "It can be dangerous to you and people on the street"
o Inform DVLA about recent fits
3. Address work situation
o Advise against working at heights
o If patient resists: "I cannot stop working. I've worked with these guys for
quite a long time. It's not possible for me to stop."
o Your response: "Working at heights is quite dangerous. As you have been
developing fits, you can develop fits anytime. If you develop fits while
working on heights, you can have a fall. If you fall from heights, you can have
a head injury. This can put your life in danger."

Scenario 4: Discharge Scenario - Child with Epilepsy

Context

• F2 in neurology department
• 13-year-old girl discharging after admission for seizure
• Admitted 3 days ago with generalized tonic-clonic seizure
• EEG showed epileptic focus in the brain
• Medication already explained to mother
• Task: Talk to the mother and address concerns

Approach

1. Greeting and Paraphrase

o "I understand your daughter has been admitted with us. I've been asked to
come and talk to you, explain what has been happening with her, and answer
your questions. Before that, I'd like to ask you some questions."
2. History Taking
o "What made you bring her to the hospital in the first place?"
o Explore seizure details:
§ "When did she develop fits for the very first time?"
§ "What sort of fits did she develop? Was it part of the body or the full
body?"
§ "How long did each fit last?"

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§ "Was it very intense? Did she have severe jerky movements during the
fit?"
§ "Did she lose control of her bowels or bladder, or bite her tongue or
lips?"
§ "Were there any injuries?"
§ "Just before having fits, does she tell you if she gets any warning or
abnormal sensation? Any experiences like seeing or hearing things?"
§ "Does she become unwell before the fits?"
§ "After the fits, does she lose consciousness? Does she remember what
happens?"
§ "Are there any other symptoms after the fits, like vomiting?"
§ "How many fits has she had so far?"
3. Medical History
o "Does she have any medical problems?"
o "Is she on any medication?"
o "Does she have any allergies?"
4. Social History
o "Does she go to school? What sort of school?" (e.g., grammar school, sports
school, college school)
o "What are her hobbies? What sort of activities does she like to do?"
o "Is she into any extreme sporting activities?" (e.g., horse riding, gymnastics,
rock climbing, bicycle riding)
o "Does she sleep on time? Eat on time?"
o "Does she spend time on computers or gadgets?"
o "Does she watch TV with flashlights?"
o "Does she have any siblings? Has anyone in the family got a similar
condition?"
5. Diagnosis Explanation
o "After you brought your daughter, we measured her brain activity. We did a
test called electroencephalogram, which measures the electrical activity of the
brain."
o "Unfortunately, that test revealed she has a condition called epilepsy. Have
you heard about epilepsy?"
o "Epilepsy is a condition of the brain where some abnormal electrical activity
or impulses cause these jerky movements."
o "I understand the medication has been explained to you. Do you have any
questions at this point?"
6. Addressing Mother's Questions
o Can she dance?

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§ "Dancing shouldn't be a problem, but avoid dancing under flashing

lights or in dangerous places like on tables, heights, or edges of
stages."
o Can she swim?
§ "Swimming also shouldn't be a problem. She should be able to swim,
but it's better to inform the lifeguards when she goes swimming, in
case she's in the water and they need to take her out."
o Will other siblings have fits?
§ "Unfortunately, there is a slim chance that other siblings might also
develop these fits."
o Do I need to accompany her wherever she goes?
§ "She can be independent. You don't need to accompany her to all
places. As long as she takes her medication and the fits are well-
controlled, she can lead a normal life like everyone else."
§ "At the moment, as she's young, whenever she's usually with an adult,
you can inform the other adult about her condition so they can help
if she develops fits."
o If she develops fits, what should I do?
§ "First, see where she is at the moment. If it's a dangerous place like
staircases, remove her to a safe place."
§ "Place her on a flat surface and protect her head with a cushion."
§ "Let her have the fit. Don't try to restrain her or put any medications
or anything in her mouth."
§ "If the fit lasts for more than five minutes, call an ambulance."
§ "After the fit, try to find out why she developed it. There may be a
trigger, or it might be due to medication."
§ "Try to avoid that trigger in the future."
§ "If she gets repeated fits, speak to your GP for a review."

Key Points to Remember

• Don't ask about swimming or dancing in your initial history; wait for the mother to
ask
• This is a discharge scenario, different from follow-up
• Focus on explaining the diagnosis and addressing the mother's concerns
• Provide practical advice for managing the condition in daily life
• The questions about dancing and swimming are unusual and specific to this
scenario; don't include them in your routine history-taking
• Let the mother ask her questions; don't anticipate them in your history-taking
• Be prepared to explain epilepsy in simple terms and provide practical advice for
daily life management

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