Clinical Notes

Table of Contents (new cases are marked in RED)

01. Problem colleague (Posting on Facebook)................................................................ 3
02. Simman (Hypoglycaemia) ........................................................................................ 4
03. Epilepsy Follow up .................................................................................................. 6
04. Medical error (Mislabelled Blood Sample) ............................................................... 8
05. Oxybutynin Confusion ............................................................................................. 9
06. Diarrhoea after Dog Bite Treatment ...................................................................... 11
07. Peripheral Arterial Disease (Claudication) .............................................................. 13
08. Psoriasis ............................................................................................................... 15
09. Simman (Sepsis) .................................................................................................... 17
10. Prescription (COPD) .............................................................................................. 19
11. Gonorrhoea .......................................................................................................... 20
12. Urinary Incontinence due to UVP .......................................................................... 22
13. Teaching (EpiPen) ................................................................................................. 25
14. Developmental Delay (Walking) ............................................................................ 26
15. Abdominal Examination (Alcoholic Liver Disease)................................................... 28
16. Breast Examination (Mastitis) ................................................................................ 30
17. Dermoid Cyst Ovary .............................................................................................. 33
18. Anorexia Nervosa.................................................................................................. 35
19. Medical Error (Missed MI) ..................................................................................... 38
20. PCOS .................................................................................................................... 39
21. Problem Colleague- Cocaine + Alcohol ................................................................... 41
22. Lithium Toxicity .................................................................................................... 42
23. Post MI Heart Failure Medication .......................................................................... 44
24. Tinea Pedis ........................................................................................................... 47
25. Prescription (Palliative care) .................................................................................. 50
26. Toxoplasmosis Eye Examination ............................................................................ 53
27. Meningitis ............................................................................................................ 56
28. Gonorrhoea .......................................................................................................... 58
29. Venepuncture with PCM Overdose ........................................................................ 60
30. Stroke Counselling ................................................................................................ 61
31. Teething ............................................................................................................... 63
32. Osteoporosis ........................................................................................................ 65
33. Renal Colic ............................................................................................................ 67
34. Depression with Failed CBT ................................................................................... 69
35. Malaria ................................................................................................................. 70
36. Simman (Hypoglycaemia) ...................................................................................... 72
37. Developmental Delay (Walking) ............................................................................ 74
38. Prescription (VTE risk) ........................................................................................... 76
39. Subarachnoid Haemorrhage (SAH) ........................................................................ 77
40. Immunisation (8th Week Vaccines) ....................................................................... 79
41. Abdominal examination (Acute Cholangitis)........................................................... 81
42. Aortic Dissection ................................................................................................... 83
43. Somatic Disorder .................................................................................................. 85
44. Leukaemia ............................................................................................................ 87
45. Molluscum Contagiosum ....................................................................................... 89
46. Unwanted Pregnancy ............................................................................................ 91
47. Dementia.............................................................................................................. 93
48. Teaching (Subcutaneous Injection) ........................................................................ 95

2
01. Problem colleague (Posting on Facebook)

Key point
You are FY2 in medicine department.
A nurse has called you to talk about some issues.
Talk to him and address his concern.

Þ Another FY2 had posted about a patient regarding the patient

condition.
Þ And also mentioned negative things about a consultant.
Þ This is the first time that he noticed about it.
Þ Does not contain patient picture.
Þ Friend only post.
Þ He does not want to tell him directly.

Concern
No particular concern, just informing.

Station Approach
! Greet and built rapport.
! Ask the reason for calling.
! Ask him about the post, what he wrote? Any patient information
included? any Comment or Share about this post?
! Ask about what he wrote about the consultant? Any mentioning name of
the consultant and hospital?
! Is this the first time that he writes about like this?
! Did you talk about this to him? To anyone else?
! If not, why?
! What is his concern about it?
! What he thinks should do about this?
! Advise him to talk to the colleague directly and make sure to delete it.
! And let him knows that this is the break of patient confidentiality and it
apologize the patient if there are the chances of patient knows about it.
! Advise him to delete about what he wrote to consultant.

3
 ! Advise him to inform the consultant for further advice.
! Advise him to read about good medical practice.
! If he denies to talk to the colleague, then tell him to talk together with
you as you are not the person who saw the post.

Praise him for raising this issue and let him knows that you are always
welcome him if he needs any help.

02. Simman (Hypoglycaemia)

Key Point
You are FY2 in Medicine.
58 years old man was admitted to medical ward with pneumonia and taking
treatment for it.
Today he was found unconscious on bed by a nurse colleague.
You are the only one doctor in the ward at this moment.
Please talk to the patient, assess the patient do the initial management.

Þ Patient is unconscious
Þ Monitor- normal
Þ Blood glucose 1.6mmol initially
Þ Becomes 3.0mmol after 2nd time glucose
Þ Patient regain conscious after giving glucose 2 times

Station approach
! Greet examiner
! Mention universal precautions.
! Introduce and identity confirmation by wrist band if the patient is
confused.
! Patient is not talking back Tap on the shoulders:
• Patient is not responding again.
• Patient is UNCONSCIOUS.
! Acknowledge unresponsiveness

4
 ! Do ABCDE approach as taught in the Academy.
o Give 10% glucose 150 ml over 15 min after checking glucose in D
(use 150ml to reduce time consuming)
o Reassess RBS after E (assume 15min is done)
o give next dose of glucose if patient is still hypoglycaemic (can give till
regain consciousness or give up to total 250ml of 10% glucose and
recheck the glucose)
! when the patient regains conscious, introduce yourself
! Explain the situation, and what was done.
! Encourage him to eat like biscuits and a slice of bread.
! Take focused history about what happened.
! MMA

! Management
- Patient is already in the hospital (no need another Admission)
- Inform senior
- Once discharged refer to Diabetes Clinic.
- Safety Netting – if feel unwell, ring the bell which is beside your
bed

(Don’t get confused if ABC are all normal. Just continue to D and E. You will get
the clues)

NICE BNF: Medical Emergencies in the Community (Hypoglycaemia)

5
03. Epilepsy Follow up

Key Point
You are FY2 in GP.
A 36-year-old man made an appointment for follow-up visit.
He was diagnosed epilepsy 4 years back, and was prescribed anti-epileptic
medication.
He was taking the medication as prescribed and was fit free for 2 years.
However, he develops seizure 1-time last week.
Talk to him and address his concern and manage the patient.
Þ He stopped taking medicine abruptly a week back, he said he is feeling
okay.
Þ No problem with taking medications.
Þ No other MMA
Þ DESA (-)
Þ He is a bus driver.

Examination -normal

Concern
How long do I have to take those Med?
Why do I have to stop driving?

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore the how is he doing
o Any symptoms of epilepsy
o Any new issues/problems
o If any (+) then explore it
! MMA – Epilepsy medication
! DESA
! Driving
! Risky hobby
! Occupation
! Psychosocial
! ICE

6
Examination
! Vital
! GPE
Explanation- stopping medication causes relapse of the symptoms

Management
! Routine investigation for follow up
! Explain why it is important to take the medications regularly
! Advise to inform DVLA and stop driving now as it can dangerous to lives
of many people on-board on your bus.
! How long you will have to stop driving depends on what type of seizure
you have. DVLA will give you a form to fill and then they will advice you
what to do next (or how many years you have to stop).
! Connect him to citizens advisory for jobs.
! S/N
! F/up

For Your Information

*DVLA requirement for driving BUS or LORRY with epilepsy
• had more than one seizure attack
o must free from epileptic seizure for 10 years + other criteria
• had a one-off seizure
o must free from epileptic seizure for 5 years + other criteria

*DVLA requirement for driving CAR or MOTORBIKE with epilepsy

• had epileptic seizures while awake and lost consciousness
o must free from seizure for 6 months + other criteria
• had seizures while asleep
o may still qualify for a licence if it’s been 12 months or more since
your first seizure.
• had seizures while asleep and awake
o may still qualify for a licence if the only seizures you’ve had in the
past 3 years have been while you were asleep

7
04. Medical error (Mislabelled Blood Sample)

Key Point
You are FY2 in surgical department.
35 years old man visited the pre-op clinic a few days ago for upcoming hernia
repair surgery. Pre-op investigations were done. Blood samples were taken,
but they were mislabelled.
Telephone call has been made with the patient.
Talk to him, explain the incident and rectify it.
Þ He is now at work
Þ Has busy schedule
Þ Reluctant to come
Þ Surgery in 10 days

Concern
Þ Why is this happened?
Þ How can I report this?

Station Approach
! Greet and confirm identity
! Introduce yourself and build rapport
! Telephone protocol
! Set up the scenario
! Tell him you are calling to update about his surgery
! Explore how is he doing now and general health.
! Any new symptoms
! Continue with the medical error approach: explain what happened,
apologize, empathize and explore his concern
! Explain you need to take the sample again
! Request him to come and give the sample, if the patient refuses, convince
him as this is an important part of the assessment before surgery.
! Explain how you will make sure this will never happen again.
! Explain about incident form.
! PALS if he wants to report.

8
05. Oxybutynin Confusion

Key Point
You are FY 2 in A&E.
65 years old man comes with some complaint.
Talk to him, take relevant history and discuss further management.

Þ He has visited GP a month ago with the complaint of urinary

frequency
Þ He was prescribed oxybutynin.
Þ He was travelling to his friend last week. Got diarrhoea during
travelling.
Þ Forget to take enough water intake too.
Þ After that he has been feeling confused.
Þ His friend took him to local clinic and had some treatment which he
didn’t remember.
Þ He was asked to stopped medications by the local Doctor.
Þ It has been 2 days he does not take oxybutynin and now feeling
better.
Þ But urinary symptoms come back.
Þ Fever or other signs of infection (-)

Examination
Vital- normal
MMSE- normal

Concern
Þ What is wrong with me?
Þ Am I having dementia?

Station Approach
Greet and confirm identity
Paraphrase the scenario

9
 ! Explore confusion
! Differential Dx (stroke, head injury, meningitis, dementia, delirium, any
infection, drugs, alcohol, DM)
! Med/Sx History
! When you got history of taking oxybutynin, explore it and search
symptoms of side effects
! Personal History
! ICE

Examination – vital, GPE, MMSE

Management
! Stop Med
! Discuss with Senior
! Investigation- Blood- Routine tests, urine dipstick/urine RE,
inflammatory marker,
! Refer to kidney specialist for drug review
! Stop Driving
! Advice/ Leaflet
! S/N – confusion
! F/up – after drug review

10
06. Diarrhoea after Dog Bite Treatment

Key Point
You are FY2 in GP.
30 years old man comes with the complaint of diarrhoea for 5 days.
He had dog bite a week ago and treated with Co-Amoxiclav.
Talk to the patient, take focused history and address his concern.

Þ Dog bite wound is now healed.

Þ No symptoms of infections.
Þ No fever.
Þ No signs of dehydration.
Þ He completed the tetanus vaccine.
Þ Rabies vaccine is not given.

Examination results
Þ Vital- normal
Þ No fever
Þ Wound is healed. Clean and dry

Concern
Þ Why I got this terrible diarrhoea?
Þ Why did you give that antibiotic to me then?

Station Approach
! Greet and confirm identity
! Paraphrase the scenario

! Explore the complaint (Diarrhoea) – ODIPARA

! Associated symptoms – fever, vomiting, blood or mucus stool
! Explore previous visit (Dog bite)
o When
o Where (which part of body)
o What treatment given

11
 o How is it now
o Explore signs of infections
! MMA
! DESA
! Psychosocial
! ICE

Examination
! Vitals
! Wound

Diagnosis
! Diarrhoea due to side effect of the antibiotics (open BNF and show
him Co-Amoxiclav SE if you have time).
! Diarrhoea is a common consequence of treatment with
antibiotics, occurring in 2–25% of people taking antibiotics.
! Antibiotics kill the bad bacteria as well as good bacteria which can
lead to this diarrhoea

Management
! Discuss with senior and confirm the diagnosis
! Investigation
o Blood- routine tests, electrolytes
o Stool- RE and culture
! Stop the antibiotic, as it has been giving a week and wound is healed.
! Encourage regular fluid intake, and supplement with fruit juice and
soups.
! Oral rehydration salt (ORS)
! Probiotics
! If culture shows C. difficile, which is a nasty bacterial, I will discuss with
specialist and will give empirical antibiotics to get rid of bugs.
! S/N – symptoms of electrolytes imbalance
! F/up – if not relief

12
Concern
Benefit
Þ wound is healed quickly
Þ no fever
Þ no infection, prevented by Co-Amoxi
Risk/ SE
Þ Diarrhoea
Þ +/- nausea

07. Peripheral Arterial Disease (Claudication)

Key Point
You are FY2 in GP
58 years old man makes an appointment with the compliant of leg pain.
Talk to him, assess him and discuss the management with the patient.

Þ Leg pains off and on for 4 months

Þ Getting worse
Þ No ulcer or injury
Þ Hypertension (+), Hypercholesterolemia (+)
Þ Taking antihypertensive and statin
Þ Smoking (+)
Þ Play golf but now he cannot play well because of the pain
Þ Need to rest (sit) for 5-7 min after 15 min walk

Examination finding normal (no swelling, no ulcer)

Concern
How will you treat me?

Station approach
! Greet, introduce yourself and confirm identity
! Explore about leg pain (SOCRATES)

13
 ! Red Flags- acute limb ischaemia (persistent pain, pallor or cyanosis,
numbness, paralysis)
! Chronic complications (skin changes, ischaemic ulcers, gangrene)
! Differential Dx (Trauma, DVT, DM neuropathy, Sciatica)
! MMA
! DESA
! MAFTOSA
! Psychosocial- impact on daily living and works
! ICE

Examination
! Vitals
! Leg examination
! ABPI

Diagnosis and explanation- Peripheral Arterial Disease (Claudication) is a

common condition where a build-up of fatty deposits in the arteries restricts
blood supply to leg muscles. It's also known as peripheral vascular disease (PVD).

Management
! Discuss with senior to confirm the Dx
! Investigation
o Blood- routine tests+ Lipid profile, D-dimer, HbA1c, CRP, Clotting
profile
o Imaging- USG/Doppler, +/- Angiogram
! Involve vascular surgeon
! Offer supervised exercise programme
! If not available, offer unsupervised exercise
! Refer angioplasty or bypass surgery if not improving with exercise
program
! Give advice on risks of limb loss and cardiovascular events
! Give advice on key modifiable risk factors (Smoking, DM,
Hyperlipidaemia, Diet, Weight loss)
! Give advice on foot care
! Leaflet/ NHS patient info website

14
 ! Safety net – symptoms of acute limb ischaemia
! F/up – review progress after 3–6 months

NICE CKS management for Intermittent Claudication

08. Psoriasis

Key point
You are FY2 in GP
35 years old lady comes with rash on forearm for 2 weeks.
Take history and discuss the management with the patient.
Þ Rash on extensor surface of forearm
Þ Itchy, scaly and bloody when scratch
Þ ?? recurrence
Þ No Joint pain, no fever
Þ No insect bit or trauma
Þ No sun exposure
Þ Applied Emollient at home but not relieve
Þ PMH – nil
Þ Family Hx – nil
Þ She is presenter and need to work in public. Now affecting her job.

Examination – Vital normal

Concern – Transmissible? Can it spread to other part of the body?

Station Approach
! Greet and confirm identity
! Paraphrase the scenario

15
 ! Explore the lesion
! Site, size, shape, surface, colour, discharge, itchiness
! Changes?
! ODIPARA
! Trauma, Insect bite, Sun exposure, Contact Hx
! Associated symptoms (fever, joint pain)
! Differentials – Meningitis, Anaphylaxis, Fungal, Eczema
! PMH
! MAFTOSA+ DESA
! ICE

Examination – Vital, GPE, Lesion

Diagnosis - Psoriasis is a skin condition that causes flaky patches of skin which
form scales. Although the process is not fully understood, it's thought to be
related to a problem with the immune system.

Management
! Discuss with senior and do blood tests
! Start with topicals (Emollients and Corticosteroids creams) and vit-D
! If not relieve refer to skin specialist
! Further treatment can be Phototherapy with UV or Medications (like
methotrexate or adalimumab)
! Advice – Dos and DONTs
! Education – leaflet/ NHS patient info website
! Support group
! S/N – red flag symptoms such as widespread skin redness, severe pain,
fever, or signs of infection, and instruct them to seek immediate medical
attention if these occur.
! F/up – every 3 to 6 months

NICE CKS management for Psoriasis in Trunk and limbs:

16
09. Simman (Sepsis)

Key Point
You are FY2 in Rehabilitation Unit.
65 years old man was admitted following a fracture.
A nurse rushes to inform you about patient condition.
Low BP with decrease in O2 saturation.

Note: No senior in the ward at this moment. Patient was planned to discharge
today.

Assess the patient and do initial management.

Þ BP- 80/60mmHg
Þ SpO2- 95% on air
Þ Fever- 39’C
Þ ECG- normal
Þ Patient is confused and mumbling
Þ Air entry reduce in Rt lung
Þ SpO2 becomes 98% with O2 supplement
Þ BP becomes 90/60 after 500ml and becomes 100/70 after 2nd bottle
Þ Patient is mumbling till the end***(all candidates)
Þ You cannot get full history from patient

17
 Þ You will get just some yes or no answers

Concern
No concern provided

Station approach
! Greet examiner
! Mention universal precautions.
! Introduce and identity confirmation by wrist band if the patient is
confused or mumbling.
! Patient is not talking back clearly.
! Exclude PE by asking Chest Pain, Calf Pain, SOB (use yes or no question)
! (Some cases are PE, some cases are Sepsis with after-surgery scenario)

! Acknowledge the condition and proceed with your assessment.

! Mention PPECC.
! Do ABCDE approach as taught in the Academy.
! Take 3, give 3
! After ABCDE, tell him that you suspecting HAP (even though patient is
confused)
! Cancel the discharge plan and inform senior
! Do remining investigation like sputum culture
! S/N – if you feel confuse or unwell, ring the bell beside your bed

18
10. Prescription (COPD)

Key Point
You are an FY2 in Medical Ward.
50 years old man has admitted to the ward for the acute exacerbation of
COPD.
One of your colleague hand-over the patient to you to prescribe the
medication.
Consultant suggest to give the antibiotics for the patient.
Prescribe:
Þ Relevant Antibiotic
Þ Seretide 250 EVO haler One puff BD
Þ Salbutamol 100 micrograms 1 to 2 puffs PRN
Þ Atorvastatin 10mg OD
Special Note: Patient is allergic to Penicillin & Clarithromycin. He had rash.

Station Approach
! Greet the examiner.
! Start writing the prescription using a black ink pen.
! On the front page, on top write your name and GMC number.
! Fill up all the details, patient details and Allergy.
! Use provided stickers.
! Prescribe
o DOXYCYCLINE 200 mg Loading dose in “once only” section.
o DOXYCYCLINE 100 mg Maintenance dose PO OD 4 days starting
from 2nd day in “antibiotic” section.
o SERETIDE 250 EVO HALER One puff BD and
o ATORVASTATIN 10 mg OD in “regular medication” section
o SALBUTAMOL 100 micrograms 1 to 2 puffs in “as required” section.

! Open BNF at least once.

! Keep everything organized before you leave the cubicle.

19
11. Gonorrhoea

Key point
You are FY2 in GP
30 years old man comes with dysuria
Task: take history and discuss further management

Þ Dysuria for 1 week

Þ Discharge (+) - yellowish
Þ No rash, No ulcer, No lumps
Þ Sexual Hx
o stable partner – wife (+) but doesn’t have sex for 1 month now
o other partner of same sex (+)
Þ No safe sex (no protection)
Þ No symptoms in partners
Þ No previous STD screening
Þ PMH – nil
Þ Agree to visit GUM clinic

Concern
I want this to be confidential.
Don’t want to inform wife as we didn’t have sex for 1 month.

Station Approach
Greet and confirm identity
Paraphrase the scenario

Explore on complaint
! ODIPARA
! DDx
! Past Hx

Explore on other factors

! PMH

20
 ! DESA
! MAFTOSA
! ICE

Sexual history
! sexually active?
! stable partner?
! another partner?
! durations
! safe sex?
! partners symptoms

Management
! Senior
! Symptomatic:
o Gonorrhoea is usually treated with a short course of antibiotics.
o In most cases, treatment involves having an antibiotic injection –
ceftriaxone 1 g intramuscular (IM) injection (usually in the buttocks or
thigh).

! General advice
o You should avoid having sex until you, and your partner, have been
treated. It is advisable to practice safe sex all the time by using
condoms.
o Ask your current partner and any other recent sexual partners to
take test and get treatment if needed.
o Tell patient that we can help by notifying any of your previous
partners on your behalf anonymously.

! Refer to GUM for further assessments.

! S/N – persistent or worsening discharge, severe pelvic or abdominal pain,

severe testicular or scrotal pain, fever or chills, joint pain or swelling, or
any new or worsening symptoms after starting treatment.

21
 ! F/up - after about 1 week

NICE CKS management for gonorrhoea

12. Urinary Incontinence due to UVP

Key Point
You are FY2 in Urology department.
46-year-old woman comes to the hospital with some concerns.
Talk to the patient, assess, and address his concerns
Þ Feeling dragging down below
Þ No protruding from both front passage
Þ Urine leakage (+) when cough or straining
Þ Has to wear diaper
Þ 5 normal Vaginal Deliveries
Þ She is a nurse aid. She needs to lift the patients
Þ DES (-) A (+)

Concern
That is embarrassing me. Help me to stop leaking urine.

Bear in mind that no examination findings given even if you verbalize

everything. Move on to Diagnosis and management if patient doesn’t hand
over the findings.

Station Approach

22
Greet and confirm identity
Paraphrase the scenario

! Explore the complaint.

! Explore the urine prolapse.
! Explore other DDx (UTI, Constipation, Caffeine, Medications, Overreactive
bladder, Increase Abd pressure, Neurological)
! MMA
! DESA
! MAFTOSA
! Psychosocial
! ICE
Examination
! Vital
! GPE and Abdominal Exam
! BMI
! Pelvic/Front Passage
! Urine Dipstick

Diagnosis and explanation- Stress incontinence is usually the result of the

weakening of or damage to the muscles used to prevent urination, such as the
pelvic floor muscles and the urethral sphincter.

Management
! Senior:
! Investigations:
o FBC, RFT, LFT, U&E and Urine RE
o USG (Residual urine test)

! Refer to Urogynecologist
! Offer referral for a trial of at least 3 months' supervised pelvic floor muscle
training (PFMT)

! Give lifestyle advice on:

23
 o Reducing caffeine intake — this may improve symptoms of urgency
and frequency but not incontinence.
o Fluid intake — advise the woman to avoid drinking either excessive
amounts, or reduced amounts, of fluid each day.
o Weight loss if the woman's body mass index is 30 kg/m2 or greater.
o Smoking and drinking if (+)

! Offering duloxetine as a second-line treatment, but only if the woman

prefers drug to surgical treatment or is not suitable for surgical treatment,
and is counselled about its adverse effects.

! S/N – blood in urine, severe pelvic pain, fever or chills, sudden worsening
of symptoms, and neurological issues like weakness or numbness.
! F/up – 4-6 weeks

NICE CKS management for Stress Incontinence

24
13. Teaching (EpiPen)

Key Point
You are FY2 in GP.
4 years old boy was admitted to the hospital with anaphylaxis after ingesting
chocolate cake containing peanuts one week ago.
He had similar incident before. His mother has questions about how to use
the EpiPen.
Kid is now taking care by nurse colleague.
She was given EpiPen last time but did not dare to use.

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore briefly about the incident (both previous and this time)
o Allergen
o Symptoms
o Action after incident
! Explore current conditions
! Explore why did not use EpiPen at home this time.
! Assess her knowledge on EpiPen.
! Teach how to use EpiPen details as taught at the academy.
! Refer the kid to allergy clinic too.
! S/N – if you have any questions. Watch out for S/S of anaphylaxis
! Leaflet

25
14. Developmental Delay (Walking)

Key Point
You are FY2 in GP
Mother of 14-month-old boy makes a telephone appointment with some
concern.
Talk to the mother and address her concern.
Þ He can stand by holding chair or support
Þ But cannot walk
Þ No previous injury
Þ Pregnancy and birth is normal
Þ Speak is normal
Þ He is currently going to day care centre
Þ Other kids of the same age can walk but my son can’t
Þ No general signs and symptoms of autism
Þ No relevant family Hx

Concern
Refer us to specialist.
I worry about my son.

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore briefly about the concern (gross development)
! Explore Speaking and other development
! Red flags
! DDx (musculoskeletal, overprotective, trauma, autism, family hx)
! BIRD DDD
! MAF

Examination (Telephone)

26
 ! Tell her to bring the child to clinic, if she can, as you want to examine
him in details.

Diagnosis and explanation- Reassure the mother as it is mostly likely to be

normal. Not to worry. Wait until 18 months. Every child has their own pace.

Management
! Discuss with senior and confirm Dx
! Reassure mother and make another review appointment one month
later.
! Bring the child to the clinic that time for examination and investigations.
! Advice
o Avoid using child walker
o Encourage the child to walk by holding hands
o Discourage isolation of the child
o Try not to be over protective
! Where referral is indicated, refer to a child development service or
paediatric services depending on local referral pathways.
! Physiotherapist
! Leaflet
! S/N – watch out for S/S of infections and autism
! F/up – 1 month

NICE CKS management for Delayed Walking in Children

27
15. Abdominal Examination (Alcoholic Liver Disease)

Key point
You are FY2 in GP
46years old man comes with abdominal distension.
Talk to the patient do relevant examination and address concern.
Þ Patient has abdominal distension for 4months
Þ Gradual onset and getting worse.
Þ No tummy pain, no fever, no jaundice.
Þ Drinking for more than 10 years
Þ Drink one whisky per day

Examination
Þ Free Fluid (+)
Þ Liver palpable

Concern
Is it curable?

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore on
o Abdominal distension- ODPARA
o Associated symptoms- fever, pain, jaundice, nausea, vomiting,
constipation, confusion, breathlessness, ankle swelling, bleeding
! DDx (liver disease, heart failure, hepatitis, pancreatitis, trauma, kidney
disease)
! FLAWS
! MMA
! MAFTOSA
! DESA-explore about Alcohol
! ICE

28
Examination
! Observation
! BMI
! General and physical examination
! Abdominal examination-PPECC (complete the examination and
mentioned to do DRE and Lymph node examination.)

Diagnosis and Explanation; Distension is due to the accumulation of fluids in

the tummy. The cause of fluids accumulation might be liver damage due to
excessive alcohol intake.

Management
! Investigation (FBC, liver function test, clotting profile, GGT, Albumin, lipid
profile, Alpha-feto protein, and ascites fluid study)
! USG tummy
! Involve senior
! Water tablets (diuretics) to release fluid accumulation
! Monitor Electrolytes.
! Refer to liver specialist for further management and scan(fibroscan)
! Refer to Dietician to cutting out salt from your diet and to eat a healthy,
balanced diet for proper nutrition
! Advice about
o alcohol cessation***
o quit smoking if (+)
o lose weight if (+)
o regular exercise
! Avoid NSAIDs, ACE inhibitors and angiotensin II antagonists
! Safety net; bleeding, encephalopathy, spontaneous bacterial peritonitis
(SBP), FLAW
! F/up

29
16. Breast Examination (Mastitis)

Key Point
You are FY2 in GP
A 28-year-old lady has come to you with some concerns
Take focused history, do relevant examination and manage accordingly

ÞLeft sided breast pain for 24 hours

ÞHer breast feels hot and painful to touch
Þhas a one-month-old baby
ÞBurning sensation in the breast while breastfeeding her child
ÞLumpy swollen area on the breast (+)
ÞNo pus or bloody discharge from the nipple
ÞFever (+)
ÞLumps and bumps anywhere in the body
Þno recent trauma or injury in the breast
Þno night sweats or rashes
ÞNo history of any medical condition or use of medication
ÞNo family history of breast cancer
ÞBaby is well fed, but she is worried, wants to know if she can feed her
baby or not
Þ It’s difficult for her to breast feed due to pain
Note: Patient is allergic to penicillin

Examination
Þ tender breast around nipple
Þ lumpy area (+)
Þ no discharge, bleeding or lymphadenopathy
Þ Patient express pain when you are examining her

Concern
Þ Can I continue breast feeding to my baby?

30
Station Approach
! Greet and confirm identity
! Paraphrase the scenario

Data Gathering
! Take focused history of pain and lump
o SOCRATES and ODIPARA
o Changes in the breast, nipple + discharge
! FLAWS
! MMA
! Infant Hx
! Breast feeding Hx
! deSA
! ICE

Examination
! PPCCE
! Perform breast examination as you were taught
! Thank the patient for cooperation

Diagnosis- Explain you are suspecting you are having mastitis which is
inflammation of the breast glands, it can happen if the ducts of the breast get
clogged and become inflamed or infected

Management
! Pain killer – Ibuprofen
! Erythromycin 250–500 mg four times a day or clarithromycin 500 mg
twice a day for 10–14 days (since it has passed 24hours)
! Review antibiotic in 48hours
! Continue breastfeeding
! While feeding make sure the baby is positioned and attached well
! Advice:
o Apply warm water-soaked towel/or ICE packs on breast for a
soothing effect

31
 o A little expression of milk to relief pain, and continuing feeding
o Do not wear tight fitting cloths, don’t press the breast, do not
apply oil or creams and don’t take aspirin
! Safety netting – greenish or bloody discharge, severe pain
! F/up- 2 days

NICE CKS: Management of Mastitis

32
17. Dermoid Cyst Ovary

Key Point
You are FY2 in OB&G.
26 years old married lady, presents to the hospital with abdominal pain.
Ultrasound has been done and shows dermoid cyst 8.5cm in the right ovary.
The consultant has decided to perform an open ovarian cystectomy via
Pfannenstiel incision (8cm).
The wound will be closed using absorbable sutures.
Consultant has decided to keep the patient in the hospital after the surgery
for 2 days.
Special note:
Consent has been taken from the consultant.
Talk to the patient and address her concerns.

Þ FLAW (-)
Þ P4- nil
Þ No exam finding given when you verbalize examinations

Concern
Þ Is it cancerous?
Þ What complications of surgery?
Þ What kind of operation will you do?
Þ Can I get pregnant after the surgery?
Þ How long do I have to stay in the hospital?

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Take focused history of previous visit and the complaint which lead to
this surgery
! Assess knowledge on Operation and pre-op investigation (done or not)
! MMA

33
 ! P4
! Family Hx
! DESA
! ICE

Management
! Explain the diagnosis
o An ovarian dermoid cyst is a benign or noncancerous cyst that
develops on the ovaries. It is a fluid-filled sac that often contains
variety of tissues (such as teeth, skin, hair, and fat).
! Explain the about surgery
o We will remove the cyst through open surgery. During the
procedure, we'll make an incision in your lower abdomen along the
bikini line to remove the cyst. You’ll be asleep under general
anaesthesia and will stay in the hospital for a short time after the
surgery. Afterward, you’ll need some pain management and follow-
up visits to ensure you’re healing well. You will need to watch for
any severe pain, fever, or unusual symptoms and contact us if they
occur. Do you have any questions?
! Address her concerns
! S/N about infections
o heavy bleeding
o severe pain or swelling in your abdomen
o a high temperature (fever)
o dark or smelly vaginal discharge

***Your task here is to answer the questions patient asked and get ready for
Operation,
Not to question the patient and manage with treatment plan as in other
clinical cases***

34
18. Anorexia Nervosa

Key points
You are FY2 in psychiatry department.
17 years old girl was referred by her GP.
Talk to her and manage accordingly.
Þ She was referred by her GP because her BMI is reducing for 6 months
Þ Now BMI is 17 and GP is concerning on it.
Þ Tried to lose weight intentionally because she wants to be thin.
Þ She has role models on social media.
Þ No SCOFF
Þ No vomiting
Þ Lost 10 kg in 6 months (by diet and exercise)
Þ No dizziness, no heart racing
Þ LMP was 4 months ago
Þ Mood – 7

Examination
Þ Vital normal
Þ BMI 17

Concern
No concern, I am fine.
No need any treatment.
I will continue reducing my weight.

***Patient accept the treatment after explaining long-term complications of

excessive losing weight like electrolytes imbalance, hypotension, anaemia.

Station approach
! Greet, introduce yourself and confirm identity
! Explore about the weight loss – ODIPARA
! Ask about the mood of weight loss – diet or exercise in details, use of
any laxatives

35
 ! Ask SCOFF
! Ask about trigger
! Insight and impact (medical and psychological)
! Ask Mood, scoring, suicidal risk assessment
! P2, MAFO, DESA
! ICE

Examination; Vitals, general and physical examination, abdominal

examination, and BMI

Diagnosis and Explanation; Anorexia nervosa —which is one of the eating

disorders that a person tried to reduce their body weight by restriction of their
food intake or by doing excessive exercise.

Management

! Admit
! Senior
! Investigations – full blood count, LFT, RFT, Electrolyte, Blood sugar, ECG
! Refer her to specialist eating disorder unit after that
! Follow-up with community mental health team
! Regular follow-up in GP
! Offer fast track CBT + self-help

Safety net: medical complications, suicidal idea.

Admission criteria for anorexia nervosa:

- Severe malnutrition (e.g., body weight <75% of expected, severe
electrolyte imbalances)
More than 1kg per week indicates high risk.

- Serious medical complications (e.g., bradycardia, hypotension,

hypothermia, significant organ dysfunction, Reduced muscle power).

- Severe psychiatric symptoms (e.g., suicidal ideation, self-harm

behaviours).

36
- Risk of refeeding syndrome:
o rapid weight loss
o fasting for over five days
o BMI less than 16kg/m2
o compensatory behaviours (such as laxative misuse or vomiting)
o dehydration
o use of diet pills or diuretics
o water loading or
o excessive exercise

- Ineffective outpatient treatment or inability to maintain safety despite

intensive outpatient care.

- Risk of significant harm to oneself or others (e.g., extreme restrictive

eating, severe compulsive exercise).

- Lack of support at home

37
19. Medical Error (Missed MI)

Key points
You are FY2 in medical ward.
55 years old man admitted to the hospital with myocardial infarction 2 days
ago.
Explain the medical error to the patient, assess for any complications,
address his concerns and discuss further management.
Þ 3 days prior to the admission, he came to the Emergency Department
with chest pain.
Þ He was seen by the Emergency doctors who performed an ECG which
was reported as normal. The blood tests were done but he was
discharged home based on the normal ECG before the Troponin
results were checked.
Þ He was discharged home with a diagnosis of musculoskeletal pain.
The Cardiologist has reviewed the ECG and the blood tests and the
ECG showed T-wave inversion and Troponin: positive.
Þ He doesn’t have any signs of heart failure now.

Concern
Þ How could you miss it Dr?
Þ If you don’t miss it, I won’t have heart attack.

Station approach
! Greet, introduce yourself and confirm identity.
! Explore about current situation – (irregular heartbeat, dizziness, chest
pain, SOB, cough)
! Explore about previous visit – about chest pain, what treatment offered?
! Explain about medical error – explain about the situation and apologize.
Management
! Examination of vitals, chest examination and leg examination for pitting
oedema.
! Do ECG and blood test to see whether he developed any complications.
! Reassure that the hospital takes this incident seriously, and we will
investigate what went wrong.
! We will make an incident report and will be honest and open.

38
 ! Involve seniors (the consultant will come and explain talk to you as well)
and PALS
! Root Cause Analysis Meeting (RCA meeting)

Concern;
Could this have been prevented?
It is highly unlikely for us to do so; the heart attack could have not been
prevented because you already had a heart attack when you came in the first
time as shown by the blood test.
Who missed the MI?
I do apologize, at the moment we don't know (individual or system) but we will
investigate, and get back to you.

20. PCOS

Key Point
You are FY2 in GP.
A 25-year-old woman makes an appointment concerning about her period.
Talk to the patient, take history and manage accordingly.
Þ Period missed or irregular for 6 months
Þ She has acne (but not excessive or facial hair)
Þ She has been gaining weight for last 1year and BMI is 32 now
Þ She is a lesbian and has girlfriend
Þ She doesn’t want kid or pregnancy
Þ MMA- nil
Þ Family Hx- nil

Concern
Þ Just want to know what is wrong with me
Þ Any long-term problem?

Station Approach
! Greet and confirm identity

39
 ! Paraphrase the scenario
! Take focused history on Period
! Associated symptoms- acne, facial hair, weight, pills
! Psychosocial
! MMA
! MAFTOSA
! DESA
! 4P
! ICE

Examination
! Vital
! GPE
! BMI
Diagnosis and explanation
- PCOS is a common hormonal condition that affects women of
reproductive age.
- PCOS can cause hormonal imbalances, irregular periods, excess
androgen levels and cysts in the ovaries.
- Irregular periods, usually accompany by a lack of ovulation, can
cause difficult to become pregnant. PCOS is a leading cause of
infertility.
- Possible long-term complications
§ Infertility
§ Heart and vessels problems
§ Hormone problems like DM
§ Sleep problems like insomnia and obstructive sleep apnoea
syndrome
§ Mental problem like depression, mood swing
§ Cancer like endometrial cancer

Management
(bare in mind that patient doesn’t want to become pregnant, so you don’t
need to discuss about infertility. She doesn’t have hair problem too)

40
 ! Discuss with senior to confirm Dx
! Investigation
o Blood -routine tests
-hormone study (like testosterone, female hormone-LH FSH,
TFT to exclude DDx)
-HbA1c
-Lipid profile
o Imaging -USG (tummy and pelvic), +/- CT
! Treatment
o Lifestyle changes (DESA advice with solution)
o Contraceptive pill to induce regular periods
o Refer to Skin specialist for acne
! S/N – mood swing, FLAW
! F/up – 3-6 months

21. Problem Colleague- Cocaine + Alcohol

Key point
You are FY2 in General Medicine.
Your FY2 colleague is hyper-active and restless in ward. You saw him sniffing
white/cocaine and drink in a party last night. Nurse in the ward also notice his
unusual behaviour today.
Þ Non-verbal clue - simulator is restless and active.
Þ No particular reason for taking drug.

Concern
Þ Give me confidentiality, I will tell you.

Station Approach
Greet and set the stage
Build rapport

! Introduce the issue

! Explore on issue (what, how, how much, why, where, anything else)

41
 ! Previous incidents??
! Any reason? (Stress, personal, depression)
! During/before duty?
! Let him know the GMC rules and regulations as it can cause problem for
his career/license
! suggest him to talk to supervisor himself to get better solution and help
! Cover patient safety
! Offer support the colleague

22. Lithium Toxicity

You are FY2 in emergency department
A 63-year-old man was brought to the hospital by his son as he was confused
since morning.

Þ He is shaking
Þ He has bipolar disorder and taking Lithium for more than 10 years now.
Þ Previously his wife is taking care of him and helping with medication
dosing.
Þ But She died a few months ago.
Þ h He is now taking his medication by himself.
Þ Son is taking care of food and day-to-day activities but to medications.

Examination
Þ Vital- normal
Þ MMSE- 22

Concern
Þ Want to get better ASAP as Son is worrying.
Þ Any antidote for it?

Station Approach
! Greet and confirm identity

42
 ! Paraphrase the scenario
! Explore the complainant (ODIPARA)
! D/Dx - (Neuro- Stroke, Dementia, Head injury, GI- constipation, Uro- UTI,
CKD, Respiration -Pneumonia, Asthma, Medication)
! MMA**
o (Explore details on Lithium)
o (Lithium side-effects symptoms)
! deSA
! MAFTOSA
! Psychosocial
! ICE
! Examination - Use nurse's finding right now for management. Tell you
will confirm again.
! (Already done by nurse)
! Diagnosis
! Explanation

Management
! Admit
! Senior
! Investigation
o (Blood test- routine+ U&E, Lithium Level, Sugar, CRP)
o (Imaging- CT/MRI head, USG, ECG)
! Treatment
! O2
! IV fluid to wash out
! Stop Lithium
! Monitor Li level
(May need dialysis if severe)
! Specialist for drug review and F/up
! S/N- to avoid NSAID

43
23. Post MI Heart Failure Medication

Stem
You are FY2 in GP
65 years old woman was admitted to hospital with MI. She had a heart attack
1 weeks ago and was discharged yesterday with some medications.
(Aspirin, Clopidogrel, Ramipril, Atorvastatin, Bisoprolol)
Her next follow up appointment is next week.
Talk to the patient and address her concern.

Station Flow
Þ She comes today as she has some questions about her medications
Þ She will give you the names and doses which she writes in a piece of
paper (name of medication also given in the stem)
Þ No S/S of MI
Þ No complication of MI
Þ No current issues
Þ DESA- nil

Concern
Can you explain me about the medications?
Why do I need to visit follow up appointment next week?

Station Approach
Greet and confirm identity.
Paraphrase the scenario.

! Take focused history on previous incident.

! Explore on sign and symptoms of MI and its complications (pericarditis,
HF, depression).
! PMH + MMA
! DESA
! ICE
Examination

44
 ! Vital
! GPE
! ECG

Management
! Explain about effects and side effects of each medication and time to
take
o Aspirin, Ticagrelor
- It is a blood thinner medication to prevent further heart attack or
stroke
- Take one tablet in the morning with meal for lifelong
- SE: GI upset, nausea, vomiting, risk of bleeding because it is a blood
thinner
- Watch out for injury and bleeding from any part of body (severe
headache, nose bleeding, vomiting of blood, dark stool)

o Ramipril
- It is blood pressure lowering medication and to prevent further
damage to your heart (Heart failure)
- Dose: use the dose mentioned in the stem (e.g. Oral tablet,2.5mg
once daily, for lifelong)
- SE: Can induce persistent dry cough, excessively lowered blood
pressure like feeling dizzy, lightheaded, blurred vision, headaches.
If they don’t subside, please come back so we review the
medications.

o Atorvastatin
- It is a cholesterol lowering medications
- Dose: Orally (40mg or 80mg, use what is mentioned in the stem)
everyday preferably at night
- SE: minor - might upset your tummy
major - muscle pain, joint pain, kidney problem or liver
problems

o Bisoprolol

45
 - It is a medication to control your heart rate as well as blood
pressure
- Dose (use what is mentioned in the stem), in the morning for
every day, for probably lifelong
- SE: slow heart rate - feeling dizzy or unwell >> call 999
immediately
Erectile dysfunction, sleeping disorder, fatigue, Cold fingers or
toes

o GTN
- It can relief chest pain by dilating the blood vessels of the heart
- Explain -can use a spray form, whenever you have chest pain
- SE- headache

Then reassure, all these side effects don’t appear in every individual, as
everybody is different.
We will monitor you closely so you don’t have to worry about that and even if
SE develops, we can change the dose or even the medication.

! Explain about important of medications

! Check understanding
! Address her concern
o Following up 1 week to check renal function test for ramipril
(ACEI)
! Give DESA advice if you have time
! S/N – HF, Pericarditis, Depression
! F/up

46
24. Tinea Pedis

Key Point
You are FY2 in GP
18 years old girl come to the clinic with the complaint of rash on her foot.
Talk to her, assess her and discuss management plan.

Þ Rash between toes for 3 weeks

Þ Itchiness (++)
Þ No discharge or bleeding
Þ No injury
Þ No insect bites

Examination finding
Þ Vital- normal
Þ Picture given

Concern
Þ Can I run?
Þ How long does it take for recovery?
Þ Recurrent?

47
Station Approach
! Greet and confirm identity.
! Paraphrase the scenario.
! Explore the complaint (rash)
o Site, size, shape, surface-hairs, colour, discharge, itchiness
o ODIPARA
! DDx/Risk
(Trauma, Foot wear, Insect bite, Sun exposure, Contact Hx)
! Red Flag
(Changes in size, colour, margin)
(FLAWS)
! Past Hx
! MMA
! dESa
! Family Hx (Similar symptoms, Eczema, Asthma)
! Occupation/Hobby
! Psychosocial
! ICE

Examination
! Vital
! GPE
! Lesion

Diagnosis and explanation- Athlete's foot (tinea pedis) is a fungal skin infection
that usually begins between the toes. It commonly occurs in people whose feet
have become very sweaty while confined within tight-fitting shoes.

Management
! Investigations (blood tests, skin scraping test for culture)
! Treatment
o Anti-Fungal cream- terbinafine cream or an imidazole such as
clotrimazole, miconazole, or econazole cream
! Advise on self-care management to answer concern:

48
 o Wear well-fitting, non-occlusive footwear that keeps the feet cool
and dry. Consider replacing old footwear which could be
contaminated with fungal spores.
o Maintain good foot hygiene by wearing a different pair of shoes
every 2–3 days.
o Wear cotton, absorbent socks.
o Avoid scratching affected skin, as this may spread the infection to
other sites.
o After washing the feet, dry them thoroughly, especially between
the toes.
o Do not share towels and wash them frequently, to reduce the risk
of transmission.
o Wear protective footwear when using communal bathing places,
locker rooms, and gymnasiums, to reduce the risk of transmission.
o After finishing running, wash the legs off the sweat, clean and pat-
dry.
! S/N – Seek immediate medical attention if occurs severe pain, rapid
spread of the infection, signs of secondary bacterial infection (e.g.,
increased redness or pus), fever or systemic symptoms, and no
improvement with treatment.
! F/up – Ask the patient to come back if not relieve by above management

NICE CKS management for fungal skin infection – foot

49
25. Prescription (Palliative care)

Key point
You are FY2 in palliative department.
80 years old woman is diagnosed with metastatic breast cancer. Patient is
terminal. Palliative care has been prescribed. She has been referred from
hospital to hospice for the continuation of palliative care. She cannot eat or
drink very well.
Patient is allergic to Penicillin and had rash.
o Morphine for pain via syringe driver 30mg per 24-hour SC.
o Morphine for breakthrough pain.
o Cyclizine 50mg SC TDS for nausea and vomiting.
o Midazolam 2.5mg SC 4 hourly for agitation.
o Hyoscine butylbromide 20 microgram SC 4 hourly.
o Atorvastatin 10mg PO od.
Write down the prescription for above medications. Check dose with BNF.

Station Approach
! Greet the examiner.
! Start writing the prescription using a black ink pen.
! On the front page, on top write your name and GMC number.
! Fill up all the details, patient details and Allergy.
! Use provided stickers.

50
51
! Open BNF at least once.
! Keep everything organized before you leave the cubicle.

52
26. Toxoplasmosis Eye Examination

Key Point
You are FY2 in GP.
58years old woman comes with some concern.
Talk to the patient, do relevant examination, and discuss further
management with patient.

Þ Cloudy vision for 2 months

Þ Gradual onset.
Þ No eye pain, discharge, redness.
Þ No previous eye problems.
Þ PMH- she has PMR and taking steroid for it.
Þ Work at animal shelter
Þ Psychosocial- she lives alone and has 8 cats.
Þ She does not drive

Concern
Þ I want to see clearly. How will you treat me?

Station Approach
Greet and confirm identity.
Paraphrase the scenario.
! Take focused history on eye problem.
! (Onset, duration, vision, eye pain, discharge, redness, injury)
! DDx
! PMH**
! Smoking
! MAFTOSA
! Driving
! Psychosocial
! ICE

53
Examination
! General observation and eye examination (visual field, visual acuity,
fundoscopy)
! Do eye examination as taught in the Academy.

Diagnosis and Explanation- It is a type of eye infection called Toxoplasmosis.

Toxoplasmosis is a common infection that you can catch from the poo of
infected cats, or infected meat. It's usually harmless but can cause serious
problems in some people.

Management

! I will refer you immediately to hospital to be seen by ophthalmology and

infectious disease team. You are likely to need blood tests (IgG, IgM and
PCR) to confirm the diagnosis and a CT scan of your head to ensure that
the infection hasn’t spread to your brain. You will also need to be seen by
rheumatology to review your steroid use.
! Recovery depends on the site of lesion and duration of symptoms and
hence prompt treatment is needed to avoid permanent visual loss
! Medication- combination of pyrimethamine and sulfadiazine, give for 4-6
weeks

54
 (Treatment should be continued for at least 10 days after inflammation
resolves)
! Educate the patient-
DOs
-wear gloves while gardening
-wear gloves when emptying cat litter trays and empty them every day
-wash your hands before preparing food and eating
-wash hands, knives and chopping boards thoroughly after preparing raw
meat
-wash fruit and vegetables thoroughly to get rid of any traces of soil

DON’Ts
-do not eat raw or undercooked meats like salami
-do not have unpasteurized milk
! S/N – If your vision deteriorates further or you have difficulty in
swallowing or talking then please let us know
! F/up – 1-2 weeks after starting treatment

Treatment for ocular diseases should be based on a complete ophthalmologic

evaluation. The decision to treat ocular disease is dependent on numerous
parameters including acuteness of the lesion, degree of inflammation, visual
acuity, and lesion size, location, and persistence.

Concern
The infection causes scarring and damage to the eye that can lead to visual
impairment.

55
27. Meningitis

Key Point
You are FY2 in A&E
20 years old boy is brought to the hospital by his father with the complaint of
seizure and high fever.
Blood test has been done and results are pending.
Talk to the father and discuss management plan with him.
Þ Fever and headache for 3 days
Þ Seizure today
Þ It’s continuous
Þ Photophobia (+)
Þ Neck pain (+)
Þ Travel to Kenya last month
Þ On examination- Skin rash (+)

Concern
Þ Can it transmit to other people?

Station Approach
Greet, confirm identity
Paraphrase the scenario
! Explore Headaches and fever
! Associated symptoms (nausea, vomiting, cough, neck stiffness,
photophobia, fit, vision)
! Differentials – Trauma, SAH, SOL, GCA, PMR, Cluster headache,
Migraine, Brain tumor, Glaucoma
! MMA
! MAFTOSA
o Explore contact (symptoms of infection)
! DESA
! ICE

56
Examination- Already done but tell that you will confirm by yourself again.
(Vital signs, GPE, Neuro- GCS, Brudzinski and Kernig signs, check the features of
shock)

Diagnosis and explanation- Meningitis is an infection of the protective

membranes that surround the brain and spinal cord.

Management
! Admit the patient
! Inform the senior to confirm the Dx and to perform further advanced
investigations
! Inform public health as it is notifiable disease
! Investigation
o Blood test- routine tests + U&E, CRP, Blood culture,
o CT
o Lumbar puncture to check ICP and organism
! Treatment
o O2+ fluid
o Isolate the patient+ inform infection control
o Antibiotics if bacterial (penicillin or cephalosporin)
o Antiviral if viral and severe (acyclovir)
o Steroid to reduce inflammation
o Painkiller for headaches
o Monitor closely
! Educate- leaflet/NHS patient info website
! S/N – ring the bell if you are not feeling well or if you need somethings

Concern
The risk of someone with meningitis spreading the infection to
others is generally low, but if someone is thought to be at high risk of
infection, they may be given a dose of antibiotics as a precautionary measure.
This may include anyone who’s been in prolonged close contact with
someone who developed meningitis such as family member.
Once the diagnosis of bacterial meningitis is confirmed, GP will do
contact tracing and if someone is found to be in closed contact and high risk

57
 of having the infection, GP will offer antibiotic prophylaxis within 24 hrs after
the diagnosis.
If the high-risk person is already in the hospital, can give treatment in the
hospital.

28. Gonorrhoea

Key point
You are FY2 in GP
30 years old man comes for follow up visit.
He visited the clinic 3 days ago with dysuria.

Swab test result- Neisseria gonorrhoeae positive.

Task: take history and discuss further management

Þ Discharge (+) - greenish

Þ No rash, No ulcer, No lumps
Þ Sexual Hx
o stable partner (+) – Girl friend
o other partner (+) and had unprotective sex just 1 time
Þ No safe sex (no protection)
Þ No symptoms in partners
Þ No previous STD screening
Þ MH – nil

Concern
Þ Don’t want to inform my GF
Þ Can it be transmitted by having unprotected sex just once?

Station Approach
! Greet and confirm identity.
! Paraphrase the scenario

58
 ! Request the patient and take a moment to read the test results
! Take focused history on previous presenting symptoms
! Any new symptoms?
! DDx – (Candidiasis, Bacterial vaginitis, STI)
! Risk factor- sexual activity, safe sex, partner symptoms
! MMA
! ICE

Diagnosis and explain test results- It is a type of sexually transmitted infection

caused by bacteria called Neisseria gonorrhoeae. Symptoms include pain when
peeing, sore or itchy genitals, and abnormal genital discharge.

Management
! Senior
! Symptomatic:
o Gonorrhoea is usually treated with a short course of antibiotics.
o In most cases, treatment involves having an antibiotic injection –
ceftriaxone 1 g intramuscular (IM) injection (usually in the buttocks or
thigh).
! General advice
o You should avoid having sex until you, and your partner, have been
treated. It is advisable to practice safe sex all the time by using
condoms.
o Ask your current partner and any other recent sexual partners to
take test and get treatment if needed.
o Tell patient that we can help by notifying any of your previous
partners on your behalf anonymously.
! Refer to GUM for further assessments.
! S/N – severe pain, persistent or worsening discharge, fever, significant
swelling or redness, and joint pain. Seek immediate medical attention if
these occur.
! F/up - 1-2 weeks

NICE CKS management for gonorrhoea

59
29. Venepuncture with PCM Overdose

Key Point
FY2 in Emergency Department.
A 20-year-old boy has been brought to the hospital as he consumed 40 tablets
of paracetamol 6 hours ago.
Instruction: Senior has asked to take a blood sample to check paracetamol
level in the blood.
Talk to the patient and perform the relevant procedure.

Þ Took the tablets with water

Þ No vomiting
Þ Not making eye contact
Þ Not answering most of the questions
Þ No symptoms of liver failure yet.

Management
! Greet, Introduce, and Confirm Identity:
! Build rapport
! Explore focused Hx on incident:
o What, When, How
o How many
o Why
! Explore symptoms of liver failure:
o Jaundice
o Abdominal pain
o Nausea + Vomiting
o Confusion

60
If patient is refusing to answer your questionà skip to “explaining reason for
taking blood and PPECC”

! Explain the reason for taking blood

! PPCCE
! Perform the procedure as taught in the Academy
! Label the sample and verbalize you are going to send this to lab
o Examiner will give paracetamol level
! Admit the patient if not admitted yet
! Involve the senior
! Start N-acetylcysteine if the level is above the treatment line
! Will repeat blood test after treatment
! ICE
! Involve Psychiatric Liaison Team
! S/N - ring the bell if you are not feeling well or if you need somethings

30. Stroke Counselling

Key Point
You are FY2 in GP
55 years old man makes a telephone appointment with some concerns.
Talk to him and address his concern.
Þ He has HTN
Þ DESA (++)
Þ Brother had stroke
Þ Father died from stroke

Concern
Þ I am worrying that I might have stroke
Þ How can I prevent it?

Station Approach

61
! Greet and confirm identity.
! Telephone protocol
! Explore concern
o What
o Why

! Explore background Hx for risk of stroke

o Symptom of stroke
o MMAà if (+) explore details
o DESA à if (+) explore
o Family Hx
o Occupation or lifestyle
o ICE

! Management
o Assess knowledge on stroke and awareness on its risk factor
o Invite to clinic to assess her and investigations
o Explain about her condition and level of stroke risk
o Advice on MMA and DESA in details
o S/N – S/S of stroke
o (F/up – not yet needed)

62
31. Teething

Key point

You are FY2 in paediatric department.

A mother of 7 months old baby makes video appointment for having some
concern.
Þ Baby is dribbling more than usual. Chewing a lot. Rash on cheek.
Þ Irritable and sleep time reduced in these days.
Þ No fever
Þ No pulling ears
Þ No photo or exam findings given
Þ Concern – what is teething? What do I have to do?

Station Approach
Greet and confirm identity
Phone call procedure
Paraphrase the scenario

Explore the concern

! ODIPARA
! Associated symptoms (fever, rash, discharges, swelling)

Differentials/Red flags
! Meningism
! Dehydration
! Urinary and bowel

BIRD DDD
MAF

Examination – mention that you love to take a look at the baby to make sure
everything is okay if mother can bring her to clinic.

63
Provisional Dx - Teething is when your baby's teeth start to come through their
gumline around the age of 6 month. It can cause pain or discomfort. It is a
normal process and try not to be worried so much.

Management
Comforting a teething baby
! Gently rubbing their gums with a clean finger may also help.
! Comforting or playing with your baby can distract them from any pain in
their gums.
Preventing teething rashes
! If teething is making your baby dribble more than usual, gently wiping
their face may help prevent a rash.
Chewing aids
! Teething rings give your baby something to chew safely. This may ease
their discomfort and distract them from any pain.
! Never tie a teething ring around your baby's neck, as it may be a choking
hazard.
! you can give them healthy things to chew on, such as raw fruit and
vegetables. Soft fruit like melon can soothe gums.
Medications
! Paracetamol and ibuprofen
! General oral pain relief gels are not suitable for children.
Advice
! To register at dental clinic

Education- Leaflet/ NHS patient info website

S/N – Look out for any swelling or inflammation or if teething is prolonged.

64
32. Osteoporosis

Key Point
You are FY2 in GP surgery
60 years old woman comes to the clinic with some concerns.
She had a fall and fractured her hip 3 months ago.
DEXA scan was done few weeks ago and the result today is osteoporosis.
She is now prescribed with Alendronate 70 mg once weekly, Calcium 1000mg
and Vit-D 10 micrograms.
Talk to her and address her concern.
Þ Menopause 10 years ago
Þ MMA- nil
Þ DESA- nil
Þ No other issues

Concern
How long do I have to take these medications?
What are the side effects?

Station Approach
! Greet and confirm identity.
! Paraphrase the scenario
! Request to give a moment and read the test result if given in the cubicle
! Briefly explore previous incident which lead to fracture and treatment
given
! Explore risk factors for osteoporosis
o early menopause
o removal of ovaries
o family history
o malabsorption problems
o long-term use of high-dose steroid
o heavy drinking and smoking
! MMA
! DESA

65
 ! P4
! ICE

Examination
! Vital
! BMI
! GPE

Diagnosis and explain result- result of DEXA and what it means. Explain what
osteoporosis means.

Osteoporosis is a health condition that weakens bones, making them fragile and
more likely to break. It develops slowly over several years and is often only
diagnosed when a fall or sudden impact causes a bone to break (fracture).

! Investigations- routine tests+ PTH, Calcium, Phosphate and vit-D level

! Explain about the given medications and how to take them
! Their effect + side effects
! Address her concerns
! Leaflet/ NHS patient info website
! S/N - seek medical advice if severe back pain, noticeable loss of height,
difficulty moving, and neurological symptoms like numbness or weakness
! F/up – 3 – 6 months

66
33. Renal Colic

Key Point
You are FY2 in A&E
45 years old man comes to hospital with back pain.
Take history and manage the patient.
Þ Back pain is radiate down from loin to groin
Þ Episodic pain
Þ 2 to 8/10
Þ Nausea, vomiting (+) 2-3 times
Þ Urine colour- reddish to pinkish
Þ deSA (+)
Þ No family Hx

Concern
How will you treat me?
Can you give me sick note? (He works at IT department of a company)

Station Approach
! Greet and confirm identity.
! Paraphrase the scenario
! Explore the pain (SOCRETES)
! Associated symptoms (Fever, GI, Urinary)
! DDx (AAA, Cauda equina, PID, Stone, Trauma, Sprain)
! MMA
! DESA
! MAFTOSA
! ICE

Examination
! Vital
! GPE
! Abdomen
! Urine dipstick

67
Diagnosis- Renal colic is pain that may occur when a stone gets stuck in part of
your urinary tract.

Management
! Involve senior
! Admit if patient has
o signs of infections
o risk of acute kidney injury
o dehydration or can’t tolerate oral
o doubtful diagnosis
! Otherwise keep the patient in observation unit and do investigations
! Investigations
o Blood- routine tests+ urea and electrolytes, Uric acid, cholesterol,
ESR, CRP
o Imaging- urgent CT or USG and KUB Xray
o Urine analysis + Stone analysis
! Initial Treatment
o Pain killer
o Fluid
o Antiemetic
o Antispasmodics (not recommended by NICE guideline)
! Specific Treatment (depend on size of stone)
o <5mm à watchful waiting
o <10mm à medical treatment with Alpha blockers
o >10mm or failed medical Mx or recurrent caseà surgery
! Surgical options include:
o Shockwave lithotripsy
o Percutaneous nephrolithotomy
o Ureteroscopy
o Open surgery
! Advice
o drinking plenty of fluid
o reduce salt intake and red meat, reduce oxalate intake
! Leaflet when D/C
! S/N - ring the bell if you are not feeling well or if you need somethings

68
34. Depression with Failed CBT

Key Point
You are FY2 in GP.
35 years old man comes for an appointment. He was diagnosed with clinical
depression after divorced. He was referred to Psychiatrist and taking CBT as
treatment. However, his depression is not improving so far.
Talk to him, manage him and address his concerns.

Þ Divorced 7 months ago

Þ Mood 4-5 and still the same after CBT
Þ Have done CBT 6 sessions
Þ Sleep, appetite – reduce
Þ Suicidal thoughts – nil

Concern
I don’t want CBT. It is not helping me.

Station Approach
! Greet and confirm identity.
! Paraphrase the scenario
! Explore how is he doing/feeling
! Explore current treatments
! Explore previous symptoms and different after CBT
! Any new symptoms of other mental health disorders, including anxiety,
eating disorders, bipolar disorder, or psychosis?
! Any new or ongoing personal, social, or environmental factors that may
impact on symptoms and recovery
! Smoking, Alcohol, Other drugs
! Impact on life
! Suicidal thought?
! ICE

Examination

69
 ! Vital
! GPE

Management
! Discuss the options for further-line treatment, depending on the person's
wishes, experiences with previous treatment(s), hopes and expectations
of treatment, involving family/carers in shared decision-making where
appropriate.
! Involve Senior
! Consider selective serotonin reuptake inhibitor (SSRI) antidepressant
! Suggest
o Lifestyles changes
o Pursuing hobbies or going on holidays
o Stopping smoking or alcohol if (+)
! S/N- hallucination, suicide
! F/up – 1-2 weeks

35. Malaria

Key point
You are FY2 in GP
30 years man comes with fever with chill and rigor for 1 week.
Task: take history and discuss management

Þ No cough, no jaundice, no rash, no photophobia or neck stiffness

Þ Abdomen discomfort (+)
Þ Joint pain (+)
Þ Travel to Uganda 2 weeks ago.
Þ Unplanned trip. So, can’t take prophylaxis
Þ Examination finding – fever (+)
Þ Other GPE – normal
Þ Liver, Spleen- normal

70
Station Approach
Greet and confirm identity
Paraphrase the scenario

Explore on fever
! SOCRATES
! Associated symptoms
! DDx (neuro, respiratory, GI, urinary)
! S/S of cerebral malaria (Red Flag)
! FLAWS
Explore on other factors
! PMH
! MAFTOSA**
! DESA
! ICE

Examination and investigation

Take observations and examination head to toe, look for rashes, abdomen
examination
Routine blood tests, thick and thin film to check malarial parasite, LFT, KFT,
covid test, Inflammatory markers

Management
! Admission
! Senior
! if it is confirmed, anti-malarial drugs will be given
(Artesunate or Artemisinin combination therapy (ACT) or Quinine plus
doxycycline or Primaquine)
! Notify
! Symptomatic:
o Painkillers
o Antipyretics
o Anti-sickness medication
o Hydration

71
 ! Specialist
! S/N – ring the bell if you feel severe headache, confusion or respiratory
distress.

NICE CKS management for Malaria

36. Simman (Hypoglycaemia)

Key Point
You are FY2 in A&E.
61 years old man was found unconscious on the street and brought to the
hospital by by-standers.
You are the only one doctor in the ward at this moment.
Please talk to the patient, assess the patient do the initial management.

Þ Patient is unconscious
Þ Monitor- normal
Þ Blood glucose 1.6mmol initially
Þ Becomes 3.0mmol after 2nd time glucose
Þ Patient regain conscious after giving glucose 2 times

Station approach
! Greet examiner
! Mention universal precautions.
! Introduce and identity confirmation by wrist band if the patient is
confused.
! Patient is not talking back Tap on the shoulders:
• Patient is not responding again.

72
 • Patient is UNCONSCIOUS.
! Acknowledge unresponsiveness
! Do ABCDE approach as taught in the Academy.
o Give 10% glucose 150 ml over 15 min after checking glucose in D
(use 150ml to reduce time consuming)
o Reassess RBS after E (assume 15min is done)
o give next dose of glucose if patient is still hypoglycaemic (can give till
regain consciousness or give up to total 250ml of 10% glucose and
recheck the glucose)
! when the patient regains conscious, introduce yourself and take consent
! Explain the situation, and what was done.
! Encourage her to eat like biscuits and a slice of bread.
! Take focused history about what happened.
! MMA

! Management
- Admit
- Inform senior
- Once discharged refer to Diabetic Clinic.
- Safety Netting – if feel unwell, ring the bell which is beside your
bed

73
37. Developmental Delay (Walking)

Key Point
You are FY2 in GP
Mother of 14-month-old boy makes a telephone appointment with some
concern.
Talk to the mother and address her concern.
Þ He can stand by holding chair or support
Þ But cannot walk
Þ No previous injury
Þ Pregnancy and birth is normal
Þ Speak is normal
Þ He is currently going to day care centre
Þ Other kids of the same age can walk but my son can’t
Þ No general signs and symptoms of autism
Þ No relevant family Hx

Concern
Refer us to specialist.
I worry about my son.

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore briefly about the concern (gross development)
! Explore Speaking and other development
! Red flags
! DDx (musculoskeletal, overprotective, trauma, autism, family hx)
! BIRD DDD
! MAF

Examination (Telephone)

74
 ! Tell her to bring the child to clinic, if she can, as you want to examine
him in details.

Diagnosis and explanation- Reassure the mother as it is mostly likely to be

normal. Not to worry. Wait until 18 months. Every child has their own pace.

Management
! Discuss with senior and confirm Dx
! Reassure mother and make another review appointment one month
later.
! Bring the child to the clinic that time for examination and investigations.
! Advice
o Avoid using child walker
o Encourage the child to walk by holding hands
o Discourage isolation of the child
o Try not to be over protective
! Where referral is indicated, refer to a child development service or
paediatric services depending on local referral pathways.
! Physiotherapist
! Leaflet
! S/N – watch out for S/S of infections and autism
! F/up – 1 month

NICE CKS management for Delayed Walking in Children

75
38. Prescription (VTE risk)

Key Point
You are FY2 in obstetrics and gynaecology. A 32-year-old lady delivered a
baby 3 hours back. It's her 4th delivery, it was an instrumental delivery.
She has lost more than 1200ml of blood, Breastfeeding started. She is in
pain, not on any drugs, no allergies, Weight 62kg and height 163cm.

Task: Prescribe VTE prophylaxis medication.

Management
! Greet the examiner
! Write your name and GMC number on top of first page of prescription
paper.
! Start filling prescription as you were taught in the academy
! There is BNF, calculator, pen and prescription paper
! There is also a chart for VTE prophylaxis NICE guideline
! Prescribe Enoxaparin (as breastfeeding) in the specific doses according
to the number of risks here it is more than two risks, find out the dose
from the chart.
! Prescribe Pain killer as patient is in pain.
! Clear your table and thank the examiner.

76
39. Subarachnoid Haemorrhage (SAH)

Key Point
You are FY2 in A&E.
45years old man comes to the hospital with headache.
Talk to the patient, assess him and manage accordingly.
Þ Sudden
Þ Severe headache 9/10
Þ Unbearable
Þ Nausea & Vomiting (+)
Þ Sensitivity to light
Þ Hypertension (+), not taking treatment
Þ Family Hx (+)

Concern
Þ Help me. It is really painful
Þ Is that serious?
Þ How will you treat me?
Þ

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore headache (SOCRATES)
! Acknowledge Pain and offer painkiller
! D/Dx (Meningitis, SAH, Migraine, Trauma, Tumour, Cluster Headache,
GCA)
! Past Hx
! MMA
! DESA
! MAFTOSA,
! ICE

Examination

77
 ! Vital
! GPE
! Neuro exam

Diagnosis- A subarachnoid haemorrhage is an uncommon type of bleeding on

the surface of the brain. It's a very serious condition and can be fatal.

Management
! Urgent Admission to ICU
! Involve Senior
! Investigation
o Blood- routine tests, clotting profile, bleeding profile
o Imaging- urgent CT head
o Lumber puncture

! Symptomatic treatment
o Pain killer- Morphine
o Anti-emetic
o Anti-seizure
o Nimodipine
o Labetalol for HTN
! Neurosurgical treatment - refer to neurosurgeon
o Clipping or coiling of bleeding vessel
! Monitor closely
! S/N – if feel unwell, ring the bell which is beside your bed

78
40. Immunisation (8th Week Vaccines)

Key Point
You are FY2 in GP.
Mother of 6 weeks old boy makes an appointment for having some concerns
regarding 8th week vaccines.
Talk to her and address her concern.
Þ worrying that her son will be sick after vaccination
Þ Baby has no issues currently
Þ A vaccine chart is given in the cubicle

Concerns:
Þ Why is it important?
Þ Is there any side effect?
Þ What if the baby is allergic to the vaccine?

Station Approach
! Greet and confirm identity
! Relationship with the baby
! Paraphrase the scenario
! Explore the concern
o What
o Why
o Any particular concern
o Assess prior knowledge on baby vaccines
! Explore background health status (quickly)
! Any illness
! MMA if any
! BIRD DDD

Management
! Explain about 3 vaccines
o The 6-in-1 vaccine helps protect against serious illnesses like polio
and whooping cough. It's given to babies when they're 8, 12 and 16
weeks old. (1 injection)

79
 o The MenB vaccine helps protect against meningococcal group B
bacteria that can cause serious illnesses, including meningitis and
sepsis. It's given to children when they're 8 weeks, 16 weeks and 1
year old. (1 injection)
o The Rotavirus vaccine is the best way to protect your child against
rotavirus diseases like severe watery diarrhoea, vomiting, fever,
and abdominal pain. Children who get rotavirus disease can
become dehydrated and may need to be hospitalized. (1 oral)
! Explain about common side effects
o swelling or pain where the injection was given
o fever
o loss of appetite
o being sick or diarrhoea
o irritability
! Reassure the mother that a simple painkiller like Paracetamol can be used
to ease those symptoms.
! Explain about rare and severe side effect like anaphylaxis. Mention that
the person who vaccinates your child will be trained to deal with allergic
reactions and treat them immediately.
! Answer the questions asked by the mother
! Make sure you consult the station with two ways conversation with
friendly manner.
! Confirm about upcoming appointment
! S/N about sign infections and illness before vaccination.

NICE CKS management for Childhood immunizations - up to 1 year of age

80
41. Abdominal examination (Acute Cholangitis)

Key point
You are FY2 in A&E.
42years old woman comes with abdominal Pain.
Talk to the patient do relevant examination and address concern.
Þ Patient has abdominal pain for 2 days, sudden onset and getting worse.
Þ Right sided
Þ Radiate to shoulder
Þ Jaundice (+)
Þ Fever (+)
Þ No abdominal distension

Examination
Þ Patient show pain when you touch
Þ Pain at right hypochondrium
Þ Murphy’s sign (+)
Þ Fever 39’C

Concern
How will you treat me?
How long do I have to stay in the hospital for key hold surgery?

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore on abdominal pain – SOCRATES
! Associated symptoms- fever, pain, jaundice, nausea, vomiting, stool and
urine colour, confusion, breathlessness, ankle swelling, bleeding
! DDx – acute coronary syndrome, hepatitis, pancreatitis, Appendicitis,
trauma, kidney disease
! MAFTOSA
! DESA

81
 ! ICE
(Ask quickly. Don’t take too much time on history taking. You need enough time
for examination and management. A long and perfect history taking “only” will
not make you pass the station)

Examination
! Observation
! BMI
! GPE
! Abdominal examination
o PPECC
o Do abdominal exam as taught in the academy
o Check patient face during examination

Diagnosis and Explanation- Acute cholecystitis is inflammation of the

gallbladder. It usually happens when a gallstone causes blockage and infection
making the gallbladder swollen and painful. This condition is called acute
cholecystitis.

Management
! Admit the patient
! Confirmation of the diagnosis,
o Blood – FBC, CRP, serum amylase, LFT, lipid profile
o Imaging – USG
! Monitor (blood pressure, pulse, and urinary output).
! Treatment
o Nil by mouth
o Intravenous fluids
o Antibiotics
o Analgesia
! Surgical assessment for cholecystectomy(keyhole/open)
! Advice about DESA if any
! S/N - if feel unwell, ring the bell which is beside your bed

82
42. Aortic Dissection

Key Point
You are FY2 in A&E.
A 64 years old man presented with back pain since last night.
Talk to him, address his concerns and manage him accordingly.
Þ Sudden onset
Þ Severe sharp pain
Þ Start from chest then radiated to back
Þ Dizziness (+)
Þ Hypertension (+) and not complaint with medications.
Þ Smoking (+)
Þ Family history (-)
Examination
Þ no pulse in one leg
Þ BP high
Þ Different BP between right and left hand

Concern
Is this serious?
What will you do for me?

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore on pain – SOCRATES
! Associated symptoms – features of shock
! DDx – AAA, PID, Cauda equina, Ankylosing spondylitis
! Red flag – spinal cord compression, shock
! P2+ MMA
! DESA
! MAFTOSA
! ICE

83
Examination
! Vitals
! Straight leg raise test
! Neurological examination
! Abdominal examination
! Radio radial and radio femoral pressure index

**You may know the case is Aortic Dissection only after the examination. If so,
ask about associated symptoms or features of shock now**

Diagnosis- Aortic rupture is when the wall of the aorta loses its elastic nature,
tears and causing blood to leak out from the aorta often due to a large aortic
aneurysm that bursts. This will stop blood being pumped around the body and
is life threatening.

Management
! Admit
! Monitor BP at Right arm
! Involve senior
! Investigation
o Blood – routine + blood G&M, D-dimer
o Imagine – urgent CT
! Treatment
o Oxygen
o Analgesia – IV morphine
o Anti-emetic – IV ondansetron
o If Hypertension – Labetalol
o If Hypotensive – IV fluid resuscitation +/- Blood transfusion
o If Hypovolaemic shock – Noradrenaline
o If Cardiogenic shock – Dobutamine
(use relevant medications, not need to verbalize ALL)
! Call Vascular surgeon (urgent)
! Type A dissection (involves ascending aorta)
o open surgery to prevent rupture into the pericardial sac and
causing pericardial tamponade.

84
 ! Type B dissections (does not involve the ascending aorta)
o managed medically but may require endovascular stenting if the
patient has persistent pain, a rapidly expanding aortic diameter, or
malperfusion of branch vessel organs.
! S/N - if feel unwell, ring the bell which is beside your bed

43. Somatic Disorder

Key Point
28 years old man presented with a neck lump
He has multiple GP visit previously with complaints of lump on chest and mole
on hand.
He had some investigations and everything came back normal every time.
Talk to the patient and management accordingly.

Þ He thinks he felt lump on left side of the neck

Þ No other symptoms
Þ MMA- nil
Þ Examination- nil
Concern
Þ Doctor I am worried about cancer?
Þ Is it cancer?
Þ How you rule out it is not cancer?
Þ Will you not take a sample?

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore the complaint (ODIPARA)
! Associated symptoms – fever, pain, discharge, lymph node

85
 ! Why worried for cancer
! FLAWS
! MMA
! DESA
! Job?
! Explore about previous visits
! Ask about do they understand what’s going on?
! Psychosocial
! What troubles them most about this situation
! Access mood/sleep/work
! Support system

Examination
! Vital
! GPE

Diagnosis and explanation – All my examinations are normal and the tests that
have been done last time were also comes as normal. This shows that there is
no life-threatening illness that could put your life at risk. However, I am a bit
worry about your well-being as this condition is affecting you seriously.
Somatic symptom disorder is diagnosed when a person has a significant focus
on physical symptoms, such as pain, lump, weakness or shortness of breath, to
a level that results in major distress and/or problems functioning. The individual
has excessive thoughts, feelings and behaviours relating to the physical
symptoms.

Management
! Reassure the patient
! Refer to psychiatrist
! CBT in the meanwhile
! Yoga, Exercise, Relax, Take break from work.
! Develop a hobby
! S/N – Mood
! F/up – 4-6 weeks

86
44. Leukaemia

Key Point
50-year-old man came on his follow up visit.
Few investigations were done for him on a previous visit.
Results are inside the cubicle. He has come for his results.
Talk to the patient, explain test results, tell management plan and address his
concerns.

Þ He came to the clinic a few days back because his wife was worried that
he is losing weight
Þ He doesn’t know himself
Þ FLAW (-)
Þ He considers himself fit and healthy
Þ No significant past medical history
Þ No family history

Test result – WBC 40 with increase lymphocytes

Concern
Þ Why am I having this?
Þ Any treatment for it Dr?

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore the why he took the test at first place
! Sign and symptom of leukaemia
o FLAWS
o Tiredness
o Rash or bruise
o Bleeding from gum or nose etc
o Bone pain
! PMHx
! deSa
! Family Hx

87
 ! Occupation
! ICE
Examination
! Vital
! GPE

Diagnosis – Explain what you found and what is in the test result. Explain which
is not normal to have such high levels of WBC in absence of any infections.

Management
! Use BBN approach to deliver that you are worrying for serious condition
like leukaemia. However, which need to be confirmed by the specialist.
! Act like you empathise him.
! Refer to blood specialist within 2 weeks
! Do routine investigation before referral
! S/N – mood, bleeding, pain
! F/up – after specialist assessment

88
45. Molluscum Contagiosum

Key point
You are FY2 in GP
A mother of 5 years old boy made a video appointment for having some
concern regarding her son skin.
A picture of his skin taking by this morning is sent via email and which is inside
the cubicle.
Talk to her and address her concern.
Þ Bump on chest 6 weeks
Þ Started as rash
Þ Increasing in number
Þ No pain
Þ Itchy (+)
Þ MMA (-), Family Hx (-), Contact Hx (-)

Picture given

Concern
Þ What should I do for him?
Þ How long does it take to relief?

89
Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Request for a moment and take a look at picture/ test results
! Explore skin condition (ODIPARA)
! Site, size, shape, surface, colour, discharge, itchiness
! Changes?
! ODIPARA
! Trauma, Insect bite, Sun exposure, Contact Hx
! Differentials – Meningitis, Anaphylaxis, Fungal, Eczema
! PMH + MMA
! Family Hx
! Contact Hx
! ICE

Diagnosis – Molluscum contagiosum is a viral infection that causes spots on the

skin. It's usually harmless and rarely needs treatment. It’s most common in
children.

Management
! Request to come to clinic as you like to examine him and do routine
investigations.
! Typically, it doesn’t need treatment for molluscum contagiosum because
it usually clears up on its own. (around 18 months)
! DOs
o try things to help with dryness and itchy skin, such as holding a
damp towel against the skin, having cool baths or using an
unperfumed moisturiser regularly
o keep the affected area covered, including using waterproof
bandages if you go swimming
! DON'T
o do not squeeze or scratch the spots, as it could cause an infection
or scarring
o do not share baths or things such as towels, bedding or clothes

90
 ! S/N – Let us know if severe itching or pain, rapid spread of lesions, signs
of secondary infection, and systemic symptoms like fever
! F/up – 3-6 months

46. Unwanted Pregnancy

Key Point
You are FY2 in GP
16 years old girl made an urgent appointment.
Talk to her and address her concern.
Þ Vomiting repeatedly for 1 week
Þ No other symptoms
Þ LMP – 6 weeks
Examination
Þ Pregnancy test – positive

Concern
Þ I don’t want my mom to know about this.

Station Approach
! Greet and confirm identity
! Paraphrase the scenario
! Explore vomiting
o ODIPARA
o Content
o Relation with food
! Associated symptoms (fever, headache, tummy pain, diarrhoea, urine
problem, medications, pregnancy)
! LMP
! MMA
! DesA
! Travel Hx
! ICE

91
Examination
! Vital
! GPE
! Pregnancy test

Diagnosis – Pregnancy
! Explore on pregnancy (plan or unplanned, friend or family know about
this? patient perspective on the pregnancy)
! Offer confidentiality if patient is shy or reluctant to open up
! Her Plan for this
o Continuing with the pregnancy and keeping the baby
o Having an abortion
o Continuing with the pregnancy and having the baby adopted
! Give her some time (a week) to think and decide what to do next.

Management
! Continue with routine investigation
o Blood tests
o USG
o Urine analysis
! Treatment for vomiting
o Oral combination of doxylamine + pyridoxine (vit B6) called Xonvea
! Folic acid
! Offer support
! Advise her to discuss the issue with her family
! S/N- mood
! F/up- 1 week

92
47. Dementia

Key Point
You are FY2 in GP
A daughter of 70 years old woman comes to the clinic with some concerns.
Her mother had blood test last week and came back as all normal.
She was diagnosed with dementia. She also had hypertension which is well
control with medications.
Talk to the daughter and address her concern.

Note: She has consent from her mother to talk about her mother’s health.

Þ Mom is forgetting her sometimes

Þ Mom can perform her daily activities on her own now.
Þ Daughter is working and she cannot live by her mom side all day long
Þ Daughter is sad about her absence and cannot help every day
Þ But she doesn’t want to put her mom to care home.
Þ She stressing about this issue

Concern
Þ What is happening with my mom?
Þ What is dementia?
Þ What kind of help can I get?

Station Approach
! Greet and confirm identity
! Relationship with patient
! Confirm she has consent from mother
! Paraphrase the scenario and assess her knowledge on her mom
! Explore her concern
! Explore her mom conditions/ symptoms
! MMA
! Mom’s psychosocial

93
 ! Daughter’s psychosocial
! ICE
Management
! Explain about nature of dementia and its symptoms
! Explain about treatment you can give for mom (Donepezil, rivastigmine
or Memantine)
! Explain about care package NHS can provided
! Offer daughter psychoeducation and skills training intervention including
how to deal with patient behaviours
! Offer support for both
! Support groups (e.g Dementia UK)
! S/N- mood

(The station is not about how you threat dementia. It is about how to manage
and help the psychosocial of the patient and the carers)

NICE CKS recommendation on dementia management

94
48. Teaching (Subcutaneous Injection)

Key Point
You are FY2 in Medical Department.
A final year student who is undergoing a rotation in your department.
He has been on the ward for weeks and he would like to learn how to
perform
subcutaneous injection.

Station Approach
! Greet and build rapport
! Paraphrase the scenario
! Explore 4W
! Usages of SC inj (insulin, LMWH, palliatives)
! Teach the procedure as taught in the academy
o Collect materials
o Check Medications
o Check ID
o PPECC
o Teach step by step of injection
o S/N
! Appropriate injection site
o Abdomen: avoid injecting within a 2-inch radius around the
umbilicus (this is the preferred site if administering low molecular
weight heparin).
o Upper outer aspect of the arm.
o Outer aspect of the upper thigh.
o Upper buttock.
! S/N- come back if you have questions

95