gk’s notes - part 2

gk’s notes – part 2

Based on Masterclass by Dr. Lovaan - October 2024

Compiled and edited with OpenAI Whisper and Anthropic Claude AI

gk’s notes – part 2

Table of Contents
PSYCHIATRY ......................................................................................................................................... 1
SCHIZOPHRENIA ................................................................................................................................................... 1
DEPRESSION SCENARIOS ........................................................................................................................................ 7
Follow-Up Scenario: CBT Not Working ........................................................................................................... 18
Severe Depression Scenario ...........................................................................................................................20
Postnatal Depression Scenario ...................................................................................................................... 21
Hypothyroidism Scenario .............................................................................................................................. 21
Work-Related Stress Scenario ........................................................................................................................ 22
SUICIDAL SCENARIOS........................................................................................................................................... 23
Scenario: OCP Overdose and Wrist Cutting ....................................................................................................24
Paracetamol Overdose .................................................................................................................................. 27
Paracetamol Overdose in Gay Patient............................................................................................................ 30
DRUG ADDICT .................................................................................................................................................... 32
ALCOHOL .......................................................................................................................................................... 36
Scenario 1: OBG Setting - Incidental Finding of Excessive Alcohol Use ............................................................. 36
Scenario 2: GP Setting - Patient Seeking Help for Alcohol Withdrawal ............................................................. 39
SMOKING CESSATION .......................................................................................................................................... 40
Scenario 1: COPD Patient in Hospital .............................................................................................................40
Scenario 2: Breastfeeding Mother in GP ......................................................................................................... 43
INSOMNIA SCENARIOS ......................................................................................................................................... 44
Scenario 1: 60-year-old lady with rheumatoid arthritis ...................................................................................44
Scenario 2: 28-year-old man with insomnia ...................................................................................................45
ANOREXIA NERVOSA ........................................................................................................................................... 46
BULIMIA NERVOSA .............................................................................................................................................. 47
SUSPECTED DEMENTIA ........................................................................................................................................ 48
HEALTH ANXIETY ................................................................................................................................................ 51
ADHD (ATTENTION DEFICIT HYPERACTIVITY DISORDER) .......................................................................................... 52
SUSPECTED CANCER SCENARIOS ........................................................................................................ 56
NECK LUMP ....................................................................................................................................................... 61
ENDOMETRIAL CARCINOMA .................................................................................................................................. 66
OESOPHAGEAL CARCINOMA ................................................................................................................................. 67
BLADDER CARCINOMA ......................................................................................................................................... 70
BLADDER CARCINOMA ASSESSMENT FROM TEST RESULTS......................................................................................... 74
RESPIRATORY CONDITIONS ................................................................................................................ 79
LUNG CANCER SCENARIO ..................................................................................................................................... 85
MESOTHELIOMA SCENARIOS................................................................................................................................. 87
Mesothelioma Scenario 1: Respiratory Unit .................................................................................................... 87
Mesothelioma Scenario 2: GP Setting ............................................................................................................88
Mesothelioma Scenario 3: A&E Setting ..........................................................................................................89
TUBERCULOSIS (TB) ............................................................................................................................................ 91
TB Scenario 1: GP Setting (Stable Patient) ..................................................................................................... 91
TB Scenario 2: A&E Setting (Unstable Patient) ............................................................................................... 93
LEUKAEMIA SCENARIOS ....................................................................................................................................... 96
Chronic Lymphocytic Leukaemia (CLL) Scenario .............................................................................................96
Acute Leukaemia Scenario ............................................................................................................................98

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gk’s notes – part 2

PROSTATE CANCER SCENARIOS ......................................................................................................... 100

Prostate Cancer Scenario 1: History-Only ..................................................................................................... 100
Prostate Cancer Scenario 2: Mannequin Scenario ......................................................................................... 102
Prostate Cancer Scenario 3: Frequency as Main Complaint ............................................................................ 102
Worried about Prostate Cancer Scenario ...................................................................................................... 104
PSA Test Consultation ................................................................................................................................. 107
PSA TEST RESULTS SCENARIOS .......................................................................................................................... 110
Scenario 1: Well-man Clinic Result ............................................................................................................... 110
Scenario 2: Patient Worried About Prostate Cancer....................................................................................... 110
Scenario 3: Normal PSA Result .................................................................................................................... 110
Scenario 4: Symptomatic Patient with Normal PSA ...................................................................................... 110
PSA FIRST PRESENTATION WITH SYMPTOMS AND MANNEQUIN ................................................................................. 111
COLON CANCER CONSULTATION SCENARIO ....................................................................................... 113
HYPONATREMIA ................................................................................................................................ 118
SIADH SCENARIO ............................................................................................................................................. 123
CITALOPRAM SCENARIO ..................................................................................................................................... 125
ADDISON'S DISEASE SCENARIO ........................................................................................................................... 126
BULIMIA SCENARIO ........................................................................................................................................... 128
SIADH WITH INFECTION SCENARIO ...................................................................................................................... 130
RENAL FAILURE SCENARIO ................................................................................................................................. 132
OBSTRUCTIVE SLEEP APNEA (OSA) SCENARIO.................................................................................... 134
HYPERTENSION FOLLOW-UP SCENARIOS .......................................................................................... 136
SCENARIO A: ENALAPRIL AND COUGH .................................................................................................................. 136
SCENARIO B: AMLODIPINE AND LEG SWELLING ....................................................................................................... 137
SCENARIO C: COMBINATION THERAPY.................................................................................................................. 138
MEDICAL ERROR SCENARIOS ............................................................................................................. 140
RENAL BIOPSY MEDICAL ERROR SCENARIO ........................................................................................................... 144
MISSED BLOOD SAMPLE .....................................................................................................................................151
WRONG CHEST X-RAY SCENARIO ......................................................................................................................... 158
MISSED MYOCARDIAL INFARCTION (MI) SCENARIO ................................................................................................. 165
MISSED FOREIGN BODY SCENARIO ....................................................................................................................... 171
MISSED HAIRLINE FRACTURE SCENARIO ................................................................................................................178
MISSED GLASS PIECE SCENARIO ...........................................................................................................................179
MISSED FRACTURE IN ELDERLY PATIENT SCENARIO ................................................................................................ 183
ANGRY PATIENTS .............................................................................................................................. 189
INFECTED CYST ................................................................................................................................................. 194
INFECTED HERNIA ............................................................................................................................................. 198
HEART FAILURE MOTHER ................................................................................................................................... 202
CHILD COVERED WITH POO AND VOMIT ................................................................................................................ 207
MEDICATION CHANGE NOT INFORMED TO DAUGHTER ............................................................................................. 210
GP MISSED MOTHER'S DIAGNOSIS ...................................................................................................................... 214
CEREBRAL PALSY .............................................................................................................................................. 218
ANTIBIOTIC-RELATED SCENARIO IN PEDIATRICS ..................................................................................................... 223
PCP (PNEUMOCYSTIS PNEUMONIA) SCENARIO .................................................................................. 227

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gk’s notes – part 2

ABDOMINAL SCENARIOS ................................................................................................................... 231

PID IN GP SETTING (NO MANNEQUIN) ................................................................................................................. 231
PID IN GP SETTING (WITH ABDOMINAL MANNEQUIN) ............................................................................................ 233
PID IN A&E SETTING (WITH ABDOMINAL MANNEQUIN).......................................................................................... 233
ABDOMINAL EXAMINATION TEACHING .................................................................................................................. 235
INTESTINAL OBSTRUCTION SCENARIO .................................................................................................................. 239
Scenario 2: Female Patient with Mannequin ................................................................................................ 242
Scenario 3: Real Human Patient .................................................................................................................. 243
OVARIAN CANCER SCENARIO .............................................................................................................................. 245
ALCOHOL LIVER DISEASE SCENARIO .................................................................................................................... 248
CONFUSION RELATED TO PROSTATE ISSUES SCENARIO............................................................................................ 251
HEART FAILURE SCENARIOS ................................................................................................................................ 254
Scenario 1: Heart Failure in A&E (With Mannequin) ...................................................................................... 254
Scenario 2: Heart Failure (Without Mannequin) ............................................................................................ 256
Heart Failure Scenario 3: GP Setting ............................................................................................................ 257
CHOLECYSTITIS SCENARIO .................................................................................................................................. 259
CHOLANGITIS SCENARIO .................................................................................................................................... 260
PID (PELVIC INFLAMMATORY DISEASE) SCENARIO .................................................................................................. 261
PANCREATITIS SCENARIOS .................................................................................................................................. 262
Scenario 1: Acute Pancreatitis in A&E .......................................................................................................... 262
Scenario 2: Acute on Chronic Pancreatitis in A&E.......................................................................................... 263
Scenario 3: Pancreatitis in GP Setting .......................................................................................................... 264
HEADACHE ....................................................................................................................................... 266
HANGOVER HEADACHE ...................................................................................................................................... 270
MENINGITIS ..................................................................................................................................................... 274
MIGRAINE ......................................................................................................................................................... 277
ALLERGIC RHINITIS ............................................................................................................................................ 282
UNILATERAL NASAL POLYP ................................................................................................................................. 283
MENSTRUAL MIGRAINE ...................................................................................................................................... 286
PREMENSTRUAL SYNDROME (PMS)..................................................................................................................... 287
PERIMENOPAUSE AND MENOPAUSE ..................................................................................................................... 289
SUBARACHNOID HEMORRHAGE IN A&E ................................................................................................................ 290
SUBARACHNOID HEMORRHAGE IN GP .................................................................................................................. 292
GIANT CELL ARTERITIS (GCA) ............................................................................................................................. 294
Scenario 1: Simple Headache ...................................................................................................................... 294
Scenario 2: Sudden Loss of Vision ................................................................................................................ 295
PITUITARY ADENOMA ........................................................................................................................................ 296
CARBON MONOXIDE POISONING ......................................................................................................................... 298
SINUSITIS......................................................................................................................................................... 302
TENSION HEADACHE ......................................................................................................................................... 302
INTRACRANIAL HYPERTENSION............................................................................................................................ 304
CHEST PAIN ....................................................................................................................................... 306
MYOCARDIAL INFARCTION (MI) ........................................................................................................................... 309
UNSTABLE ANGINA ............................................................................................................................................ 313
STABLE ANGINA................................................................................................................................................. 317
MUSCULOSKELETAL CHEST PAIN AND PERICARDITIS ............................................................................................... 320
Musculoskeletal Chest Pain ......................................................................................................................... 321

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gk’s notes – part 2

Pericarditis ................................................................................................................................................. 322

SHINGLES ........................................................................................................................................................ 323
PULMONARY EMBOLISM (PE) ............................................................................................................................. 326
POST-HERPETIC NEURALGIA ............................................................................................................................... 329
ECTOPIC PREGNANCY ........................................................................................................................ 331
LEGIONELLA PNEUMONIA ................................................................................................................. 332
DIZZINESS SCENARIOS ...................................................................................................................... 334
BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) .............................................................................................. 337
MENIERE'S DISEASE .......................................................................................................................................... 339
VESTIBULAR NEURITIS - FULLY EXPANDED ............................................................................................................. 341
PRE-OPERATIVE SCENARIOS .............................................................................................................. 344
DERMAL CYST REMOVAL .................................................................................................................................... 348
HERNIA SURGERY.............................................................................................................................................. 350
ANKLE PIN REMOVAL......................................................................................................................................... 352
POST-OPERATIVE CARE FOR KNEE ARTHROPLASTY ................................................................................................ 355
LEARNING DISABILITY SCENARIOS .................................................................................................... 359
RIVAROXABAN SCENARIO FOR PATIENTS WITH LEARNING DISABILITIES ...................................................................... 361
INSULIN MANAGEMENT FOR PATIENTS WITH LEARNING DISABILITIES ......................................................................... 364
DVT CONSULTATION FOR PATIENT WITH LEARNING DISABILITY .................................................................................367
HYPERTENSION FOLLOW-UP ............................................................................................................. 371
POSTURAL HYPOTENSION AND FALL SCENARIO IN GP PRACTICE ....................................................... 375
ELDERLY FALL AND HIP FRACTURE SCENARIO IN HOSPITAL WARD ............................................................................ 378
OTHER SCENARIOS ............................................................................................................................ 381
CELIAC DISEASE ................................................................................................................................................ 381
BARRETT'S OESOPHAGUS................................................................................................................................... 381
ANALGESIC NEPHROPATHY ................................................................................................................................. 381
ACE INHIBITOR-INDUCED NEPHROPATHY.............................................................................................................. 382
Scenario 1: Recent start of ACE inhibitors ..................................................................................................... 382
Scenario 2: Long-term use of ACE inhibitors ................................................................................................. 382
RENAL COLIC ................................................................................................................................................... 382
A&E Scenario:............................................................................................................................................. 382
GP Scenario:............................................................................................................................................... 382
OBESITY COUNSELLING ..................................................................................................................................... 382
Q-RISK ASSESSMENT ......................................................................................................................................... 383
CONSTIPATION (ELDERLY PATIENT) ...................................................................................................................... 383
TACROLIMUS FOR KIDNEY TRANSPLANT ............................................................................................................... 384
CAT BITE ......................................................................................................................................................... 384
DOG BITE ........................................................................................................................................................ 384
RAYNAUD'S PHENOMENON ................................................................................................................................ 385
OSTEOPOROSIS ................................................................................................................................................ 385
EYE SCENARIOS ................................................................................................................................................ 385
a. Blepharitis .............................................................................................................................................. 385
b. Retinal Detachment ................................................................................................................................ 385

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c. Toxoplasmosis ......................................................................................................................................... 385

d. Ocular Herpes ......................................................................................................................................... 386
e. Scleritis ................................................................................................................................................... 386
f. Age-Related Macular Degeneration (ARMD) ............................................................................................. 386
ANKYLOSING SPONDYLITIS ................................................................................................................................. 386
URINARY INCONTINENCE .................................................................................................................................... 388
UTERINE PROLAPSE........................................................................................................................................... 388
ERECTILE DYSFUNCTION (ED) ............................................................................................................................. 388
Scenario 1: Gay Couple ................................................................................................................................ 388
Scenario 2: Elderly Man (Psychogenic ED) .................................................................................................... 388
Scenario 3: Man with Heart Condition .......................................................................................................... 389
OB/GYN SCENARIOS ........................................................................................................................................ 389
EAR SCENARIOS ................................................................................................................................. 391
OTITIS MEDIA SCENARIOS .................................................................................................................................. 391
Scenario 1: Adult with 1-day ear pain ........................................................................................................... 391
Scenario 2: Adult with 5-day ear pain, penicillin allergy ................................................................................ 391
Scenario 3: Child with 2-day ear pain ........................................................................................................... 391
Scenario 4: Child with ear discharge............................................................................................................. 392
Scenario 5: Child with ear pain, discharge, and perforation ........................................................................... 392
EARWAX SCENARIOS ......................................................................................................................................... 392
Scenario 1: First-time earwax presentation .................................................................................................. 393
Scenario 2: Earwax follow-up ...................................................................................................................... 393
ACOUSTIC NEUROMA SCENARIOS ........................................................................................................................ 396
Scenario 1: Young Adult with Unilateral Hearing Loss ................................................................................... 396
Scenario 2: Elderly Patient with Tinnitus ...................................................................................................... 399
CHOLESTEATOMA SCENARIO .............................................................................................................................. 400
MALIGNANT OTITIS EXTERNA SCENARIO .............................................................................................................. 403
BENIGN TINNITUS SCENARIO .............................................................................................................................. 405
TESTICULAR SCENARIOS .................................................................................................................... 410
TESTICULAR CARCINOMA ................................................................................................................................... 411
EPIDIDYMAL CYST ............................................................................................................................................. 412
REASSURANCE SCENARIO ................................................................................................................................... 413
MUMPS ORCHITIS ............................................................................................................................................. 414
EPIDIDYMO-ORCHITIS ........................................................................................................................................ 416
COUNSELLING ................................................................................................................................... 417
VASCULAR DEMENTIA ........................................................................................................................................ 419
STROKE SCENARIO ............................................................................................................................................ 422
PREGNANCY COUNSELLING SCENARIO (CAPTOPRIL) ............................................................................................... 425
THALASSEMIA SCENARIO ................................................................................................................................... 427
OTHER SCENARIOS ............................................................................................................................428
CHRONIC FATIGUE SYNDROME SCENARIO ............................................................................................................. 428
VITAMIN D DEFICIENCY SCENARIO ....................................................................................................................... 431
VASCULAR CONDITIONS ..................................................................................................................................... 434
Varicose Vein Scenario................................................................................................................................. 434
UTI IN CHILD SCENARIO ..................................................................................................................................... 436
MORNING AFTER PILL SCENARIOS ....................................................................................................................... 437

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Scenario: 25-28-year-old lady with epilepsy ................................................................................................. 437

PARKINSON'S DISEASE SCENARIOS ...................................................................................................................... 438
FIRST FIT SCENARIO .......................................................................................................................................... 439
TRIGEMINAL NEURALGIA SCENARIO ..................................................................................................................... 440
DIABETIC KETOACIDOSIS (DKA) FIRST PRESENTATION ............................................................................................ 441
TEETHING SCENARIO ......................................................................................................................................... 441
RECURRENT INFECTIONS IN CHILD SCENARIO ......................................................................................................... 442
DIARRHOEA IN A ONE-YEAR-OLD CHILD ............................................................................................................... 443
SEXUALLY TRANSMITTED INFECTIONS (STI) SCENARIOS .................................................................... 445
CHLAMYDIA IN A CHILD ...................................................................................................................................... 446
CHLAMYDIA IN A MAN WITH JOINT SWELLING ........................................................................................................ 447
GONORRHOEA SCENARIOS ................................................................................................................................. 447
Scenario 1: Telephone consultation .............................................................................................................. 447
Scenario 2: Test results discussion ................................................................................................................ 448
TRICHOMONIASIS SCENARIOS ............................................................................................................................. 448
Scenario 1: ................................................................................................................................................. 448
Scenario 2: ................................................................................................................................................. 448
HIV SCENARIOS ................................................................................................................................................ 449
HIV First Presentation in GP ........................................................................................................................ 449
HIV Test Result Discussion in GUM Clinic ...................................................................................................... 450
HIV Follow-up Questions in GP .................................................................................................................... 451

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gk’s notes - part 2
gk’s notes - part 2

Psychiatry
Schizophrenia

Introduction

• Three scenarios in PLAB 2

• No psychosis or delusional disorder diagnoses
• All patients are young (schizophrenia typically occurs at a young age)
• This is another fight that has been taught to students for many years
• This consultation requires a high level of interpersonal skills

Key Points About Schizophrenia

• In schizophrenia, there's no functionality

• Patients cannot function, work, or do anything
• Delusional disorder is different:
o Functionality is intact in delusional disorder
o Patients with delusional disorder can work, earn money, look after family
o Delusional disorder usually comes in older age (after 40-50)
• All three scenarios presented are schizophrenia, not delusional disorder

Starting the Consultation

1. Introduction and Patient Identification

o Introduce yourself: "Hello, I'm Dr. [Your Name]."
o Confirm patient's identity: "Can you please confirm your name and age?"
o Patient may respond: "I'm [Name], I'm 20 years old."
2. Explain Reason for Consultation
o "We've been asked by your mother to speak with you."
o "We understand your mother has referred you and is a bit concerned."
o "Is there anything bothering you or disturbing you lately?"
3. Patient's Initial Response
o Patient may be evasive: "No, no, I'm fine."
o Offer reassurance: "Whatever we discuss will remain confidential."

Assessing Presenting Complaint

1. Open-ended Questions
o "Is there anything going on that you'd like to tell us about?"
o "Have you been experiencing anything unusual lately?"

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2. Specific Inquiries (based on referral information)

o "Your mother mentioned she's concerned. Can you tell me more about that?"
3. Handling Unusual Responses
o Patient may ask: "Are you a spy?"
o Response: "No, I'm not a spy. I'm one of your doctors in this GP practice."

Delusions Assessment

1. Common Delusions in Schizophrenia (Three Scenarios) a. Persecutory Delusions

o "The police is after me / following me."
o Context: Patient might have been brought to A&E by police after
examination at the station

b. Spying Delusions

o "There are a lot of spies around me / spying on me."

o Patient might say: "I'm a spy too. I work for MI6."
o "The people on TV, the news readers, they're spying on me."
o "Everyone is spying on me."

c. Grandiose Delusions

o "King Charles is my real father / biological father."

o Patient might say: "I'm going to the palace to meet the king."
o Context: Father brought patient to GP (concerned father scenario)
2. Follow-up Questions
o "How long have you been experiencing these things?"
o "Have you had any interactions with these spies/police?"
o "What sort of things do they do or say?"
o "Have you done any work for them?"
3. Important Note on Duration
o Don't believe patient's reported duration of symptoms
o Ask bystander (e.g., family member) for accurate duration
o Example: If patient says "last 20 years," don't believe it, but if they say "two
weeks," don't believe that either

Hallucinations Assessment

1. Auditory Hallucinations
o "Do you ever hear voices when no one is around?"
o If yes, probe further:
§ "How many voices do you hear?"

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"Do they speak to you directly or to each other?"

§
§ "What do these voices say?"
§ "Do they ever tell you to do things?"
o Patient might say: "The spies tell me to punch people on the street."
o If harmful commands mentioned:
§ "Have you ever acted on these commands?"
§ "Are you planning to act on them?"
2. Visual Hallucinations
o "Do you ever see things that others can't see?"
o "Have you ever seen spies or other people when you're alone?"

Thought Disorders Assessment

1. Thought Insertion
o "Do you ever feel like someone is putting thoughts into your head that aren't
your own?"
o "Have you experienced foreign ideas in your mind that don't feel like yours?"
2. Thought Withdrawal
o "Do you ever feel like your thoughts have been taken away or removed from
your mind?"
o "Have you experienced sudden emptiness of thoughts?"
3. Thought Broadcasting
o "Do you ever feel like others can know your thoughts without you telling
them?"
o "Do you feel like you can't prevent others from knowing what you're
thinking?"

Mood Assessment

• "How would you describe your mood lately?"

• "Do you ever feel particularly low or down?"

Suicidal Ideation Assessment

• "Have you ever had thoughts about harming yourself?"

• "Have you ever considered ending your life?" Note: Always ask about self-harm in
psychiatric assessments, regardless of presented mood.

Safety Assessment

• "Given what you've been experiencing, have you ever felt the need to protect
yourself?"

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• "Have you ever considered carrying a weapon for protection?"

Differential Diagnosis

• "Have you been physically unwell recently?"

• "Any fevers, flu-like symptoms, or other illnesses?"

Modified FAMISH Assessment

Note: FAMISH is something created for psychiatry, but it should be used logically and not
rigidly.

F - Family history and Functional assessment A - Alcohol and drugs M - Medical conditions
and Medications I - Insight S - Social history and Stress H - Hallucinations (already covered
earlier)

1. Family History (F) and Functional Assessment

o "Has anyone in your family been diagnosed with a mental health condition?"
o "Who do you currently live with?"
o Patient might say: "I live with my mom and dad."
o "Do you have any children?"
o "Are you in a relationship or do you have a partner?"
o Assess functionality: "What do you do for a living?"
o If unemployed: "When and why did you leave your last job?"
o Patient might say: "They said I was acting strange."
o If relationship ended: "Can you tell me what happened with your last
relationship?"
o Patient might say: "My girlfriend left because she said I was acting weird."
2. Alcohol and Drugs (A)
o "Do you drink alcohol? If so, how much and how often?"
o "Do you use any recreational drugs?"
o Patient might say: "I smoke cannabis."
o If cannabis use mentioned: "How long have you been using cannabis?" Note:
Cannabis use in teenage years can increase risk of schizophrenia.
3. Medical Conditions and Medications (M)
o "Do you have any diagnosed medical conditions?"
o "Have you ever been diagnosed with a mental health condition before?"
o "Are you currently taking any medications? If so, what are they?"
4. Insight (I)
o "Do you think you might need some help with what you've been
experiencing?"
o "Do you think there's anything wrong or unusual about your experiences?"

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o "Do you believe that doctors might be able to help you with these
experiences?"
5. Social History and Stress (S)
o Social History:
§ "Do you have close friends or a support network?"
o Stress:
§ "Are you experiencing any significant stress in your life right now?"
§ "How has your sleep been lately?"

Physical Examination

• Inform the patient: "I'd like to perform a brief physical examination, including
checking your blood pressure and temperature."

Diagnosis Explanation

• "Based on what you've told me, it seems you might be experiencing a condition
called schizophrenia."
• "Schizophrenia is a mental health condition."
• "People with this condition may have some strong beliefs, some firm beliefs. For
example, such as somebody's following them, or they belong to a certain family, or
somebody's spying on them."
• "In addition to that, they may also have some other unusual experiences, such as
hearing voices or seeing things when no one is around."
• "They might experience that somebody's trying to put some ideas in their head."
• "They may have some such experiences, but in the actual sense, they may not be
true."
• Avoid using terms like "reality checks" or "detachment"

Management Plan

1. Emergency Referral
o "This is a medical emergency. It's not an ambulance case, but you need to see
a psychiatrist specialist immediately."
o "Can you go to the hospital?"
o "Can your mother/father take you to the hospital?"
2. Home Treatment Team Referral
o "At the meantime, we will refer you to the Crisis Resolution Home
Treatment Team (or Home Treatment Team)."
o Explain: "They will follow you up."
3. Hospital Assessment Explanation
o "When you go to the hospital, they will assess you."

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o"They will do the examination. They will do some blood tests."

o "Once they confirm, the psychiatry team will offer you medication."
4. Medication Information
o "They can give you a medication called Risperidone as an injection."
o "Or they can give you a medication called Olanzapine as an injection or
tablet."
o Explain benefits: "When you take this medication, the experiences that you
have been having lately will disappear. That means you will be able to do
your day-to-day activities without any disturbances. This will help you to
improve your quality of life."
5. Addressing Patient Concerns
o Patient might ask: "How is this going to help me?"
o Response: Reiterate the benefits of medication
o Patient might ask: "Can you treat me at home?"
o Response: "It may be possible. If you don't want to go to the hospital, the
Home Treatment Team, which usually includes a registrar-level doctor and a
mental health nurse, will come and assess you. They will see whether it is
possible to treat at home. Otherwise, you know, they will take you with
them."

Patient Response to Treatment Plan

• Patient may respond with "whatever" to treatment suggestions

• This means they are neither refusing nor accepting treatment
• It's not a refusal of treatment, which would require mental health act intervention
(sectioning)

Important Consultation Notes

• Expect the patient to be distractible and potentially difficult to engage

• Patient may look over their shoulder, move around, shake, rock back and forth,
look up and down, or suddenly look outside
• Maintain a calm, professional demeanour even if the patient is agitated
• Be prepared to repeat questions or information as the patient may struggle to focus
• The consultation may take up to 45 minutes
• Anticipate that the conversation may jump around; try to keep it structured
• This scenario requires a different level of interpersonal skills

Things to Avoid

• Don't use terms like "psychosis" or "delusional disorder" with the patient

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gk’s notes – part 2

• Avoid asking "How long have you been thinking this?" Instead, ask about their
experiences
• Don't apply the FAMISH structure rigidly; use it as a guide but allow for natural
conversation flow
• Avoid relying on phrases like "caring father" or "caring mother" for rapport building
• Don't assume the patient's reported symptom duration is accurate; family accounts
may be more reliable
• Never treat the patient as if they are "insane" or incapable of understanding
• Avoid losing composure, even if the patient is difficult
• Don't use casual language or self-deprecating humour
• Never skip assessment steps, even if the patient is uncooperative
• Don't argue with or challenge the patient's delusions directly
• Avoid relying on advice from other students about how to handle the scenario
• Don't assume that passing marginally in a previous attempt means your approach
was correct
• Avoid starting financial questions in the middle of the psychiatric assessment

Additional Notes

• All three scenarios presented are schizophrenia, not delusional disorder or psychosis
• The "concerned father" scenario refers to the case where the patient believes King
Charles is their biological father
• Cannabis use in teenage years is a known risk factor for schizophrenia
• The inability to function (work, relationships) is a key distinguishing factor between
schizophrenia and delusional disorder
• Always consider safety (for both patient and others) when assessing a patient with
potential schizophrenia

Depression Scenarios
I. Overview of Psychiatric Scenarios in PLAB2

1. Schizophrenia: 3 scenarios
2. Depression and depression-related: 10-12 scenarios
3. Suicidal assessment: 3 scenarios
o 1 OCP (Oral Contraceptive Pills) and cutting wrist
o 2 paracetamol-related
4. Drug addict wanting to quit: 1 scenario
5. Smoking: 2 scenarios
o 1 in gynaecology
o 1 in GP

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6. Smoking cessation: 2 scenarios

o 1 COPD
o 1 breastfeeding
7. Insomnia: 2 scenarios
8. Bulimia: 2 scenarios
o 1 with 15-year-old girl (GP telephone)
o 1 hyponatremia scenario
9. Anorexia: 2 scenarios
o 1 in GP (presenting complaint: "Mother asked me to see you because I'm
losing weight")
o 1 in psychiatry (GP referral due to low BMI)
10. Suspected dementia: 1 scenario ("My daughter thinks I have dementia")
11. ADHD: 1 scenario
12. Somatic symptom disorder: 1 scenario
13. Health anxiety: 1 scenario
14. MMS (Mini-Mental State Examination): 1 scenario
15. General anxiety disorder: 1 scenario (new)

II. Understanding Depression in PLAB2

• Depression is a main topic in psychiatry for PLAB2

• Differentiation between mild, moderate, and severe depression is important
• Management differs for mild vs. moderate/severe depression
• Don't go into the exam with preconceived notions about diagnosis
• Even consultants find it difficult to distinguish between mild and moderate
depression
• The key consideration is whether the patient needs medication or can be managed
with CBT

Common Misconception to Avoid

• It's incorrect to say that depression affecting someone's life indicates moderate
depression
• All depression, by definition, affects someone's life
• The difference lies in how badly it's affecting the person's life (mild, moderate, or
severe)
• If someone has told you that depression affecting someone's life is moderate
depression, that is completely wrong

Approach to Assessing Depression Severity

• The effect on life will be mild, moderate, or severe

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gk’s notes – part 2

• We differentiate by how badly or how much it is affecting someone's life

• It is going to affect all patients with depression, but the level of impact varies

III. Depression Scenarios in Detail

A. Mild Depression Scenarios

1. Lesbian Couple Scenario (less common now)

o One partner had a miscarriage
o The other partner is feeling low
o This is considered mild depression
2. Lady Feeling Low Scenario (original scenario)
o Presenting complaint: "I feel low"
o Husband asked her to see the doctor
o Patient reports:
§ Lost interest in everything (shopping, going out with friends)
§ Problems with sleep
§ Lost weight
o Started feeling this way after her daughter went to school
o Note: Some might mistakenly call this separation anxiety, but it's depression
in PLAB2
o This is considered mild depression
3. Insomnia Scenario (most common depressive scenario currently)
o Man around 40 years old
o Presenting complaint: sleeping problems (insomnia)
o Recent life event: divorced his wife
o Duration of symptoms: 4 months
o Patient may report:
§ Feeling low
§ Losing interest
§ Symptoms present for about 6 months
§ Fear of losing job due to poor performance ("I'm on the verge of
losing my job. They're going to sack me.")
§ Inability to function or perform at work
o Assessment:
§ If symptoms are just 4 months and functioning isn't severely affected,
it's likely mild depression
§ If symptoms are 6 months and job loss is imminent, it may be
considered moderate depression

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gk’s notes – part 2

B. Moderate Depression Scenarios

1. Weight Loss Scenario

o Lady (around 40 years old) presents with weight loss as main complaint
o Presenting complaint: "Doctor, I'm losing weight"
o Note: In current PLAB2, weight loss as presenting complaint is likely
depression, not hypothyroidism or cancer
o This is considered moderate depression and requires medication
2. CBT Not Working Scenario
o Patient diagnosed with depression 2 months ago
o Given CBT, but complains it's not working
o Patient might say: "CBT is rubbish, doctor, it is not working"
o May be at risk of losing job
o This is considered moderate depression and requires medication
3. Post-Heart Attack Depression (new scenario)
o Patient had a heart attack with stent placement
o Not taking medication
o This is considered moderate depression

C. Severe Depression Scenario

• 20-year-old man
• Gay, separated from partner
• Previously admitted to hospital for depression
• Having suicidal ideas
• Patient says: "I'm collecting some tablets. If I go home sometime, I might take it."

D. Post-Natal Depression Scenarios

1. Feeling empty 4-5 weeks after childbirth

o Presenting complaint: "I feel empty"
o Husband asked to see doctor
o May report insomnia and weight loss
2. Insomnia 5 weeks, childbirth 4 months ago
o Presenting complaint: Insomnia for 5 weeks
o Had a child 4 months ago
o Mood is low
3. Insomnia and childbirth both 5 weeks ago
o Presenting complaint: Insomnia for 5 weeks
o Childbirth 5 weeks ago

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gk’s notes – part 2

Note: Any depression within one year of childbirth can be diagnosed as post-natal
depression.

E. Non-Depression Scenarios (important for differential diagnosis)

1. Hypothyroidism presenting as low mood

o Presenting complaint: "I feel low"
o On further questioning, patient has hypothyroid symptoms
2. Work-related stress (male and female versions)
o Male version:
§ Middle-aged man (around 40-42)
§ Presenting complaint: Sleeping problems
§ Wakes up early (around 4 AM) and can't go back to sleep
§ Works in a multinational company as an accountant
§ Recent promotion, lots of work
§ May ask for sleeping pills or antidepressants
o Female version:
§ Works in a multinational company
§ Presenting complaint: "I am depressed"
§ Reports lots of work, no time for anything else
§ May ask for antidepressants

IV. Approach to Depression Assessment

A. Initial Assessment

1. Explore presenting complaint:

o "How may I help you?"
o If patient says "My husband asked me to see you, doctor":
§ "Why did your husband ask you to see us?"
o If patient says "Because I feel low":
§ "What do you mean by feeling low?"
2. Score mood:
o "On a scale of 1 to 10, 1 being really, really low and 10 being happy, what
would you score your mood?"
o Always give the full scale, don't skip parts to save time

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gk’s notes – part 2

B. Major (Core) Symptoms

Ask these questions:

1. "During the last month, have you been bothered by feeling down or depressed or
hopeless?"
o Follow-up: "Would you say this is happening most of the days, most of the
time?"
2. "Would you also say during the last month that you have been mostly bothered by
losing interest in activities you used to enjoy?"

C. Minor Symptoms

Ask about:

1. Energy levels and tiredness

2. Sleep problems (insomnia)
3. Concentration issues
4. Psychomotor agitation or getting angry easily
5. Memory problems
6. Loss of appetite and weight loss
7. Loss of libido
8. Excessive guilt
9. Being tearful
10. Auditory hallucinations (in moderate to severe cases)

• "Have you had some sort of experiences with hearing voices when no one is
around?"

D. Suicidal Assessment

• "Have you had any thoughts of harming yourself?"

• Note: This is not a diagnostic criterion but a complication of depression

E. Differential Diagnosis

Based on presenting complaint:

1. For females, ask about recent childbirth:

o "Do you have any children?"
o "Have you had any recent childbirth?"
o "How is the bonding with the child?"

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gk’s notes – part 2

o If bonding issues: "Have you ever had any thoughts of harming the baby?"
2. Hypothyroidism (don't need to ask about symptoms if you're a doctor)
3. Bipolar disorder:
o "Have you ever experienced having so much energy in order to get things
done?"
4. PTSD:
o "Have you ever had any traumatizing event in your life that gives you
nightmares and flashbacks and hampers your day-to-day activities?"

F. MAFTOSA Assessment

1. Medical history:
o "Have you ever been diagnosed with any mental health conditions?"
o "Have you ever been diagnosed with depression in the past?"
2. Alcohol and drugs
3. Prescription medications
4. Treatment history
5. Occupation and stress:
o "Has anything significant happened in your life recently?"
o "Have you lost anything significant like a relationship, job, or money?"
6. Social history:
o "Who do you live with?"
o "Is your husband supportive?"
o "How are you finding it difficult to look after your child?"
o "Are you into exercise?"
o "What do you do in your free time?"
7. Appetite/diet

G. Patient's Ideas, Concerns, and Expectations

• "What do you think may be causing this?"

• "What are your concerns?"
• "What are your expectations from this consultation?"

H. Effect of Symptoms on Daily Life

• "How has this been affecting your life in general?"

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gk’s notes – part 2

V. Depression Diagnosis

Definition: "Depression means feeling constantly low and losing interest in activities
someone used to enjoy. When these symptoms start affecting or impacting someone's day-
to-day life, we call that clinical depression."

Diagnostic Criteria:

• At least one core symptom

• Multiple minor symptoms
• Symptoms present for at least 4 weeks
• Significant impact on daily functioning

VI. Depression Management

A. Alpha-Beta-Gamma Approach:

1. Alpha (for all severities): a. Lifestyle changes:

o Regular exercise
o Pursuing hobbies
o Making new friends
o Arranging holidays
o Getting a pet
o Improving sleep patterns
o Addressing negative lifestyle factors (e.g., alcohol consumption) b. Crisis card
with hotline number for suicidal thoughts c. Follow-up appointments (1
week if under 30, 2 weeks if over 30) d. Provide informational leaflets about
depression and its treatment
2. Beta (for all severities):
o Referral for talking therapy (CBT)
o Explain that it will be organized by therapists/psychologists
3. Gamma (for moderate to severe depression):
o Medication (e.g., Citalopram, Sertraline)
o Explain duration (at least 6 months after feeling better)
o Mention it takes about a month to show full improvement
o Ask if the patient is willing to take medication

B. Management Based on Severity:

• Mild Depression: Alpha + Beta

• Moderate to Severe Depression: Alpha + Beta + Gamma

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gk’s notes – part 2

C. Priority in Discussing Management:

1. Gamma (Medication) if moderate or severe

2. Beta (Talking Therapy)
3. Alpha (Lifestyle changes, crisis card, follow-up, leaflets)

D. Detailed Management Discussion

1. Diagnosis explanation: "It seems like you might have a condition called depression.
Have you heard about it? Let me explain. Depression is a mental health condition.
Depression means feeling constantly low and losing interest in activities someone
used to enjoy. When these symptoms start affecting or impacting someone's day-to-
day life, we call that clinical depression. Do you understand?"
2. Investigations: "First thing, we need to run some tests. Mainly, we need to take your
ECG and some blood tests. In the blood test, we need to check your sugars and salt
and the main organs like kidneys and liver, how well they are functioning. And also,
we also would like to do the thyroid hormone test as well. Would that be okay with
you?"
3. Treatment plan (for moderate depression): "In terms of your treatment, it seems like
moderate depression. Therefore, it's better to take medication. We are going to offer
a medication called Citalopram (or Sertraline). Unfortunately, medication is for
quite a long time. You may have to take it another six months after you have started
feeling better. The medication will take some time to respond. It takes about one
month to show the full improvement. Would that be okay with you? Are you okay
to take it?"
4. Talking therapy: "In addition to the medication, we also advise our patients to go
for a talking therapy as well. We do refer to talking therapy. We will refer you to a
therapist. They will organize your sessions with them."
5. Lifestyle changes: "Additionally, by making some changes in your lifestyle, you can
improve your mood significantly. For example, doing a regular exercise is proven to
be as beneficial as the medications. How does that sound to you, doing a regular
exercise? Would you consider? You also can do some other activities like pursuing
new hobbies, making some new friends, going out with your friends, participating
in sporting activities, or arranging holidays. These sort of activities can help you to
improve your mood."
6. Crisis card: "We're also going to give you a card called crisis card. In case any time if
you ever, ever felt hurting yourself, you don't need to suffer yourself. You don't need
to tackle this alone. You can call this number. There will be somebody to talk to."
7. Follow-up and information: "We would like to arrange your follow up in two weeks’
time. And we will give you some information to read about depression and its
treatment."

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gk’s notes – part 2

8. Closing: "Is that okay with you? Do you have any questions at this point?"

VII. Special Considerations

1. Psychiatric Referral Indications: a. Suicidal ideas b. Psychotic symptoms c. Postnatal

depression d. Treatment resistance e. Diagnostic uncertainty
2. Depression is typically diagnosed and treated by GPs in the UK, not requiring
immediate psychiatric referral unless meeting specific criteria
3. Be cautious about thyroid examination without clear indications
4. For insomnia cases, consider medication if job loss is imminent or patient is
suffering significantly
5. Avoid using terms like "chemical imbalance" when explaining depression
6. Don't assume patient's reported duration of symptoms is accurate; consider asking
family members
7. Be prepared for "original" scenarios that have been in the exam for years, as well as
newer "promotional" scenarios
8. Always tailor management discussion to patient's specific situation and history

VIII. Important Notes

1. Learn scenarios retrospectively ("go through the back door")

2. Understand the scenario first, then determine the severity and management
3. Be very careful with presenting complaints:
o If a patient says "I'm losing weight," think depression first in PLAB2
o If a patient says "I feel low," it could be hypothyroidism in PLAB2
4. Don't rely on mood scores of 5-6; they're not very helpful
5. Understand the difference between normal guilt and unreasonable guilt in
depression
6. Always ask about self-harm in psychiatric conditions, regardless of mood
7. Use the structured approach (Alpha-Beta-Gamma) for management discussion
8. Be thorough in your assessment and management discussion; don't try to save time
by skipping parts of questions or explanations
9. Remember that the exam is testing your ability to properly diagnose and manage
depression, not just recognize scenarios

Additional Important Points

1. Explanation of "Original" and "Promotional" Scenarios:

o "Original" scenarios are like McDonald's Big Mac - they've been in the exam
for years and don't change.
o "Promotional" scenarios come and go, like limited-time burgers.
2. Importance of Presenting Complaint:

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gk’s notes – part 2

o Always start with the presenting complaint.

o Do the differential diagnosis based on the presenting complaint.
3. Minimum Duration for Depression Diagnosis:
o To diagnose depression, you need to have a minimum of four weeks of
symptoms.
4. Overuse of Antidepressants:
o There is a global overuse of antidepressants for various conditions (sleep
problems, back pain, stress).
o This overuse is more limited in the UK due to NHS, but more common in
private prescription or insurance systems.
5. Criteria-Based Diagnosis:
o Every psychiatric condition is diagnosed according to criteria.
o You need to know the criteria for various conditions (ADHD, general
anxiety, depression, eating disorders).
6. Core Symptoms (Major Symptoms) of Depression:
o There are two core symptoms:
1. Feeling low (depressed mood)
2. Anhedonia (loss of interest or pleasure)
o One core symptom plus some minor symptoms is enough for a depression
diagnosis.
7. Detailed Questions for Core Symptoms:
o For feeling low: "During the last month, have you been bothered by feeling
down or depressed or hopeless? Does it happen most of the days, most of the
time?"
o For anhedonia: "Would you also say during the last month that mostly you
have been bothered by losing interest in activities you used to enjoy?"
8. Minor Symptoms in Pairs:
o Energy levels and tiredness
o Insomnia and its consequences:
§ Lack of concentration
§ Psychomotor agitation
§ Memory problems
o Loss of appetite and weight loss
o Loss of libido
o Excessive guilt and being tearful
9. Suicidal Ideation:
o Suicidal thoughts are not a major symptom but a complication of depression.
o Always ask about suicidal thoughts in psychiatric conditions, regardless of
mood.
10. Importance of Functional Assessment:
o Depression diagnosis requires impact on functionality.

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gk’s notes – part 2

o In schizophrenia, there's no functionality; patients cannot function, work, or

do anything.
o In delusional disorder, functionality is intact; patients can work, earn money,
look after family.
11. Delusional Disorder vs. Depression:
o Delusional disorder usually comes in older age (after 40-50).
o All scenarios presented in the transcript are depression, not delusional
disorder.
12. Caution with Thyroid Examination:
o Don't examine the thyroid in every depression case.
o Only check if there are clear thyroid symptoms.
13. Crisis Card Details:
o Given to everyone diagnosed with depression.
o Contains a hotline number for suicidal thoughts, not for feeling low.
14. Follow-up Appointments:
o If patient is less than 30 years old: follow up in 1 week
o If patient is more than 30 years old: follow up in 2 weeks
15. Medication Information:
o Citalopram or Sertraline are commonly prescribed.
o Medication should be taken for 6 months after feeling better.
o It takes about 1 month to show full improvement.
16. Importance of Exercise:
o Regular exercise is proven to be as beneficial as medications for depression.
17. Addressing Work-Related Stress:
o For the "work, work, work" scenario, don't diagnose as depression.
o Explain that it doesn't look like depression after assessment.
18. Handling Patient Requests for Antidepressants:
o If a patient directly asks for antidepressants, assess thoroughly before
deciding.

Follow-Up Scenario: CBT Not Working

Setting:

• F2 in GP
• 40-year-old man
• Diagnosed with depression by psychiatrist 2 months ago
• Started on CBT
• Coming for follow-up

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gk’s notes – part 2

Approach:

1. Initial Greeting and Assessment:

o "I understand you're here for follow-up. I also understand that you have been
recently diagnosed with a condition. So what have you been told?"
2. Patient Response:
o "Doctor, I've been diagnosed with depression. I've been given CBT. CBT is
rubbish. It is not working. I cannot go to work." (Patient may cry)
3. Empathetic Response:
o "I'm sorry you feel this way. Okay, so let me see what we can do for you. Let
me ask you some questions to understand you better."
4. Understanding of Condition:
o "What do you have been told in terms of your condition? What is your
understanding about depression?"
o "Do you know what depression is?"
o If patient doesn't know, provide definition: "Depression means feeling
constantly low and losing interest in activities someone used to enjoy. When
these symptoms start affecting or impacting someone's day-to-day life, we call
that clinical depression."
5. Treatment Assessment:
o "Can you tell me about the talking therapy? Whether you have been given
any medication at all?"
o "How long have you been taking this talking therapy?"
o "How often do you go to the therapy?"
o "How long does each session last?"
o "Is it like a one-to-one? Is it group?"
o "Did you miss any sessions?"
6. Symptom Review:
o "When you were diagnosed, what sort of symptom you had?"
o Review major symptoms and minor symptoms
o "How are you feeling now? Are you still having the same symptoms?"
o "I understand you were feeling low. What was the mood score then? What is
the mood score now?"
7. Complication Assessment:
o Always ask about suicidal thoughts: "Have you had any thoughts of harming
yourself?"
8. Side Effects:
o "Is there any side effects for CBT?" (Note: There typically aren't side effects
for CBT)
9. MAP-TOSA Assessment:

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gk’s notes – part 2

o Complete brief assessment of Medical history, Alcohol, Prescription

medications, Treatment history, Occupation, Social history, Appetite
10. Management Plan:
o "Okay, let me explain to you what we need to do for you now. We can offer
you medication."
o "We can give you a medication called citalopram."
11. Addressing Patient Questions about Medication:
o Duration: "The medication is to be taken for quite a long time. You need to
take it for another six months extra after you have started feeling better."
o Onset of Action: "It takes some time to respond. It takes about two to three
weeks to show improvement."
o Full Effect: "The full impact comes after about one month."
o Side Effects: Be prepared to discuss SSRI side effects (hyponatremia,
tiredness, dry mouth, dry eyes, sweating, insomnia, sexual dysfunction)
o Sexual Function: "Unfortunately, it may affect sexual function. If this is a
concern, we can offer a medication called reboxetine, which has the lowest
impact on someone's sexual life."

Severe Depression Scenario

Patient:

• 20-year-old
• Diagnosed with severe depression
• Having suicidal ideas

Approach:

1. Ask the patient to go to the hospital (not via ambulance)

o "This is not an ambulance case, but you need to go to the hospital."
2. Expected patient response: "I will go"
3. Important instruction: "Please do not drive"
4. Referral: "We're going to refer you to CRHD (Crisis Resolution Home Treatment
team)"
5. Explain: "They will follow you up. Once you get discharged, you can come back to
us, we can follow you up."
6. Discuss treatment using Alpha-Beta-Gamma approach

Note: Do not physically take the patient to the hospital yourself. The system doesn't work
like that.

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gk’s notes – part 2

Postnatal Depression Scenario

Approach:

1. Diagnosis:
o "This could be postnatal depression."
2. Explain Definition:
o First, give the general depression definition
o Then explain: "Any mother, if they develop depression within one year of
childbirth, we call this postnatal depression."
3. Management:
o Urgent referral to psychiatry (4-6 weeks, not cancer pathway)
o "We may be able to start you on a medication."
o Medication: Sertraline (safest for breastfeeding)
o "Before we start you on a medication, as you are breastfeeding, GPs can start
after consulting with a specialist."
o "We are going to contact a specialist. After contacting the specialist, we may
start you on a medication within the next two or three days."
o Follow-up within one week
4. Medication and Breastfeeding:
o Explain potential impact on child
o Advice to minimize impact: "The medication is only once in a day, in the
morning. You can breastfeed, then take the medication. If you wait for
another four to five hours, you can reduce the impact of the medication to
the child."
5. Additional Management:
o Implement Alpha and Beta approaches (lifestyle changes and talking therapy)

Hypothyroidism Scenario

Approach:

1. Explain: "Hypothyroidism is diagnosed and treated by the GPs."

2. Treatment: "This condition is treated with a medication called levothyroxine."
3. Prognosis: "When we treat the thyroid levels, your symptoms should improve. Your
mood should improve."
4. Follow-up: "We will follow you up. If that doesn't improve, then we can take action
for that."

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gk’s notes – part 2

Work-Related Stress Scenario

Presentation:

• Male and female versions

• Complaining of stress, asking for antidepressants or sleeping pills

Approach:

1. Listen carefully to the patient

2. Assess thoroughly using major and minor symptom criteria
o Note: They will likely not fit the criteria for major symptoms
o They may have one or two minor symptoms
3. If criteria for depression not met:
o "It doesn't look like clinical depression."
o "You may be overwhelmed and stressed out due to your workload."
o "You may be starting to burn out."
4. Management:
o Explain antidepressants not necessary: "Antidepressants have serious side
effects and they are for long term. We don't think that you need to take
medication at the moment."
o Decline sleeping pills: "Sleeping pills are highly addictive, and after some
time, they stop working. Therefore, it is not recommended in situations like
this."
5. Advice:
o Suggest taking a break (Note: Patient may laugh or dismiss this idea)
o Recommend lifestyle changes:
§ Make some changes in the lifestyle
§ Take some break from work
§ Do regular exercise
§ Go for holidays
§ Keep some balance in work and life
§ Meditation, yoga
o "Speak to your employer"
6. Warning:
o "At the moment it doesn't look like depression. But if you continue like this,
at some point you might develop depression. Depression is a serious
condition. Therefore, take some action right now."
7. Follow-up:
o "We'll follow up in one month time. If the situation continues, after one
month, we can arrange some talking therapy."

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gk’s notes – part 2

Important Notes:

• Be prepared for the patient to test your confidence and try to shake it. Don't change
your approach.
• These scenarios are designed to test your ability to properly assess, diagnose, and
manage various presentations related to depression.
• Always maintain a structured approach, show empathy, and tailor your management
to the specific patient scenario.
• Remember that the exam is testing your ability to properly diagnose and manage
depression, not just recognize scenarios.

Suicidal Scenarios
There are three main scenarios:

1. OCP (Oral Contraceptive Pill) overdose

2. 16-year-old girl taking paracetamol
3. 20-year-old gay male taking paracetamol

Note: These scenarios are slightly different but all require suicidal risk assessment.

II. Understanding Suicidal Risk Assessment

Purpose: To determine if the patient is high-risk or low-risk for suicide.

• High-risk patients need admission and treatment

• Low-risk patients can be sent home with community follow-up

III. Characteristics of High-Risk vs. Low-Risk Patients

High-Risk Patients:

1. Pre-attempt behaviour:
o Plan and prepare extensively
o Write suicide notes
o Write wills (specifying who gets their possessions)
o Close bank accounts, social media accounts
o Leave group chats
o Use the right time (e.g., when everyone is asleep or out)
o Choose the right place (e.g., their room)
2. During attempt:
o Lock the door

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gk’s notes – part 2

o Put the curtain down

o Switch off the light
o Use more lethal methods (e.g., very sharp blade)
o Genuinely want to die
3. Post-attempt:
o May be found unconscious
o Brought to hospital by others
4. Future outlook:
o May express intent to try again
o Might say "I'm not sure" when asked about future attempts
o Regret being alive

Low-Risk Patients:

1. Pre-attempt behaviour:
o Impulsive actions
o No extensive planning
o May tell many people about their intentions
2. During attempt:
o May act in front of others
o Use less lethal methods
o Often want attention rather than to die
3. Post-attempt:
o Often seek help themselves
o Stop the bleeding themselves
o Come to hospital on their own
4. Future outlook:
o Express regret for actions
o State they won't repeat the behaviour

Scenario: OCP Overdose and Wrist Cutting

Setting: Psychiatry department, 16-year-old girl Context: Patient came to A&E, received
dressing, and was referred to psychiatry

Approach:

1. Initial Greeting:
o "I understand that you have taken some tablets and also cut your wrist. I'm
sorry to hear about that. Can I please ask you some questions about this?"
2. Assessment of Tablet Ingestion:

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gk’s notes – part 2

o"What sort of tablets have you taken?" Expected response: Contraceptive pills
o "Why did you take them?" Expected response: Thought she was pregnant
o "How many tablets did you take?"
o "When exactly did you take them?" Expected response: Last night
o "Did you take any other tablets with that?"
o "Were you under the influence of alcohol at the time?"
o "What happened immediately after? Did you vomit?"
o "Have you had any symptoms like tummy pain or psychotic symptoms?"
o "Where did you get the tablets from?" Expected response: Mother's tablets
o "Does your mother know about this?" Possible response: She will find out
soon
3. Assessment of Wrist Cutting: a. Pre-attempt:
o "Have you ever planned this before?"
o "Have you ever had ideas of hurting yourself?"
o "Was this impulsive or planned?"
o "Did you do any preparation?"
o "Did you write any suicide note or will?"
o "Did you call or text anyone before?"
o "Did you switch off your phone?"
o "Did you close any bank accounts or leave social media groups?"

b. During attempt:

o "Where were you when this happened?"

o "Was anyone else there?"
o "Were you in your room? Did you close the door?"
o "Did you wait for everyone to leave the house?"
o "Did you put the curtain down or switch off the light?"
o "What did you use to cut?"
o "What was going through your mind before and during the cutting?"
o "When you saw the blood, what did you think? How was your reaction?"

c. Post-attempt:

o"How did you stop the bleeding?"

o "Did you faint?"
o "How did you come to the hospital?"
o "What sort of treatment did they offer in A&E?"
4. Current Feelings and Future Outlook:
o "How do you feel about everything you've done so far?"
o "If you had a similar situation in the future, would you repeat this?"

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gk’s notes – part 2

o If she says no: "Why would you say no? What would you do differently?"
5. Past History:
o "Have you done similar things in the past?"
o "Do you take any alcohol or recreational drugs?"
o "Do you sometimes feel low? How is your mood generally?"
o "Have you ever been diagnosed with any mental health conditions, like
depression?"
6. Relationship Assessment:
o "How is your relationship generally, apart from this incident?"
o "Is your boyfriend supportive?"
o "Has he ever been abusive or aggressive?"
7. Family History:
o "Has anyone in your family been diagnosed with any mental health
conditions?"
o "Has anyone in your family done something similar?" Note: Suicide and
depression can run in families
8. Pregnancy Concerns:
o "When was your last menstruation?"
o "Have you done any pregnancy test?"
o "Did the doctors in A&E do a pregnancy test?"
o "Have you had any unprotected sexual intercourse since your last period?"
9. Additional Information:
o Ask about medical conditions, medications, allergies
o Social history: Who do you live with? Who is at home? Is your family
supportive?

V. Management Plan

1. Explanation about OCP:

o "I understand you took the pills to try to end a possible pregnancy. If you are
already pregnant, contraceptive pills won't work for that purpose."
o "To prevent similar situations, we advise you to speak to your GP about long-
term contraception options."
2. Pregnancy Test:
o "We would like to do a pregnancy test for you."
o "If you are pregnant, we'll advise you to seek the right advice. You can speak
to your GP or the National Unplanned Pregnancy Advisory Service for
guidance."
3. Risk Assessment Outcome:
o "From the information I've gathered, it is highly unlikely you may repeat this
again."

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gk’s notes – part 2

o "Therefore, you should be able to go home today."

o "Before you go home, I would like to speak to my seniors before we discharge
you."
4. Follow-up Plan:
o "If we discharge you today, you'll be followed up in community psychiatry."
o "They'll offer you a card called a crisis card."
o "If you ever come across a similar situation in the future, you don't need to
do the same again. You can just call the number on the card and talk to
somebody."

VI. Important Notes

1. Distinguish between actions intended for self-harm and those for other purposes:
o In this scenario, taking OCP was to end potential pregnancy, not for self-
harm
o Cutting wrist was for self-harm and requires full suicidal risk assessment
2. Approach to greeting:
o Don't say "How may I help you?" to someone who has attempted suicide
o Instead, acknowledge their actions and express empathy
3. Assessment should cover before, during, and after the suicide attempt
4. Pay attention to details that distinguish high-risk from low-risk behaviour:
o Planning vs. impulsive action
o Isolation vs. seeking attention
o Lethal methods vs. less lethal methods
o Genuine desire to die vs. cry for help
5. Always assess for suicidal ideation in psychiatric conditions, regardless of presenting
complaint
6. Be thorough in your assessment, covering all aspects mentioned
7. In your management plan, don't directly tell the patient they are low-risk. Instead,
phrase it as "it is highly unlikely you may repeat this again"
8. Always consult with seniors before discharging a patient who has attempted suicide

Paracetamol Overdose

I. Scenario Overview

Setting: F2 in the emergency department Patient: 16-year-old girl Presenting complaint:

Took paracetamol overdose (7 or 8 tablets) Context: Paracetamol level already done, below
treatment line Task: Discuss the management with the patient

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gk’s notes – part 2

II. Assessment Approach

1. Conduct a thorough before, during, and after risk assessment

2. Assess all risk factors
3. Key Questions and Expected Responses:
o "How many pills did you take?" Expected response: Seven or eight tablets
o "Is there any particular reason you took this amount of tablets?"
o "How many tablets have you taken in the past? Was it the same amount?"
o "Do you know generally anything about normal paracetamol dose?" Note:
These questions help determine if the patient deliberately chose a "safe" dose
to scare others
4. Explore Reason for Overdose:
o Expected findings:
§ Took pills because of a fight with her boyfriend
§ Boyfriend not paying attention (described as a "good boy", "alpha
man")
§ Patient got frustrated and took the pills
5. Past History:
o Ask: "Have you done this before?"
o Expected response: Yes, she has done the same thing in the past
o Ask about the reason for past attempts
o Expected response: Same reason as current attempt
6. Future Intentions:
o Ask: "If you were in a similar situation in the future, would you do this
again?"
o Expected response: "I'm not sure. I might do."

III. Risk Assessment

• Despite previous attempts and uncertainty about future actions, this is considered a
low-risk case
• Patient doesn't need admission, but caution is required in communicating this

IV. Management Plan

1. Referral:
o Refer the patient to the psychiatry department on the same day
2. Discharge Plan:
o Tell the patient: "You should be able to go home today after seeing the
psychiatrist specialist."
o Note: Do not say "after speaking to seniors" as in the previous scenario
3. Follow-up:

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gk’s notes – part 2

o Inform: "When you go home, they will arrange some counselling sessions for
you with the community psychiatry department."
4. Advice on Future Behaviour:
o Strongly advise: "We advise you not to repeat this again."
5. Education on Paracetamol Use:
o Acknowledge the patient's actions: "We understand you took either 7 or 8
tablets."
o Explain normal dosage: "Doctors do offer 8 tablets or 4 grams for 24 hours,
but we spread it throughout the day. We have a 4-hour gap between each 1-
gram dose."
o Warn about potential harm: "Any amount of paracetamol can harm the liver.
Even some people are affected by normal doses."
o Emphasize the risk: "If you take 4 tablets or 8 grams at once, it has the
potential to damage your liver."
o Address past attempts: "In the past, you have been okay. You have done this
twice and been okay, but we cannot guarantee this will be the same in the
future."
o Strong advice: "Therefore, we advise you not to take this again, not to do this
again."
6. Relationship Advice:
o Identify the root cause: "The problem seems to come from your
communication with your partner, your boyfriend."
o Suggest communication: "We advise you to speak to your partner about this."
o Offer additional support: "You can speak to your GP about your relationship
issues. They might arrange some couple counselling."

V. Important Notes and Things to Avoid

1. Do not tell the patient it's "highly unlikely" she will do this again, as she expressed
uncertainty about future actions.
2. Be cautious in your language, showing understanding of the situation while firmly
advising against future attempts.
3. Emphasize the potential dangers of paracetamol overdose, even if past attempts
didn't cause harm.
4. Address the underlying relationship issues as part of the management plan.
5. Ensure to refer to psychiatry before discharge, given the repeat nature of the
behaviour.
6. When discussing normal paracetamol dosage, emphasize that even though doctors
may prescribe up to 4 grams per day, it's spread out over 24 hours, not taken all at
once.

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gk’s notes – part 2

7. Be aware that some patients might deliberately choose a "safe" dose to scare others
without causing harm to themselves. The specific questions about dose knowledge
aim to uncover this.

Paracetamol Overdose in Gay Patient

I. Scenario Overview

Setting: F2 in A&E (Emergency Department) Patient: 20-year-old man Presenting

complaint: Took paracetamol overdose (20 tablets) Time since ingestion: 2 hours ago Task:
Assess and manage

II. Patient History

1. Sexual Orientation:
o Patient is gay
o Recently came out to his mother
2. Precipitating Event:
o Told his mother he's gay today
o Mother got upset and said some hurtful words
o Patient had an argument with his mother
3. Overdose Details:
o Took 20 paracetamol tablets
o Taken 2 hours ago
o Action was impulsive
4. Post-overdose Action:
o Called his boyfriend/partner
o Partner advised him to go to the hospital
5. Future Intentions:
o Patient indicates he's not going to do it again

III. Assessment Approach

1. Conduct a thorough before, during, and after risk assessment

2. Assess all risk factors
3. Note: This case is considered low risk

Important: The assessment should be the same as in previous scenarios, covering:

• Planning and preparation

• Circumstances of the overdose
• Immediate actions after overdose

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gk’s notes – part 2

• Future intentions
• Past history of self-harm or overdose
• Mental health history
• Family history
• Social support

IV. Medical Management Plan

1. Waiting Period:
o Advise patient: "We need you to wait for another 2 hours in the emergency
department."
o Explanation: "We need to wait for a total of 4 hours since you took the
tablets."
2. Blood Test:
o Inform patient: "After 4 hours from when you took the tablets, we need to
do a blood test."
o Explanation: "We need to wait for the paracetamol to break down and check
for some metabolites in your liver."
3. Treatment Decision Based on Paracetamol Levels:

a. If levels are high (above treatment line):

o Inform patient: "Your paracetamol levels are high and need treatment."
o Explain treatment: "You will be given a medication called N-acetylcysteine."
o Detail the process: "The treatment lasts for 24 hours. You'll receive two
doses, each lasting 12 hours. Each dose is 500 millilitres."
o Next steps: "After the treatment, we will refer you to a psychiatrist. After the
psychiatric assessment, you should be able to go home."

b. If levels are low (below treatment line):

o Inform patient: "Your paracetamol levels are low and don't require medical
treatment."
o Next steps: "We will refer you to a psychiatrist. After the assessment, you
should be able to go home today."

V. Patient Education

If patient asks: "Can the amount of tablets I've taken harm me?" Response: "Well, it has the
potential to cause harm, but the chances are low."

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gk’s notes – part 2

VI. Psychiatric Referral

• Inform patient: "Regardless of your paracetamol levels, we will refer you to a

psychiatrist for an assessment."
• Explain: "This is to ensure we address any underlying issues and provide you with
appropriate support."

VII. Important Notes

1. This is an old scenario that has recently reappeared in PLAB2 exams after not being
used for about four years (2020-2024).
2. The case is considered low risk due to:
o Impulsive nature of the act
o Patient calling for help (boyfriend)
o Indication of not wanting to repeat the action
3. Always conduct a thorough risk assessment despite the apparent low risk.
4. Emphasize the importance of both medical management and psychiatric assessment.
5. Be aware that this scenario might be found in older study materials (referred to as
"moniker" in the transcript).
6. The management plan differs from previous scenarios due to the recent ingestion
and higher tablet count, necessitating blood tests and potential N-acetylcysteine
treatment.

Drug Addict
I. Scenario Overview

Setting: Psychiatry outpatient department Patient: 28-year-old drug addict Presenting

complaint: Wants to stop taking drugs Context: Patient made the appointment themselves

II. Initial Approach

1. Greet the patient and confirm their name

2. Paraphrase: "I understand you need some help because you wanted to quit taking
drugs."
3. Appreciate their initiative: "It is good that you have made this decision. We should
be able to help you with this."
4. Transition to assessment: "Let me ask you some questions to understand your
situation better" or "Let me ask you some questions to have a better understanding
about yourself."

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gk’s notes – part 2

Things to avoid:

• Don't say "You are in the right place" (This is not a biryani business)
• Avoid phrases like "You have done the right thing" without context

III. History Taking

Use a structured approach, visualizing a prescription with medication, route, dose,

duration, and frequency:

1. Drug Information:
o Ask: "What sort of drugs do you take?"
o Note: Main drug is likely heroin, but patient may mention other drugs (e.g.,
ASD, PSD, RMT, "one shot")
o Listen to all drugs mentioned, even if unfamiliar
2. Route of Administration:
o Ask: "How do you take those drugs?"
o Specifically inquire: "Do you swallow? Do you chew? Do you smoke? Do you
sniff?"
o Always ask: "Do you inject? Do you use any needles?"
o If needles are used, follow up with:
§ "Do you share any needles?"
§ "Do you know anything about needle exchange programs?" Note:
Don't explain the program if they say yes
3. Duration and Frequency:
o Ask: "How long have you been taking drugs?"
o "How often do you take? Is it every day?"
o If daily, ask: "Do you take more than once?" Note: Taking more than once a
day indicates severity
4. Dosage:
o Ask: "How much do you take?"
o Note: Quantities may be described differently (e.g., one joint, one tablet, one
shot, or in milligrams)
5. KHTW Assessment (Signs of Dependency):
o K (Quit): "Have you ever tried to quit in the past?" or "Have you ever tried to
stop taking it?" If yes, explore:
§ "How long ago did you try?"
§ "How did you try? Did you try with some medications?"
§ "Did you try by yourself or get any professional help, like doctors or
any counsellors?"
§ "What sort of methods did you use?"

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gk’s notes – part 2

§ "Why did that fail? What was the reason that you had to go back to
the drugs?"
o H (annoyed/guilty):
§ Annoyed: "When other people talk about you taking drugs, do you get
angry? Do you get upset?"
§ Guilty: "Do you sometimes feel bad yourself, because you have been
taking drugs for quite a long time?"
o T (Tolerance): "Do you need to take more and more drugs? Would you say
that you are taking more and more drugs these days in order to have the
same effect as the days before?"
o W (Withdrawal): "If you don't take drugs for one day or two, if you stop
taking drugs, do you develop any symptoms?" If yes, explore:
§ "After how many days of stop taking the drugs do you develop these
symptoms?"
§ "What sort of symptoms do you develop in that case?"
§ "What do you do for that? Do you take any treatment or do you take
drugs? Do you drink alcohol or do they settle on their own?"
§ "How do you manage those symptoms?"
6. Reasons for Drug Use:
o Ask: "Can I please ask you, is there a particular reason that you continue to
take drugs?"
o Explore possible reasons: feeling low, inability to function, peer pressure,
physical pain
o Ask about initial use: "When did you start taking? How did you start? Did
you start occasionally?"
o Current reasons: "What is the reason for you to still take it?"
7. Mood Assessment:
o Ask: "How is your mood lately? Do you feel low?"
8. Self-harm:
o Ask: "Have you ever tried to harm yourself? Whether because of the
withdrawal symptoms or when you are under influence of drugs?"
9. Modified FAMISH Assessment:
o Family history of drug use
o Friends and relationships: "Do you have a girlfriend?"
o Living situation: "Where do you live?" (Important as many drug users live on
the street)
o If living with partner: "Does she take any drugs at all? Does she take
regularly?"
o Children: "Do you have any children?" If yes, "How many children? Are you
the biological parents?"
o Financial situation: "How do you fund yourself? How are your finances?"

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gk’s notes – part 2

o Legal issues: "Have you had any problem with the police?"
o Medical history: Ask about any other medical conditions or medications
o Allergies

IV. Physical Observations

• Note any physical signs of withdrawal, e.g., shaking, shivering, restlessness

• If observed, comment: "I can see that you're a little bit shaking and shivering. Is it
because you haven't taken drugs for some time?"

V. Management Plan

Use a structured approach with two main components: Medical (Red) and Psychosocial
(Blue)

1. Explain Effects of Continued Drug Use: "It's better for you to quit taking drugs as
you wish, because if you continue to take, you can become more addicted to it, and
it can impact your health and your social life."
2. Medical Management (Red): a. Examination:
o Check temperature (may have fever)
o Measure body weight
o Check heart (may have irregular heartbeats)
o Perform ECG
o Inspect injection sites b. Tests:
o Take urine sample to send to laboratory to check for drugs
o Blood tests (including tests for blood-borne infections like hepatitis and
HIV) Explain: "It's better to check for infections like hepatitis and HIV.
Would that be okay?" c. Medication:
o Prescribe methadone
o Explain:
§ Methadone is a syrup that you drink
§ Treatment duration is typically for two years (or one to two years)
§ Available on prescription from us, and as a repeat prescription from
GPs or some pharmacists
3. Psychosocial Management (Blue):

a. Counselling:

o Arrange counselling for substance misuse

o Explain: "We have group counselling and individual counselling"

b. Support Group:

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gk’s notes – part 2

o Offer support group

o Explain: "You'll go and you will meet people in a similar situation, in the
same boat as you. You share the experience with other people, help each
other, get motivated. You'll find somebody who has completely come out of
it, you get motivated by seeing other people's progress."

c. Social Services:

o Offer social services involvement

o Explain: "We offer a key worker. Somebody from the social services will
monitor your progress, help you with benefits."

VI. Important Notes

1. This is considered an "original" or "Big Mac" scenario in PLAB2, meaning it's a long-
standing, consistently used scenario.
2. The structure for taking history (name, route, dose, duration, frequency) can be
visualized like writing a prescription.
3. KHTW assessment is crucial for determining dependency. 'K' stands for quitting in
drug scenarios, not cutting down as in alcohol scenarios.
4. Always assess mood and self-harm risk in psychiatric scenarios.
5. When asking about children and biological parents, only do so in specific scenarios
(non-accidental injury, domestic violence, and this drug scenario).
6. The management plan should always start with the medical (red) aspects before
moving to psychosocial (blue) aspects.
7. Be prepared to explain the methadone treatment in detail if asked.
8. Emphasize both medical and psychosocial aspects of management.

Alcohol
Scenario 1: OBG Setting - Incidental Finding of Excessive Alcohol Use

Setting and Context:

• Patient came for hysteroscopy in OBG

• Tests were normal
• Nurses overheard patient is taking alcohol excessively
• Task: Assess for alcohol dependency and discuss further management

Initial Approach:

1. Greet the patient and paraphrase

36
gk’s notes – part 2

2. Deliver good news about normal test results:

o "I understand you have come for the scan. The good news is, Mrs. Johnson,
all the scan came as normal. Did anyone tell you about this?"
o Ask: "How do you feel about this?"
o Note: This is one of the few scenarios where saying "good news" is
appropriate
3. Transition to general health questions:
o "Before you go home, is it okay if I can ask you some questions about your
general health, your health in general?"
o If patient agrees: "Can I ask you some questions about your health?"

Assessment:

1. Start with general health questions:

o "How is your diet? Do you try to eat healthy? Do you cook or get food from
outside?"
o "Do you do any exercise at all?"
2. Transition to alcohol:
o "Do you drink any alcohol at all?"
o If patient becomes defensive: "Oh, do you want to talk about my drinking
habit?"
o Response: "Is it okay if we can have a small chat about that?" (Be very nice
and show all your teeth)
3. Alcohol History:
o Type: "What type of alcohol do you drink?" (Focus on wine, beer, spirits)
o Amount: "How much do you drink?"
§ Wine: 1 bottle = 9 units, 1 large glass = 3 units
§ Beer: 1 pint ≈ 2.5 units (including lager)
§ Spirits: 1 shot (25ml) = 1 unit, 1 bottle ≈ 30 units
o Duration: "How long have you been drinking this amount of alcohol?"
o Frequency: "Do you drink every day? Do you have any alcohol-free days?"
o Weekend habits: "Do you drink anything extra on the weekends?"

Note: Avoid asking "How many bottles of alcohol do you drink?" as it shows lack of
knowledge

4. CAGE Assessment:
o Cut down: "Have you ever tried to cut it down in the past?" If yes, explore:
"How long ago? What methods did you use? Did you try professional help or
on your own? Why did that fail?"
o Annoyed: "Do you get angry or upset when people talk about your drinking?"

37
gk’s notes – part 2

o Guilty: "Do you sometimes feel a little bad for yourself that you have been
drinking excessively?"
o Eye-opener: "Do you need to drink alcohol in the morning to start your day?"
o Tolerance: "Do you need to drink more and more alcohol these days to have
the same effect as before?"
o Withdrawal: "If you don't drink alcohol for a day or two, do you develop any
symptoms? What sort of symptoms? How do you manage those symptoms?"
5. Reasons for Drinking:
o "Is there a particular reason that you continue to drink?"
o "When did you start drinking? How did you start?"
o "What is the reason for you to still drink now?"
6. Mood Assessment:
o "How is your mood lately? Do you feel low?"
7. Self-harm Assessment:
o "Have you ever tried to harm yourself? Whether because of withdrawal
symptoms or when under the influence of alcohol?"
8. Modified FAMISH:
o Family history of alcohol use
o Friends and relationships
o Living situation
o Work-related drinking: "Where do you work? Do you get free drinks or need
to drink with customers?"
o Financial situation: "How do you fund your drinking?"
o Legal issues: "Have you had any problems with the police?"
o Medical history and medications
9. Insight:
o "Do you think that you need some medical help or some help with your
drinking habit?"

Management Discussion:

1. Express concern: "We are a little bit concerned about your drinking habit."
2. Provide recommendations: "Unfortunately, you have been drinking a little bit
excessively. We recommend less than 14 units per week. According to my
understanding, you've been drinking roughly [calculated amount] units."
3. Offer help: "We would like to offer some help in order for you to cut it down."
4. Ask permission: "Do you want to know what we are going to do for you? We can
offer some help if someone wanted to quit drinking. Would you like to know in
what ways we can help?"
5. If patient agrees, discuss management: a. Medical (Red):

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gk’s notes – part 2

o Medication for withdrawal: "We have a medication called chlordiazepoxide

for withdrawal symptoms and detoxification."
o Medication for craving: "We have a medication called acamprosate for
craving." b. Psychosocial (Blue):
o Counselling: "We offer one-to-one counselling and group counselling."
o Support group: "There's a support group called Alcoholics Anonymous
(AA)."
o Confidential helpline: "There's a confidential helpline called Drinkline."
6. Closure: "What do you think about it? If you'd like to receive some help, there's a
lot available. We can offer support."

Scenario 2: GP Setting - Patient Seeking Help for Alcohol Withdrawal

Setting and Context:

• 50-year-old patient
• Made appointment themselves
• Stopped drinking yesterday, experiencing withdrawal symptoms
• Scared of developing fits (had fits last time when stopping)
• Asking for diazepam

Assessment:

• Conduct alcohol history as in Scenario 1

• Perform CAGE assessment
• Complete modified FAMISH

Management:

1. Address diazepam request:

o "As you developed fits last time, you may develop fits again, but it's not safe
to take diazepam at home. That is not recommended."
2. Recommend hospital admission:
o "This is an ambulance case. You need to go to the hospital."
o "You'll be admitted under the psychiatry team."
3. Explain hospital treatment:
o "They will treat you and offer rehabilitation treatment to take the situation
under control."
o "In the hospital, they will give medications to control the withdrawal
symptoms."
o "For the craving, they might give you diazepam under medical supervision."
4. Follow-up plan:

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gk’s notes – part 2

o "Once you get stable, we'll arrange other treatments."

5. If patient resists going to hospital:
o Explain why it's better to go, emphasizing safety and proper medical
supervision

Important Notes and Things to Avoid:

1. Never mention that nurses overheard about excessive drinking.

2. Don't waste time discussing the hysteroscopy or why it was done.
3. Be empathetic and non-judgmental throughout the assessment.
4. Calculate alcohol units quickly and accurately. Doctors should have good math
skills.
5. In Scenario 1, reflect on patient's autonomy by asking if they want to know about
help options.
6. In Scenario 2, prioritize patient safety by recommending hospital admission for
supervised withdrawal.
7. Always assess mood and risk of self-harm in alcohol-related cases.
8. Be prepared to explain treatment options in detail if asked.
9. Avoid phrases like "You are in the right place" or "You have done the right thing"
without context.
10. Don't use the term "happy hormone" or oversimplify medical concepts.
11. Remember that this structure (alcohol history, CAGE, FAMISH) is similar for drug
and smoking scenarios as well.

Smoking Cessation
Scenario 1: COPD Patient in Hospital

Setting and Context:

• F2 in acute medicine
• 70-year-old man admitted for COPD exacerbation
• Patient is going home
• Task: Counsel about smoking and negotiate with the patient
• Note: This is the only scenario where "counsel" and "negotiate" are explicitly
mentioned

Initial Approach:

1. Paraphrase: "You've been admitted with us and you're going home today."
2. Ask about understanding:
o "What's your understanding about what happened?"

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gk’s notes – part 2

"What was the reason for your admission?"

o
o "What sort of treatment did they offer?"
o "How are you feeling now?"
3. COPD Understanding:
o "How long have you been diagnosed with COPD?"
o "What sort of treatment were you on?"
o "Is this condition getting better or worse with time?"
o "What's your understanding of the cause of COPD?"
o "Do you understand this is because of smoking?"

Smoking History:

1. "Do you smoke?" or "Do you still smoke?"

2. "What do you smoke?" (Use 'cigarettes', not 'sticks')
3. "How long have you been smoking?"
4. "How many cigarettes do you smoke?"
5. "Is this the same amount since you started?"

Quit Attempts:

1. "Have you ever tried to quit smoking in the past?" If yes:

o "How long ago?"
o "How did you try?"
o "What methods did you use?"
o "Why did that attempt fail?"
2. Withdrawal symptoms:
o "If you don't smoke for one or two days, do you develop any symptoms?"
o "What sort of symptoms do you develop?"
o "How do you feel?"

Additional Assessment:

1. Reason for smoking: "What's the reason for you to smoke?"

2. Mood: "How is your mood lately? Do you feel low sometimes?"
3. Self-harm: "Have you tried to harm yourself for any reasons?"
4. Modified FAMISH assessment
5. Insight: "Do you think you need some help with your smoking?"

Management Discussion:

1. Express concern: "We're a little bit concerned about your smoking."

2. Explain consequences:

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gk’s notes – part 2

o "Smoking is the reason for your condition COPD."

o "If you continue to smoke, your condition COPD will get worse."
o "If this condition gets worse, you might need more frequent hospital
admissions."
o "You may have a continuous cough."
o "You may have a problem with breathing."
3. Advise quitting: "Therefore, we would like to advise you to quit smoking. What do
you think about it?"
4. Anticipate refusal. If patient refuses:
o Ask: "Can I please ask you why you don't want to quit?"
o "What do you like about smoking?" Expected responses:
o "The idea of quitting smoking scares me."
o "I like everything about smoking."
o "I like holding the cigarettes in my hand."
o "I like the smoke in my throat."
5. Acknowledge difficulty:
o "I understand that you have been smoking for many years now."
o "Smoking has become part and parcel of your life."
o "Therefore it may be difficult for you to make a decision today."
o "There is no need to rush."
6. Suggest consideration:
o "Why don't you go home and think about it?"
o "Speak to your family."
o "Once you have made up your mind, you can talk to us or your GP."
o "But let me explain to you why this is important for you to quit."
7. Explain importance of quitting (negotiate with bigger weapons):
o "If you continue to smoke, this condition will get worse."
o "If the condition gets worse, at some point, you may not be able to breathe."
o "Your breathing can be severely affected when the COPD gets worse."
o "Your lung function will be affected."
o "In that situation, you may have to wear a mask for breathing."
o "If you wear a mask, most of the time you will be bedridden."
o "This will affect your mobility."
o "You will not be able to enjoy your usual day-to-day activities, like going out
with friends."
o "Your quality of life will be compromised."
o "You may have a continuous cough."
o "You might get frequent infections."
o "You may have to come in and out of the hospital all the time."
o "In the worst-case scenario, people can also develop cancers if they continue
to smoke."

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gk’s notes – part 2

8. Offer help options:

o "If somebody wanted to quit, we do offer help."
o "Would you like to know in what ways we can help?"
o "Do you want to know what we are going to do for you?"
9. Explain quitting process: a. Decide a quit date (two weeks before quitting date) b.
Two options:
o Nicotine replacement:
§ Different forms (lozenges, gums, tablets, sprays, patches)
§ Can start using at any time, slowly
§ Mostly need to buy yourself (NHS can help to some extent)
o Medication:
§ Bupropion
§ Take 1-2 tablets, 1-2 weeks before quit day
§ Take for about two months c. Counselling (one-to-one, group
counselling) d. Support group e. NHS quit smoking app (for self-
counselling)
10. Address e-cigarettes if asked:
o Recommended if used with help of medical professionals
o Slightly better than cigarettes (don't have toxic substances like tar, cyanide,
carbon monoxide)
o Not completely safe (can cause complications like puncturing the lungs,
pneumonitis)

Scenario 2: Breastfeeding Mother in GP

Setting and Context:

• 30-year-old woman in GP surgery

• Had a child one month ago
• Stopped smoking during pregnancy, started again
• Wants to quit now

Assessment:

1. Smoking history (as above)

2. Motivation: "What is the reason for you to quit smoking?" Expected response:
"Because of my child."
3. Child's health: Ask about childbirth, weight, general health
4. Modified FAMISH assessment

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gk’s notes – part 2

Management Discussion:

1. Affirm decision to quit

2. Explain benefits of quitting:
o "Your breathing can improve."
o "You can reduce the chances of developing stroke and heart attack, some sort
of cancers."
3. Explain risks to child:
o "If you smoke, it can affect your child."
o "The child's heartbeat can go up."
o "It can affect the child's breathing."
o "Child can develop some lung conditions, like asthma."
o "It can also cause some ear infection, ear inflammation, like otitis media."
4. Discuss quitting plan:
o Set quit date
o Explain options: a. Nicotine replacement (best for breastfeeding mothers)
§ Spray for instant craving
§ Explain timing with breastfeeding: "You can breastfeed the child, then
take a spray. Then wait for 3-4 hours before breastfeeding again." b.
Medication c. E-cigarettes
5. Address concerns:
o Nicotine replacement will affect the child
o Medication will affect the child
o E-cigarettes:
§ One of the options
§ Don't have some toxic substances like tar, nicotine, carbon monoxide
§ Recommended if used with smoke-free clinic/services
§ Slightly better than cigarettes

Insomnia Scenarios
Scenario 1: 60-year-old lady with rheumatoid arthritis

Context:

• Takes methotrexate
• Husband died six months ago

Assessment:

1. Ask about insomnia

2. Explore causes of insomnia

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gk’s notes – part 2

3. Ask proper sleep hygiene questions

Management:

1. Explain possible insomnia diagnosis

2. Do not offer pills
3. Recommend lifestyle changes
4. Offer talking therapy
5. Explain why medication is not useful:
o Highly addictive
o They stop working after some time (tolerance)
o They have serious side effects

Scenario 2: 28-year-old man with insomnia

Context:

• Takes mother's pill

• Plays video games till 4 o'clock
• Takes cannabis
• Drinks a lot of coffee
• Asking for pills

Management:

1. Do not give pills

2. CBT is not necessary
3. Focus on lifestyle changes:
o Address video game habits
o Address cannabis use
o Address coffee consumption
4. Explain importance of sleep hygiene

Important Notes and Things to Avoid:

1. In the COPD scenario, never mention that nurses overheard about excessive
smoking.
2. Don't waste time on discussing the hysteroscopy or other unrelated medical issues.
3. Be empathetic and non-judgmental throughout the assessment.
4. In smoking scenarios, avoid using terms like "sticks" for cigarettes. Use professional
language.

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gk’s notes – part 2

5. In the COPD scenario, start negotiation within 4 minutes of starting the

consultation.
6. For insomnia cases, focus on lifestyle changes and avoid offering medication.
7. Remember that the structure (smoking history, CAGE, FAMISH) is similar for drug
and alcohol scenarios as well.
8. Always assess mood and risk of self-harm in these scenarios.
9. Be prepared to explain treatment options in detail if asked.
10. In the breastfeeding scenario, emphasize nicotine replacement therapy as the best
option.

Anorexia Nervosa
Settings:

1. GP scenario
2. Psychiatry scenario

Presenting Complaint:

• Weight loss
• "My mother is concerned"

Assessment:

1. Ask about weight loss

2. Detailed dietary habits:
o "What do you eat for breakfast?"
o "What do you eat for lunch?"
o "What do you eat for dinner?"
3. SCOFF Questions:
o Memorize exactly: "Do you believe yourself to be fat when others say you are
too thin?"
o Note: Use of "fat" is acceptable in this context, although usually offensive
o This question is important for anorexia nervosa (2 scenarios) and bulimia (2
scenarios)
4. Differentials: Ask a couple of differential diagnosis questions
5. Modified FAMISH assessment
6. BMI:
o GP scenario: Say "I would like to check your BMI"
o Psychiatry scenario: BMI will be given (e.g., 17)
7. Mood assessment (important in psychiatry scenario)

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gk’s notes – part 2

8. Self-harm assessment
9. Effect on symptoms

Diagnosis Explanation:

"You could be having a condition called anorexia nervosa. It is an eating disorder, a

condition related to eating. It's a mental health condition. People with this condition will
perceive themselves as overweight or fat, but in the actual sense, they will be underweight."

Management (5 things, same for bulimia):

1. Urgent referral to eating disorder clinic (psychiatry)

o If under 18, refer to CAMHS (Child and Adolescent Mental Health Services)
2. CBT (talking therapy)
3. Antidepressants (if talking therapy doesn't work)
4. Nutritional advice:
o Referral to nutritionist
o Books about how to eat healthy and maintain a good body weight
o Exercise programs (gym referral)
5. Support group

Note on Psychiatry Scenario:

• GP referred the patient due to low BMI

• Ask: "What was your BMI?" (Expected answer: 17)
• Patient will be seen by eating disorder clinic under CAMHS

Bulimia Nervosa
Setting:

• Telephone consultation (always a 15-year-old girl calling)

Presenting Complaint:

"My mom saw me vomiting"

Assessment:

1. Ask about vomiting:

o "Did you vomit?"
o "How long have you been vomiting?"

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gk’s notes – part 2

o "Did this happen spontaneously or did you induce vomiting?"

o "Why did you induce vomit?"
o "Can I ask why you want to lose weight?"
2. SCOFF Questions (same as anorexia)
3. Ask: "What else do you do in order to lose weight?"
4. BMI:
o Say: "The next thing we need to do once you finish the history, we need to
check your BMI."
o Ask: "Do you know anything about BMI?"
o Patient response: "My BMI is 24"
o Note: BMI is normal in bulimia (24), unlike anorexia

Diagnosis Explanation:

"This could be a condition called bulimia nervosa. It is an eating disorder. This is a mental
health condition that causes someone to eat a large amount of food at one time. That is
called binge eating. Then they will try to get rid of it. That is called purging, for example,
by induced vomiting."

Management:

Same as anorexia nervosa (5 things)

Suspected Dementia
Setting:

GP appointment, 65-year-old lady

Presenting Complaint:

"My daughter asked me to see you"

Initial Approach:

1. "Why did your daughter ask you to see us?"

2. Patient response: "Because she thinks I have dementia"
3. "Why does she think that you have dementia?"

Patient Characteristics:

• Very talkative (confabulation, a feature of dementia)

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gk’s notes – part 2

• Shows denial (another feature of early dementia)

Assessment:

1. Ask about specific incidents:

o Patient might say: "I missed my appointment with bank. I was supposed to go
at 9 o'clock, I went at 2 o'clock thinking it was 9."
o Patient might add: "I missed another appointment with my daughter."
o Patient may try to deny issues: "But doctor, you know, I'm busy, I go out with
girls and I go to book club..."
2. Living situation:
o "Who do you live with?"
o "What does your husband say about this? Has he noticed anything?"
3. Memory:
o "How is your memory lately?"
o "Are you becoming forgetful?"
4. Specific memory issues:
o "Do you forget your day-to-day activities, household activities?"
o "Do you forget to close the front door or putting something on the cooker in
the oven and forgetting?"
o "Do you forget the names of your loved ones?"
o "Do you forget family affairs?"
o "Do you forget important dates?"
5. Other dementia symptoms:
o "Have you ever got lost on the street?"
o "Are you finding it difficult to manage your day-to-day activities?"
o "Are you finding it difficult to take care of your personal hygiene?"
6. Differentials:
o Parkinson's (Lewy body dementia): Ask about slowness of movement, speech
problems, swallowing problem, problem with walking
o Frontotemporal dementia: Ask about behavioural changes, personality
changes
o Brain tumour: Ask about numbness, weakness, neurological symptoms,
speech, swallowing, hearing issues
o Normal pressure hydrocephalus: Ask about bladder problems, loss of control
of bowel or bladder
7. Modified FAMISH assessment:
o Note: Patient has diabetes, mother had Alzheimer's
o Occupation: Judge
8. Driving: Ask about driving habits

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gk’s notes – part 2

Mini Mental State Examination (MMSE):

• Say: "Now, I would like to check your memory with an assessment called mini
mental state examination."
• In-person: Examiner will give you the score (e.g., 22)
• Telephone: Ask patient to come to practice for MMSE
• If already done: Patient might say "The nurses did it yesterday, they told me 22"

Diagnosis Discussion:

"Unfortunately, it's quite low. You may have some early signs of dementia. Dementia is a
condition of the brain that affects the memory. Initially, it affects memory, and it is a
progressive condition. As this condition progresses, it can start affecting various functions
of the body."

Risk Factors:

• "You mentioned your mother had Alzheimer's."

• "You also have some other conditions like diabetes."

Management:

1. Referral to memory clinic (seen by psychiatrist, not neurologist)

o Note: It used to be urgent referral, now it's just a referral
2. Explain medications:
o "Medications are given to improve your memory and slow down the progress
of your condition."
3. Multidisciplinary team involvement (physiotherapy, occupational therapist)
4. Advise not to drive
5. Advise not to get out from the house alone
6. Discuss with family:
o "We would like to speak to your daughter about this. Is that okay with you?"

Important Notes and Things to Avoid:

1. In eating disorder scenarios, BMI is crucial:

o Anorexia: BMI is low (e.g., 17)
o Bulimia: BMI is normal (e.g., 24)
2. SCOFF questions are essential for both anorexia and bulimia scenarios
3. For telephone scenarios (like bulimia), findings are either given by the patient or
available from the start, never interrupted by the examiner

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gk’s notes – part 2

4. In the dementia scenario, pay attention to patient behaviour (talkative, denial) as it

demonstrates features of dementia
5. Always complete the modified FAMISH assessment
6. Be prepared for the patient to be evasive or in denial, especially in the dementia
scenario
7. Remember the 5-point management plan for eating disorders
8. For dementia, emphasize the importance of the memory clinic referral and
medication explanation
9. Always ask about driving in the dementia scenario
10. Be empathetic and professional throughout all scenarios

Health Anxiety

Scenario:

• Patient made an appointment

• Thinks he has sickle cell anaemia
• Brother has been diagnosed with sickle cell
• Patient has been tested and doesn't have it
• Has done tests in private clinic as well
• Believes something is wrong with the testing

Assessment:

• Listen to patient's concerns about sickle cell anaemia

• Note that patient has been tested and results were negative
• Explore patient's belief that something is wrong with the testing

Diagnosis:

• "You may be having health anxiety."

Management:

• Refer to psychiatry department

• Treatment is counselling

Somatic Symptom Disorder

Scenario:

• Patient thinks he has cancer

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gk’s notes – part 2

• Has a rash at the back of his neck

• Had a lump before, biopsy showed it was adipose tissue (adipoma)
• Worried about cancer because a friend died of cancer
• Now has a rash behind his neck and thinks it's cancer

Assessment:

• Listen to patient's concerns about cancer

• Note previous biopsy results
• Examine the rash (examiner will tell you there are scratch marks)

Key Point:

• Somatic symptom disorder requires a physical symptom (in this case, the
rash/scratch marks)

Diagnosis:

• Diagnose as somatic symptom disorder

Management:

• Refer to psychiatry
• Treatment is counselling

ADHD (Attention Deficit Hyperactivity Disorder)

Scenario:

• 18-year-old patient in GP
• Referred by school or educational supervisor
• Patient may not have insight into the problem

Initial Approach:

1. Greet the patient (who may be standing)

2. Introduce yourself: "I am Dr. [Name]" (Note: Always use "I am," not "My name is")
3. Offer a seat: "Would you like to have a seat, please?"
4. Ask: "How may I help you?"
o Patient may say school nurse or educational supervisor asked them to see the
doctor
5. Ask: "May I know why they wanted you to see the doctors?"

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gk’s notes – part 2

o Patient might say: "I forget things" or mention memory problems

ADHD Assessment:

Assess for inattention and hyperactivity symptoms (need at least 5 in each category, but can
diagnose with less)

Inattention Symptoms:

1. Forgetting daily activities: "What sort of things do you forget?"

2. Losing items: "Do you often lose items like your wallet, your phone, keys?"
3. Easily distracted: "Do you get easily distracted?"
4. Careless mistakes: "Do you make careless mistakes?"
5. Problem maintaining concentration: "Do you have problem with maintaining
concentration when you play games or participate in plays?"
6. Problem with listening: "Do you have problem with listening without obvious
distraction?"
7. Failing to follow instructions: "Do you fail to follow instructions, for example, given
in the class?"
8. Difficulty organizing tasks: "Do you have difficulty in organizing tasks?"
9. Dislike of challenging mental tasks: "Do you like to do challenging mental tasks?"

Hyperactivity Symptoms:

1. Fidgeting or tapping: Observe and comment, "I can see you have some sort of
sudden movements, some fidgeting of your hands, sometimes you tap your hands.
How long have you been experiencing this? Does it happen very often?"
2. Leaving seat: "Do you leave your seat when you are expected to be seated?"
3. Feeling restless: "Do you feel restless sometimes?"
4. Being loud during leisure activities: "Are you being loud when you do some leisure
activities?"
5. Talking excessively: "Do you talk excessively?"
6. Answering before questions are completed: "Do you have a habit of answering
questions before somebody questioned you?"
7. Difficulty waiting for turn: "Do you have difficulty waiting for your turn?"
8. Interrupting others: "Do you have a habit of interrupting others?"

Additional Assessment:

1. Duration: "Did these symptoms start before your 12th birthday?"

2. Settings: "Do you notice the symptoms in two places? Like work (school) and home?"
3. Duration: Should be more than 6 months (not necessary to ask for 18-year-old)

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gk’s notes – part 2

Risk Factors:

• Ask about brain injuries: "Have you had any brain injuries?"
• Ask about birth: "Do you know anything about your birth? Were you told anything
about your birth? Were you born full-term?"
• Ask about birth weight: "Do you know anything about your body weight when you
were born? Were you told anything about being underweight?"
• Ask about mother's pregnancy: "Do you know if your mother used to drink alcohol
or smoke when she was pregnant with you?"

Differentials:

• Ask about general anxiety

• Ask about autism

Additional Questions:

• Ask about mood

• Ask about suicidal thoughts (must ask in any psychiatric condition)
• Complete MAFTOSA assessment
• Ask about sleep
• Ask about alcohol, smoking, recreational drugs
• Ask about hobbies
• Ask about educational performance: "How is your studies? How is your grades?"

Diagnosis Explanation:

"This could be a condition called attention deficit hyperactivity disorder. We call this as
ADHD. It is a mental health condition. People with this condition have trouble or
difficulty in paying attention. They may have some impulsive behaviour. Impulsive means
they may act without thinking what could be the results. Or they may be overly active."

Management:

1. Refer to adult psychiatry

2. Medication: Mention amphetamine
o Explain it can influence driving (not impair, but influence)
o Mention need to keep medication records (police may check)
3. Talking therapy
4. Diet and exercise recommendations
5. Advice for symptom improvement:
o Improve sleep (adequate sleep, around 6-8 hours, going to bed early)

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gk’s notes – part 2

o Regular exercise
o Cutting down on screen time (computers, TV, phone, tablets, iPads)
o Cut down on stimulant products (caffeinated drinks, alcohol, smoking)

Important Notes and Things to Avoid:

1. Distinguish between health anxiety and somatic symptom disorder

2. For somatic symptom disorder, there must be a physical symptom
3. In ADHD assessment, observe for fidgeting or restless behaviour
4. Always assess mood and suicide risk in psychiatric conditions
5. Be prepared to explain ADHD definition and management in detail
6. Remember to complete MAFTOSA assessment for all psychiatric conditions
7. Don't confuse dementia with ADHD in young patients
8. Use "I am" instead of "My name is" when introducing yourself
9. For ADHD, the hyperactivity behaviour is similar to pre-exam behaviour
10. In depression scenarios, know which one is mild, moderate, and severe
11. Be aware of the specific scenario outcomes and how to manage each particular
scenario

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gk’s notes – part 2

Suspected Cancer Scenarios

I. Formats for Suspecting Cancer

1. History taking
o Listen carefully to patient's symptoms and history
o Look for red flags that might indicate cancer
2. Test results discussion
o Review test results that might suggest cancer
o Identify abnormalities that warrant further investigation
3. Mannequin examination
o Perform thorough physical examination
o Identify physical signs that might indicate cancer

II. Types of Cancer Scenarios in PLAB 2

1. Breast cancer
2. Ovarian cancer
3. Testicular carcinoma

Note: These are the only three scenarios involving mannequin examination for suspecting
cancer in PLAB 2.

III. Important Points about Cancer in PLAB 2

• No fever in suspected cancers or cancers

• Fever indicates infectious origin in PLAB 2
• Many suspected cancer scenarios may not present with typical cancer symptoms
(weight loss, tiredness)
• Absence of typical symptoms doesn't rule out cancer

IV. Communication Guidelines

A. Importance of Clear Communication

• Must clearly tell the patient you suspect cancer

• Patient should leave understanding cancer is a possibility
• Avoid vague terms like "something serious," "sinister growth," "blister growth," or
"worst-case scenario"
• Don't use phrases like "symbolizing patient," "best case scenario," or "worst case
scenario"

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gk’s notes – part 2

• Use phrase "until proven otherwise" or follow guidelines

• Be direct and clear, but show empathy

B. How to Communicate Suspected Cancer

1. Express concern: "Mr. Johnson, we are a little bit concerned about your
symptoms/test results."
2. Explain reason for concern: State the red flags identified Example: "You have been
having difficulties in swallowing for quite a long time," or "You have been coughing
up blood for some time and also you have lost some weight."
3. Mention risk factors if applicable: "You have been smoking for quite a long time," or
"You mentioned your mother also had this condition," or "Considering your age..."
4. Use empathy: "Unfortunately, I'm sorry to tell you..."
5. Clearly state possibility of cancer: "Cancer of the [organ] could also present in this
way."
6. Pause after delivering the information

C. Handling Patient Responses

• If patient asks, "Are you sure, doctor?": Response: "Well, Mr. Johnson, this could be
something else as well. However, we are more worried about [restate symptoms/risk
factors]. This is why we need to investigate further."
• If patient seems scared or unsure: Reassure but remain honest: "I understand this is
concerning news. We're taking this seriously and will make sure you get the proper
care and investigation."

V. Examples of Suspected Cancer Scenarios

1. Progressive dysphagia with weight loss in a smoker: Suspected oesophageal

carcinoma
o Key symptoms: Difficulty swallowing, weight loss
o Risk factor: Smoking history
2. Coughing up blood, weight loss, 70-year-old smoker: Suspected lung cancer
o Key symptoms: Haemoptysis (coughing up blood), weight loss
o Risk factors: Age, smoking history
3. Unexplained neck lump for more than two weeks: Suspected nasopharyngeal
carcinoma
o Key symptom: Persistent neck lump
o Guideline: Neck lump > 2 weeks requires investigation
4. Unilateral nasal polyp: Suspected nasal carcinoma
o Key finding: One-sided nasal polyp
o Note: Unilateral presentation is concerning

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gk’s notes – part 2

5. Postmenopausal vaginal bleeding: Suspected endometrial carcinoma

o Key symptom: Vaginal bleeding after menopause
o Note: Any postmenopausal bleeding warrants investigation
6. Microscopic haematuria with leucocytosis: Suspected bladder carcinoma
o Key findings: Blood in urine (microscopic), increased white blood cells
o Note: Even microscopic blood in urine needs investigation

VI. Management and Next Steps

1. Explain the need for further tests "Based on what we've discussed, we need to do
some more tests to understand what's going on."
2. Possible initial tests:
o Blood tests
§ Markers: PSA (prostate), CA125 (ovarian), beta HCG and LDH
(testicular)
o Imaging
§ Ultrasound, X-rays Explain: "We might need to do some blood tests
or scans to get more information."
3. Referral process:
o Inform about referral to a specialist "We will be referring you to a specialist."
o Mention the type of specialist Example: "You'll be seen by a urologist. They're
doctors who specialize in problems with the kidneys, bladder, and the tubes
in between."
o Explain urgency "The referral will be sent today. You should have an
appointment within two weeks."
4. Explain anticipated procedures:
o Camera tests (e.g., endoscopy, cystoscopy, colonoscopy, hysteroscopy)
o Biopsy Example explanation: "They're going to do a camera test called a
bronchoscopy. It's a small tube, about the size of a little finger, with a camera
on top. They'll spray some numbing medicine, then insert it through your
mouth to look at your lungs. They might take some small tissue samples."
5. Treatment options if confirmed:
o Surgery
o Chemotherapy
o Radiotherapy
o Immunological/biological treatments Explain: "If this is confirmed, there are
several treatment options including surgery, chemotherapy, radiotherapy,
and some newer treatments. The specialist will discuss these in detail if
needed."

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VII. Important Instructions for Patients

1. Follow-up on referral "If you don't hear anything about your appointment within
two weeks, please let us know."
2. Support at appointment "When you go to the appointment, you can take someone
from your family or a friend with you for support."
3. Reassurance "I also want to mention that not everyone referred in this pathway will
have cancer. But it's important we investigate thoroughly given your symptoms."

VIII. Things to Avoid During Consultation

1. Don't use vague terms or euphemisms Avoid: "something serious," "sinister growth,"
"blister growth"
2. Avoid sugar-coating the information Don't say: "It's probably nothing to worry
about" when you suspect cancer
3. Don't wait for the patient to ask if it could be cancer Be proactive in mentioning the
possibility
4. Don't run away from difficult conversations If asked "Are you sure?", don't say
"We're not really sure" and change the subject
5. Avoid saying "don't worry" or downplaying the situation Instead, acknowledge their
concerns and explain the next steps
6. Don't use medical jargon without explanation Always explain medical terms in
simple language
7. Avoid rushing through the conversation Take time to explain and allow the patient
to ask questions

IX. Sample Full Dialogue for Suspected Cancer Communication

Doctor: "Mrs. Jones, we are a little bit concerned about your symptoms. The reason for our
concern is that you've had some unexplainable spots of bleeding, some spontaneous
bleeding from your vagina. Considering your age, unfortunately, I'm sorry to tell you,
cancer of the lining of your womb could also present in this way."

[Pause for patient's reaction]

Patient: "Cancer? Are you sure, doctor?"

Doctor: "Well, Mrs. Jones, this could be something else as well. However, we are more
worried because of the unexpected bleeding you're experiencing at your age. This is why we
need to investigate further to be certain."

Patient: "I see. What happens now?"

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gk’s notes – part 2

Doctor: "Let me explain what we need to do next. Based on our suspicion, we need to run
some tests. We'll be referring you to a gynaecologist, who specializes in women's
reproductive health. The referral will be sent today, and you should have an appointment
within two weeks."

Patient: "What will happen at that appointment?"

Doctor: "When you go to the appointment, they might perform a test called a hysteroscopy.
This is a camera test where they insert a small tube, about the size of a little finger, with a
camera on top, through your vagina to examine the lining of your womb. They might take
some tissue samples for further testing. Before the procedure, they'll explain everything in
detail and answer any questions you have."

Patient: "That sounds a bit scary. What if it is cancer?"

Doctor: "I understand this is worrying, Mrs. Jones. If this condition is confirmed, it's
typically treated with surgery, and sometimes chemotherapy or radiotherapy. There are also
some newer forms of treatment available. But remember, the specialist will discuss all of
this with you in much more detail if it becomes necessary."

Doctor: "If you don't hear anything about your appointment within two weeks, please let us
know. You're welcome to bring someone from your family or a friend to the appointment
for support."

Doctor: "Lastly, I'd like to mention that not everyone referred through this pathway will
have cancer. However, it's important we investigate thoroughly given your symptoms."

Doctor: "Do you have any questions about what I've explained?"

Patient: "This is a lot to take in. I'm scared."

Doctor: "It's completely normal to feel scared, Mrs. Jones. We're taking this seriously and
will make sure you get the proper care and investigation. Remember, we're here to support
you through this process. Is there anything else you'd like to ask or any part you'd like me
to explain again?"

[Address any further questions or concerns the patient might have]

X. Additional Notes

• In Western countries with strong healthcare systems, it's crucial to clearly

communicate cancer suspicions

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gk’s notes – part 2

• The goal is for the patient to leave understanding that cancer is a possibility being
investigated
• This approach allows for timely investigation and treatment if cancer is confirmed
• Clear communication also protects healthcare providers and institutions from
potential legal issues
• Remember, in real clinical presentations, cancer may not always present with typical
symptoms

Neck Lump
I. Patient Profile and Scenario Setup

1. Age:
o Definitely more than 24 years old
o Typically around 28-30 years old
o Sometimes up to 40 years old
o Note: If less than 25, same-day referral is required
2. Gender: Male
o Reason: Nasopharyngeal cancer is more common in males
3. Presenting complaint: Neck lump
4. Additional background information:
o Patient has been diagnosed with anxiety in the past Note: This is included to
test decision-making. Do not let this influence proper assessment and
communication.
o Family history: Father and mother had leukaemia Note: This is included as a
distraction. Do not let it influence your diagnosis.
o Smoking history: Patient smokes a lot, more than 10 years Important:
Smoking is a serious risk factor for head and neck tumours
5. Scenario setup:
o The presenting complaint (neck lump) is written outside the room
o You have 1.5 minutes to prepare differentials before entering

II. Initial Assessment

1. Opening question: "How may I help you?"

Expected patient response: "I have a lump in my neck."

III. History Taking

Use the MES approach: Morphology, Evolution, Symptoms

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gk’s notes – part 2

A. Morphology

1. Location: "Which side is the lump on? Left side or right side?"
2. Size: "How big is that?" "Can you compare it? Is it the size of a grape? Or smaller
than that? The size of a pea? Or somewhere in between?"
3. Consistency: "How is the consistency? Is it a soft lump?" "Does it feel like it's filled
with fluid?"
4. Shape: "How is the margin? Is it smooth?" "Does it have an irregular shape or regular
shape?"
5. Mobility: "Is it moving? Or is it attached to underlying tissue or overlying skin?"

B. Evolution

1. Onset: "When did you notice it?"

2. Progression: "Since then till now, is it getting bigger? Smaller? Same size?"
3. Changes with position or activity: "Does it change when you change your position?
For example, when you lie down?" "Does it change when you cough or sneeze?"
"Does it change when you swallow or drink something? When you eat something?"
"Does it move when you move your tongue?"

C. Symptoms

1. General symptoms: "Does it have any symptoms at all?" "Is it painful?" "Any
numbness? Tingly sensation?" "Any redness? Any swellings around?"
2. Thyroid-related: "Have you had any thyroid problem in the past?"
3. Mouth and throat: "Any ulcers in your mouth?" "Any wound in your tongue?" "Any
ulcers on your lips?" "Any problem with your teeth? Any teeth decay?" "Any problem
with your swallowing?" "Any throat pain?" "Any voice changes?"
4. Nasal: "Any problem with your smell? Finding it okay? Any changes in your smell?"
"Any bleeding from the nose?" "Any growth in the nose?"
5. Respiratory: "Any problem with your breathing?" "Cough? Shortness of breath?"
6. Lymph node-related: Ask about TB and HIV
7. Leukaemia symptoms: "Any bruises?" "Any anaemia symptoms?"
8. Lymphoma symptoms: "Any weight loss?" "Any back pain?" "Any night sweats?"

IV. Risk Factors

1. Smoking: "How long have you been smoking?" "How much do you smoke?"

Note: Smoking is the main risk factor for head and neck tumours

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V. Physical Examination

Note: In PLAB 2, examination findings are usually provided on paper

Typical findings for suspected cancer:

• Lymph node swelling

• Size: 1x1 centimetre
• Consistency: Fixed mass

VI. Diagnosis and Communication

Suspected diagnosis: Nasopharyngeal tumour (or oro-pharyngeal tumour)

How to communicate the suspicion:

"Unfortunately, I'm sorry to tell you, cancer of this region could present in this way. We
call this naso-oro-pharyngeal tumours. This could be cancer from any of this area - your
nose, your throat, or your mouth. Unfortunately, you do have some risk. That is, you've
been smoking for quite a long time, which increases the chances."

VII. Management and Next Steps

1. Referral:
o Two-week pathway referral to ENT (Ear, Nose, and Throat) or Head and
Neck surgeons
2. Investigations:
o Ultrasound
o Needle biopsy (no open biopsy)
o Possible CT scan to locate the original tumour
3. Treatment options:
o Surgery (mainly for the original tumour)
o Possible chemotherapy
o Possible radiotherapy

VIII. Important Notes

1. Do not let a patient's history of anxiety or other mental health issues deter you from
proper assessment and clear communication about cancer suspicion.
2. Family history of other cancers (like leukaemia in this scenario) should not distract
you from focusing on the presenting symptom and its most likely causes.
3. Always consider smoking as a significant risk factor for head and neck tumours.

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4. The two-week wait referral pathway is crucial for suspected head and neck cancers.
5. Clear communication about the suspicion of cancer is essential, even if it seems
difficult or uncomfortable.
6. There are three types of lumps to be particularly aware of: breast lump, neck lump,
and testicular lump.
7. In PLAB 2, if fever is present, it usually indicates an infectious origin, not cancer.

IX. Things to Avoid

1. Don't be distracted by the patient's history of anxiety or family history of leukemia.

2. Don't avoid clear communication about cancer suspicion due to the patient's
anxiety history.
3. Don't ignore or downplay the significance of smoking history.
4. Don't perform an open biopsy - needle biopsy is preferred.
5. Don't delay the two-week referral pathway.
6. Don't use vague terms when communicating cancer suspicion. Be clear and direct,
while maintaining empathy.

X. Sample Dialogue

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

Patient: "I've noticed a lump on the side of my neck."

Doctor: "I see. Which side is the lump on? Left or right?"

Patient: "It's on the right side."

Doctor: "How big would you say it is? Can you compare it to something, like a grape or a
pea?"

Patient: "It's about the size of a grape, I'd say."

Doctor: "How does the lump feel? Is it soft or hard?"

Patient: "It feels quite firm."

Doctor: "Does it have a regular shape? Are the edges smooth?"

Patient: "It seems pretty round and smooth."

Doctor: "When did you first notice this lump?"

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Patient: "I first noticed it about three weeks ago."

Doctor: "Since you noticed it, has it gotten bigger, smaller, or stayed the same size?"

Patient: "It seems to have stayed about the same size."

Doctor: "Does the lump change when you swallow or when you move your tongue?"

Patient: "No, it doesn't seem to move at all."

Doctor: "Is the lump painful at all? Any numbness or tingling around it?"

Patient: "No, it doesn't hurt or feel numb. It's just there."

Doctor: "Have you noticed any problems with swallowing or any changes in your voice?"

Patient: "No, nothing like that."

Doctor: "Any problems with your sense of smell or any bleeding from your nose?"

Patient: "No, everything seems normal in that regard."

Doctor: "Have you been experiencing any unexplained weight loss or night sweats?"

Patient: "No, I haven't noticed anything like that."

Doctor: "I understand you're a smoker. How long have you been smoking?"

Patient: "I've been smoking for about 15 years now."

Doctor: "And how many cigarettes do you smoke per day?"

Patient: "About a pack a day."

Doctor: "Thank you for all this information. I'd like to examine the lump now if that's
okay."

[After examination]

Doctor: "Mr. [Patient's name], based on our discussion and the examination, I'm a bit
concerned about this lump in your neck. Unfortunately, I'm sorry to tell you, cancer of this
region could present in this way. We call these naso-oro-pharyngeal tumours. This could be

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cancer from your nose, throat, or mouth area. Unfortunately, you do have some risk.
You've been smoking for quite a long time, which increases the chances."

Patient: "Cancer? Are you sure?"

Doctor: "At this point, we can't be certain, but it's a possibility we need to investigate. I'm
going to refer you to a specialist - an Ear, Nose, and Throat doctor. They'll be able to do
more detailed tests, including an ultrasound and possibly a needle biopsy of the lump. This
referral will be urgent, and you should be seen within two weeks."

Patient: "What will happen then?"

Doctor: "The specialist will perform more detailed examinations. They might do an
ultrasound of your neck and a needle biopsy of the lump. If necessary, they might also
arrange a CT scan to get a clearer picture. Based on these results, they'll be able to
determine if this is indeed a tumour and, if so, where it originated from."

Patient: "And if it is cancer?"

Doctor: "If it turns out to be a tumour, the main treatment is usually surgery to remove it.
Sometimes, additional treatments like chemotherapy or radiotherapy might be needed. But
let's not get ahead of ourselves. The first step is to get these tests done and get a clear
diagnosis. Do you have any other questions?"

Patient: "This is a lot to take in. I'm scared."

Doctor: "I understand this is very worrying news. It's natural to feel scared. Remember,
we're taking this seriously and acting quickly to get you the proper care and investigation.
The specialist will be able to give you more detailed information once they've done their
tests. Is there anything else you'd like me to explain again?"

[Address any further questions or concerns the patient might have]

Endometrial Carcinoma
Patient Profile

• Age: Around 60 years old

• Gender: Female
• Menopausal Status: Postmenopausal (had last period 10 years ago)

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Presenting Complaint

• Few spots of bleeding

• Occurring for the last two weeks
• Patient may describe it as "period-type bleeding"

Important Notes

• No other cancer symptoms may be present

• There is nothing else in the history
• Unexplained bleeding in a postmenopausal woman is a red flag

Diagnosis

Suspected endometrial carcinoma

Communication

"Unfortunately, I'm sorry to tell you, cancer of the lining of your womb could also present
in this way."

Management

1. Referral:
o Two-week pathway to gynaecology
2. Investigations:
o Hysteroscopy (camera test)
o Biopsy may be taken during hysteroscopy
3. Treatment options:
o Surgery
o Chemotherapy
o Radiotherapy

Oesophageal Carcinoma
Patient Profile

• Age and Gender:

o If female: Elderly, around 65-70 years old
o If male: Around 50-55 years old
o Note: These days, it can be a lady as well, not just men

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Presenting Complaint

Progressive dysphagia (difficulty swallowing)

History Taking

1. Nature of dysphagia: Question: "Do you have difficulty swallowing solids or liquids?"
Expected patient response: "It was only for solid foods at first, but now it's for
liquids as well." Note: If difficulty is initially with liquids and then solids, consider
achalasia as a differential diagnosis
2. Ability to eat and drink: Question: "Are you able to eat and drink?" Important: If
patient cannot eat or drink, consider immediate admission
3. Signs of dehydration: Questions: "Are you passing urine normally?" "Do you feel
more thirsty than usual?"
4. Weight loss: Question: "Have you noticed any unintentional weight loss recently?"
Note: With the progress of this disease, there may be weight loss
5. Smoking history: Question: "Do you smoke? If yes, for how long and how much?"
Note: Smoking is a risk factor

Important Notes

• If this is a telephone consultation:

o Ask the patient to come in today or tomorrow for a face-to-face review
o You can start the referral process based on the telephone consultation
• Eating and drinking ability is crucial to assess
• In PLAB 2, if a patient presents with difficulty swallowing, it's likely to be
oesophageal carcinoma

Diagnosis

Suspected oesophageal carcinoma

Communication

"Unfortunately, Mr./Mrs. [Patient's name], I'm sorry to tell you, but this difficulty in
swallowing could be a sign of cancer of the food pipe. This is one of the possibilities we
need to investigate."

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Management

1. Referral:
o Two-week pathway to gastroenterology
2. Investigations:
o Endoscopy
o Barium meal (as an alternative or additional test)
3. Explanation of procedures: Note: Explain either barium meal or endoscopy, not
both. The explanation is to showcase language ability and communication skills.
Barium meal explanation: "You'll be given a special drink called a barium drink.
After drinking it, we'll take an X-ray. In the X-ray, we can see if there's anything
growing or any obstructions in your food pipe. This is a quick test. Meanwhile, we
might also do an endoscopy to take a tissue sample."
4. Treatment options:
o Surgery
o Chemotherapy
o Radiotherapy

III. General Notes on Communicating Cancer Suspicion

1. Clarity is crucial:
o Be clear and direct about the possibility of cancer
o Avoid vague terms like "something serious" or "sinister growth"
2. Empathy is important:
o Show sympathy and understanding while delivering the news
o Balance clear communication with empathetic delivery
3. Examples of communication styles: a. Ahmad style (very nice, sugar-coating): "Maybe
there's something serious or sinister going on." Note: This style is not preferred in
PLAB 2 b. Mohammad style (clear but less empathetic): "Unfortunately, Mr.
Johnson, this could be cancer. It's one of the possibilities for your symptoms." Note:
This style is preferred in PLAB 2, but with added empathy
4. Ideal communication: Clear and empathetic: "Unfortunately, Mr./Mrs. [Patient's
name], I'm sorry to tell you, but cancer is also one of the possibilities for your
symptoms."
5. Scoring in PLAB 2:
o Clear communication about cancer suspicion is prioritized over extremely
empathetic but vague communication
o In the old system: Ahmad (very nice but vague) might score 6, Mohammad
(clear but less empathetic) might score 7, with 6.05 as a pass mark
o In the current system: The pass mark might be 6, with Mohammad scoring 6
and Ahmad scoring 5

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6. If suspecting cancer during a telephone consultation:

o Ask the patient to come in for a face-to-face review today or tomorrow
o You can start the referral process based on the telephone consultation

Bladder Carcinoma
I. Patient Profile Evolution

1. Previous scenario (before pandemic):

o Age: 55 years old
o Presenting complaint: Pink colour urine
2. Current scenario:
o Age: 65-70 years old (a little older now)
o Gender: Male
o Presenting complaint: Episodes of blood in the urine

II. Presenting Complaint Details

• Two episodes of blood in the urine

• Sometimes passing clots
• Painless haematuria

III. Important Notes on Symptoms

• No other symptoms present:

o No pain
o No frequency
o No weight loss
o No fever
o No back pain
o No cancer symptoms at all

IV. Risk Factor

• Patient is a smoker

V. History Taking

1. Blood in urine: Question: "Can you tell me more about the blood you've noticed in
your urine?" Expected response: "I've had two episodes of blood in my urine.
Sometimes I pass clots."

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2. Other urinary symptoms: Question: "Have you experienced any pain while urinating
or any increased frequency in urination?" Expected response: "No, I haven't had any
pain or increased frequency."
3. General health: Question: "Have you noticed any weight loss, fever, or back pain
recently?" Expected response: "No, I haven't experienced any of those symptoms."
4. Smoking history: Question: "Do you smoke? If yes, for how long?" Expected
response: "Yes, I'm a smoker. I've been smoking for many years."
5. Prostate symptoms: Question: "Have you been experiencing any symptoms related
to your prostate?" Expected response: "No, I haven't had any prostate symptoms."

VI. Physical Examination

1. Abdominal examination:
o You need to examine the patient's abdomen
2. Digital Rectal Examination (DRE):
o You need to examine the back passage due to the man's age
o Note: The examiner may say "prostate is enlarged"

VII. Diagnosis

Suspected bladder carcinoma

Key point: Painless haematuria in a smoker is bladder carcinoma until proven otherwise

VIII. Communication

"Mr. [Patient's name], I'm concerned about the blood you've noticed in your urine. Given
your smoking history, this could be a sign of bladder cancer. We need to investigate this
urgently."

IX. Management

1. Referral:
o Two-week referral to urology
2. Investigations:
o Cystoscopy (camera test)

Explanation of cystoscopy: "The urologist will perform a test called a cystoscopy. This
involves inserting a thin, tiny tube with a camera through your urethra - that's the tube in
your penis that you urinate through. They'll be able to look inside your bladder and may
take a small tissue sample if necessary."

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3. Treatment options:
o Surgery is the main treatment
§ Partial removal of the bladder
§ Sometimes full removal of the bladder (may require artificial bladder)
o Chemotherapy
o Radiotherapy

X. Important Points to Remember

1. Do not complicate the scenario:

o If told the prostate is enlarged during examination, do not change your
diagnosis
o Prostate enlargement is a disease of age; almost all men around 75 will have
an enlarged prostate
2. Decision making is crucial:
o Stick to your diagnosis of suspected bladder cancer based on the key
symptoms and risk factors
o Don't be swayed by additional information that doesn't change the primary
concern
3. Key diagnostic criteria:
o Painless haematuria in a smoker is bladder carcinoma until proven otherwise
4. Examination:
o Always mention that you would examine the abdomen
o Mention examining the back passage due to the patient's age
5. Prostate symptoms:
o Ask about prostate symptoms, but the patient will likely say they don't have
any
o This is to demonstrate thoroughness, not to change the diagnosis

XI. Things to Avoid

1. Don't say "It could be bladder carcinoma or prostate cancer":

o Avoid using "either this or that" statements
o Stick to one diagnosis based on the primary symptoms and risk factors
2. Don't change your diagnosis based solely on the enlarged prostate finding:
o Remember, prostate enlargement is common in older men and doesn't
necessarily indicate prostate cancer
3. Don't ignore the smoking history:
o Smoking is a significant risk factor for bladder cancer
4. Don't forget to mention the abdominal and rectal examinations
5. Don't overcomplicate the scenario with unnecessary differentials

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XII. Sample Dialogue

Doctor: "Hello, Mr. [Patient's name]. How can I help you today?"

Patient: "I've noticed blood in my urine twice now. Sometimes there are even clots."

Doctor: "I see. Have you experienced any pain while urinating or any increased frequency
in urination?"

Patient: "No, I haven't had any pain or increased frequency."

Doctor: "Have you noticed any weight loss, fever, or back pain recently?"

Patient: "No, I haven't experienced any of those symptoms."

Doctor: "Do you smoke, Mr. [Patient's name]?"

Patient: "Yes, I've been smoking for many years."

Doctor: "I understand. Have you been experiencing any symptoms related to your
prostate?"

Patient: "No, I haven't had any prostate symptoms."

Doctor: "Thank you for this information. I'd like to examine your abdomen and perform a
rectal examination if that's okay with you."

[After examination]

Doctor: "Mr. [Patient's name], I'm concerned about the blood you've noticed in your urine.
Given your smoking history, this could be a sign of bladder cancer. We need to investigate
this urgently."

Patient: "Cancer? Are you sure?"

Doctor: "At this point, we can't be certain, but it's a possibility we need to investigate
quickly. I'm going to refer you to a urologist - a specialist in this area. You should be seen
within two weeks."

Doctor: "The urologist will perform a test called a cystoscopy. This involves inserting a thin,
tiny tube with a camera through your urethra - that's the tube in your penis that you
urinate through. They'll be able to look inside your bladder and may take a small tissue
sample if necessary."

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Doctor: "If it turns out to be cancer, the main treatment is usually surgery. This might
involve removing part of your bladder, or sometimes the entire bladder. In some cases,
chemotherapy or radiotherapy might also be used. But let's not get ahead of ourselves. The
first step is to get these tests done and get a clear diagnosis."

Patient: "This sounds serious. I'm worried."

Doctor: "I understand this is concerning news. It's natural to feel worried. Remember,
we're taking this seriously and acting quickly to get you the proper care and investigation.
The specialist will be able to give you more detailed information once they've done their
tests. Do you have any questions for me?"

[Address any further questions or concerns the patient might have]

Bladder Carcinoma Assessment from Test Results

I. Scenario Setup

• Setting: GP follow-up (F2)

• Patient: 60-year-old man
• Reason for Visit: Diabetic follow-up
• Previous Visit: Last week for diabetic follow-up

II. Test Results

1. Diabetes Control:
o HbA1c: Normal (diabetes well controlled)
2. Urine Dipstick (new finding):
o Microscopic haematuria
o Note: This was also found in last week's urine dipstick test
3. Blood Test:
o Leucocytosis (high white cell count in blood)

III. Patient History

• Medical History: Diabetic

• Smoking History: Former smoker (quit last year)

IV. History Taking

1. General Well-being: Question: "How have you been, Mr. Johnson?" Expected
response: "I've been fine."

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2. Urinary Symptoms: Question: "Have you had any blood in the urine?" Expected
response: "No."
3. Comprehensive Haematuria Causes Assessment:
o Ask about all causes of haematuria
o Include questions about:
§ Kidney-related symptoms
§ Bladder-related symptoms
§ Urethral symptoms
§ Kidney stones
§ Urinary tract infections Expected response: No symptoms reported
4. Diabetes Control: Question: "How has your diabetes been?" Expected response: "It's
well controlled."
5. Smoking History: Question: "Do you smoke?" Expected response: "No." Follow-up
question: "Did you smoke in the past?" Expected response: "Yes." Further question:
"When did you stop?" Expected response: "Last year."

V. Physical Examination

Note: In this scenario, physical examination may not be explicitly mentioned, but it's
always good practice to include it.

VI. Diagnosis

Suspected bladder carcinoma

Key point: Microscopic haematuria with leucocytosis in a former smoker is suspicious for
bladder carcinoma (guideline-based)

VII. Communication

"Mr. Johnson, I understand you've come for your diabetes follow-up. Your diabetes is well
controlled, which is great. However, we've found some unexpected results in your urine
and blood tests that we need to investigate further. These findings, combined with your
history of smoking until last year, raise a concern that we need to rule out the possibility of
bladder cancer."

VIII. Management

1. Referral:
o Two-week referral to urology
2. Investigations:
o Cystoscopy (camera test)

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3. Treatment options (if cancer is confirmed):

o Surgery (main treatment)
o Possible chemotherapy or radiotherapy

IX. Important Points to Remember

1. Always ask about past smoking history:

o If a patient says they don't smoke, ask if they've ever smoked in the past
o Recent ex-smokers (quit within the last year) should be considered as having
the same risk as current smokers
2. Guidelines are crucial:
o Microscopic haematuria with leucocytosis in a smoker or recent ex-smoker is
suspicious for bladder carcinoma
3. Be thorough in history taking:
o Ask about all possible causes of haematuria, even if the patient reports no
symptoms
4. Don't be distracted by the original reason for the visit:
o Even though the patient came for a diabetes follow-up, the new findings
need to be addressed
5. Importance of follow-up tests:
o The fact that microscopic haematuria was found in two consecutive tests (last
week and this week) is significant
6. Time management:
o Take some time (half an hour to one hour) to study common causes of
haematuria, dysphagia, and vaginal bleeding

X. Things to Avoid

1. Don't ignore microscopic haematuria:

o Even if the patient reports no symptoms, microscopic haematuria needs to
be investigated
2. Don't forget to ask about past smoking history:
o Recent ex-smokers are still at high risk
3. Don't be satisfied with just addressing the diabetes control:
o New findings need to be thoroughly investigated
4. Don't rush to reassure the patient without proper investigation:
o While many causes of microscopic haematuria are benign, in this scenario,
cancer needs to be ruled out
5. Don't forget to explain the need for urgent referral and further tests
6. Don't miss asking about past smoking if the patient initially denies current smoking

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XI. Sample Dialogue

Doctor: "Hello, Mr. Johnson. I understand you're here for your diabetes follow-up. How
have you been?"

Patient: "I've been feeling fine, doctor."

Doctor: "That's good to hear. I can see from your HbA1c results that your diabetes is well
controlled. However, there are some other test results I'd like to discuss with you. Have you
noticed any blood in your urine recently?"

Patient: "No, I haven't noticed anything like that."

Doctor: "Okay. Have you had any pain in your lower back or sides? Any burning sensation
when urinating or increased frequency?"

Patient: "No, nothing like that."

Doctor: "I see. Have you ever passed any small stones in your urine?"

Patient: "No, I haven't."

Doctor: "Alright. Now, Mr. Johnson, do you smoke?"

Patient: "No, I don't smoke."

Doctor: "Have you ever smoked in the past?"

Patient: "Yes, I used to smoke."

Doctor: "When did you stop smoking?"

Patient: "I quit last year."

Doctor: "Thank you for sharing that information. Mr. Johnson, in your urine test from last
week and again this week, we found some microscopic traces of blood. We've also found a
high white cell count in your blood. Given these findings and your history of smoking
until recently, I'm concerned that we need to rule out the possibility of bladder cancer."

Patient: "Cancer? But I feel fine!"

Doctor: "I understand this is unexpected news. Many times, early bladder cancer doesn't
cause noticeable symptoms. That's why it's important we investigate these findings

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thoroughly. I'm going to refer you to a urologist - a specialist in this area. You should be
seen within two weeks."

Doctor: "The urologist will likely perform a test called a cystoscopy. This involves inserting
a thin tube with a camera to look inside your bladder. They may also take a small tissue
sample if necessary."

Patient: "This sounds serious. What if it is cancer?"

Doctor: "Let's not get ahead of ourselves. The most important thing right now is to get
these tests done to find out what's causing these results. If it does turn out to be cancer, the
main treatment is usually surgery, and there are other treatments available too. But the
urologist will be able to give you more detailed information once they've done their tests.
Do you have any questions for me?"

[Address any further questions or concerns the patient might have]

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Respiratory Conditions
I. Overview of Respiratory Conditions

1. Lung Cancer (2 scenarios)

2. Mesothelioma (3 scenarios)
3. Tuberculosis (TB) (2 scenarios)
4. Pneumocystis Pneumonia (PCP)
5. Legionella

Note: Pulmonary Embolism (PE) is typically covered under chest pain scenarios.

II. Common Presenting Symptoms

• Cough
• Shortness of breath

III. Essential Questions for Respiratory Cases

Ten essential questions to ask in any respiratory case, divided into upper and lower five:

A. Upper Five Questions

1. Cough characteristics: Question: "Is it a dry cough or are you coughing up phlegm?"
Notes:
o Lung cancer: Productive cough
o Mesothelioma: Dry cough
o PCP: Dry cough
2. Presence of blood: Question: "Is there any blood? Have you noticed any streaks of
blood when coughing?" Notes:
o Not very useful for differential diagnosis
o Can occur in lung cancer, TB, and sometimes mesothelioma
3. Fever: Question: "Do you have a fever?" Notes:
o Indicates infection (PCP, TB, pneumonia, Legionella)
o In exam, if fever is present, think infection
4. Weight loss: Question: "Have you experienced any weight loss?" Notes:
o Not very useful as it's common in many conditions
o Present in lung cancer, TB, mesothelioma, PCP
o Must ask, but "useless" for differentiation
5. Night sweats: Question: "Are you experiencing night sweats?" Notes:
o Only for lung cancer in this context

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B. Lower Five Questions

1. Smoking history: Question: "Do you smoke?" Notes:

o Present in most scenarios (lung cancer, mesothelioma, PCP, TB)
o Not useful for differentiation, but must ask
2. Recreational drug use: Question: "Do you use any recreational drugs?" Notes:
o Important for PCP diagnosis
o Recent addition: also consider PE with recreational drug use
3. Sexual history: Question: "Can you tell me about your sexual activities?" Notes:
o Focus on men having sex with men
o Risk factor for HIV, leading to PCP
4. Occupation: Question: "What is your occupation?" Notes:
o Crucial for mesothelioma diagnosis
o Risk occupations: builder, plumber, carpenter, bricklayer, demolition
worker, shipyard worker
o For lung cancer: white-collar jobs (e.g., teacher, judge)
5. Travel history: Question: "Have you travelled recently? Where did you go?" Notes:
o Essential for TB diagnosis
o TB-associated destinations: Tanzania, South Africa, Thailand, Philippines
o Legionella-associated destination: Spain

IV. Specific Condition Notes

Mesothelioma

• Always associated with occupational risk (building-related jobs)

• No mesothelioma without occupational risk
• Presents with dry cough
• Risk related to asbestos exposure in old buildings

Lung Cancer

• Referred to as bronchogenic cancer

• Presents with productive cough, often with blood
• Night sweats are a characteristic symptom
• Often associated with white-collar jobs in PLAB 2 scenarios

Tuberculosis (TB)

• Always associated with travel history in PLAB 2

• "No TB without travel"
• Common destinations: Tanzania, South Africa, Thailand, Philippines

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Pneumocystis Pneumonia (PCP)

• Associated with recreational drug use

• Risk factor: Men having sex with men (HIV risk)
• Presents with dry cough

Legionella

• Associated with travel, particularly to Spain

Pulmonary Embolism (PE)

• Usually presents with chest pain and shortness of breath

• Typically affects females in PLAB 2 scenarios
• "PE means female" in PLAB 2
• Risk factors: contraception use, recent addition of IV drug use
• No fever

V. Important Notes for PLAB 2

1. In PLAB 2, if fever is present, think of infectious causes.

2. Weight loss and smoking history are common in many conditions, so they're not
very useful for differential diagnosis.
3. Occupational history is crucial for diagnosing mesothelioma.
4. Travel history is essential for TB diagnosis in PLAB 2.
5. For PE, remember: female patient, no fever, risk factors like contraception or IV
drug use.
6. "Recreational means PCP" in lung symptoms, but recent addition of PE possibility.
7. The United Kingdom is considered an old country with asbestos in old buildings,
relevant for mesothelioma cases.

VI. Study Tips

1. Discuss scenarios with colleagues, especially those you may not get along with well,
as this can enhance memory retention due to the emotional component.
2. Study common causes of respiratory symptoms (cough, shortness of breath)
thoroughly.
3. Practice going through the ten essential questions for each respiratory scenario.
4. Remember the specific associations (e.g., travel for TB, occupation for
mesothelioma) as they are crucial in PLAB 2 scenarios.
5. Take time (half an hour to one hour) to study common causes of haematuria,
dysphagia, and vaginal bleeding.

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6. Discuss scenarios online with 3-4 people to better remember the details.

VII. Things to Avoid

1. Don't forget to ask about past smoking history if a patient denies current smoking.
2. Don't ignore the importance of travel history in TB cases.
3. Don't overlook occupational history in suspected mesothelioma cases.
4. Don't assume PE in male patients in PLAB 2 scenarios.
5. Don't forget to consider recreational drug use in both PCP and PE cases.

VIII. Sample Dialogue

Doctor: "Hello, I understand you're having some breathing problems. Can you tell me
more about your symptoms?"

Patient: "Yes, I've been coughing a lot lately."

Doctor: "I see. Is it a dry cough or are you coughing up any phlegm?"

Patient: "It's mostly dry, but sometimes I cough up a little phlegm."

Doctor: "Have you noticed any blood or streaks of blood when coughing?"

Patient: "No, I haven't seen any blood."

Doctor: "Have you had any fever recently?"

Patient: "No, no fever."

Doctor: "Have you experienced any unintentional weight loss?"

Patient: "I've lost a few pounds, but I'm not sure why."

Doctor: "Are you experiencing any night sweats?"

Patient: "No, I haven't had any night sweats."

Doctor: "Do you smoke or have you ever smoked?"

Patient: "I used to smoke, but I quit last year."

Doctor: "Do you use any recreational drugs?"

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Patient: "No, I don't use any drugs."

Doctor: "Can you tell me about your sexual history? Specifically, have you had any male
sexual partners?"

Patient: "No, I haven't."

Doctor: "What is your occupation?"

Patient: "I'm a carpenter. I've been working in construction for about 20 years."

Doctor: "Have you travelled recently? If so, where did you go?"

Patient: "I went to Spain on holiday last month."

Doctor: "Thank you for answering these questions. Based on your symptoms and history,
particularly your occupation as a carpenter, I'm concerned about the possibility of a
condition called mesothelioma. We'll need to do some further tests to investigate this."

Differentiating Lung Cancer from Mesothelioma

Lung Cancer:

1. Setting: GP
2. Presenting symptom: Cough with blood
3. Age: Typically around 70 years old
4. Occupation: White-collar job (e.g., teacher)
5. Additional symptoms:
o Weight loss
o Smoker (often for many years, e.g., 50 years since university)

Mesothelioma:

1. Setting: Respiratory unit (referred by GP)

2. Presenting symptom: Shortness of breath, may have dry cough
3. Age: Typically in 60s (55-60)
4. Occupation: Blue-collar job related to construction (e.g., carpenter)
5. Additional symptoms:
o Weight loss
o Smoker
o May have streaks of blood in cough (don't be surprised)

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Common Features

• Both conditions involve smoking history

• Both conditions involve weight loss

Explaining Chest X-rays

When to Explain X-rays:

• If you see an X-ray in any scenario, you must explain it to the patient
• X-rays fall under the data interpretation category
• Explanation should be brief (maximum 30 seconds, 3-4 lines)

How to Explain a Chest X-ray:

1. Introduction: "I have the X-ray with me. Let me explain this to you."
2. Explain normal structures: "If you look in the middle, this white shadow is your
heart. On both sides, these blackish areas are your normal lung tissue."
3. Point out abnormalities: "If you look on your right/left side (specify based on the X-
ray), you'll see a white shadow here. This is an abnormality."
4. Explain significance: "This white shadow should be similar to the opposite side. It
shows there might be something growing/an infection going on."

Example Script for Lung Cancer X-ray:

"I have the X-ray with me. Let me explain this to you. If you look in the middle, okay, this
white shadow, this is your heart. If you look at both sides, okay, this blackish area, this is
your normal lung tissue. If you look on your right upper corner over here, okay, this white
shadow is an abnormality. It should be similar to the opposite side. So that shows there is
something growing."

Key Points for X-ray Explanation:

• Use the term "shadow" or "figure" instead of "opacity"

• Start with explaining normal structures (heart, lungs)
• Point out the abnormality (usually a white shadow)
• Compare to the opposite side if relevant
• Keep it brief and simple
• For lung cancer, mention "coin lesion" if visible

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Lung Cancer Scenario

Typical presentation:

• 70-year-old man
• Coughing up blood
• Weight loss
• Smoker (often for many years, e.g., 50 years)
• White-collar job (e.g., teacher)

Note: There's another lung cancer scenario related to SIADH (Syndrome of Inappropriate
Antidiuretic Hormone Secretion), which will be covered separately.

Important Points to Remember

1. You cannot make a misdiagnosis between lung cancer and mesothelioma in PLAB 2
scenarios
2. The setting (GP vs. respiratory unit) is a key differentiator
3. Pay attention to the occupation (white-collar for lung cancer, construction-related
for mesothelioma)
4. Both conditions involve smoking and weight loss
5. Age difference: lung cancer patients are typically older than mesothelioma patients
6. X-ray explanation is crucial in lung cancer scenarios

Study Tips

1. Practice explaining chest X-rays briefly and clearly

2. Remember the key differences between lung cancer and mesothelioma
presentations
3. Pay attention to the setting (GP vs. respiratory unit) as it's a key differentiator
4. Don't forget to consider occupation in these scenarios
5. Study with people you may not get along with, as it can enhance memory retention
due to the emotional component
6. Take time to study common causes of respiratory symptoms thoroughly

Sample Dialogue for Lung Cancer Scenario

Doctor: "Hello, what brings you in today?"

Patient: "I've been coughing up blood and I'm worried."

Doctor: "I'm sorry to hear that. How long has this been going on?"

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Patient: "It started a few weeks ago, and it's getting worse."

Doctor: "I see. Have you noticed any weight loss recently?"

Patient: "Yes, I've lost about 10 pounds without trying."

Doctor: "Do you smoke?"

Patient: "Yes, I've been smoking since university, so about 50 years now."

Doctor: "What's your occupation?"

Patient: "I'm a retired teacher."

Doctor: "Thank you for this information. I'd like to order a chest X-ray. Once we have the
results, I'll explain them to you."

[After getting X-ray results]

Doctor: "I have the X-ray with me. Let me explain this to you. If you look in the middle,
okay, this white shadow, this is your heart. If you look at both sides, okay, this blackish
area, this is your normal lung tissue. If you look on your right upper corner over here,
okay, this white shadow is an abnormality. It should be similar to the opposite side. So that
shows there might be something growing, which we need to investigate further."

Patient: "Does this mean I have lung cancer?"

Doctor: "Based on your symptoms, smoking history, and this X-ray finding, there is a
concern for lung cancer. However, we'll need to do further tests to confirm this. I'm going
to refer you to a specialist for more detailed investigations."

Things to Avoid

1. Don't use the term "opacity" when explaining X-rays to patients; use "shadow" or
"figure" instead
2. Don't spend too long explaining the X-ray (keep it to 30 seconds maximum)
3. Don't forget to explain X-rays if they appear in the scenario
4. Don't confuse the settings for lung cancer (GP) and mesothelioma (respiratory unit)
5. Don't overlook the importance of occupation in differentiating between lung cancer
and mesothelioma

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Mesothelioma Scenarios

General Characteristics of Mesothelioma

• Age: Typically 55-60 years old

• Main symptom: Shortness of breath
• Occupational history: Usually related to construction (e.g., carpenter, plumber,
shipyard worker, demolisher)
• Often worried about lung cancer due to colleagues' diagnoses

Mesothelioma Scenario 1: Respiratory Unit

Setting:

Patient already in respiratory unit

Patient Profile:

• Age: 55-60 years old

• Occupation: Carpenter or plumber
• Main symptom: Shortness of breath
• Additional concern: Worried about lung cancer due to colleague's diagnosis

Diagnosis Communication:

"Unfortunately, I'm sorry to tell you, cancer of the lining of the lungs called mesothelioma
also could present in this way."

Management:

1. Start testing immediately (patient already in respiratory unit)

2. Tests to be done:
o CT scan
o Bronchoscopy
o Taking fluid samples from lungs
3. Treatment options:
o Main treatment: Chemotherapy
o Additional options: Palliative radiotherapy, sometimes surgery

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Mesothelioma Scenario 2: GP Setting

Setting:

F2 in GP practice

Patient Profile:

• Age: 60 years old

• Presenting complaint: Chest pain following a fall at workplace
• X-ray finding: Bilateral pleural nodular thickening

History Taking:

1. Ask about chest pain and fall: "I understand you had a chest pain. What happened?"
Expected response: "I fell down at workplace."
2. Inquire about respiratory symptoms: Use the "10 things" approach for respiratory
assessment (as mentioned in previous transcripts)
3. Ask about cancer symptoms: Include questions about weight loss, fatigue, etc.
4. Get detailed occupational history: "What's your current job? Have you worked in
any other jobs in the past, particularly related to construction or shipyards?"
Expected response: Patient likely to mention a job like shipyard worker or
demolisher
5. Get detailed smoking history: "Do you smoke? If yes, for how long and how much?"

X-ray Explanation:

"We have got the X-ray report. The X-ray report shows something called bilateral pleural
nodular thickening. This means the lining of the lungs have become thick. That is a
thickening of the lining of the lungs."

Diagnosis Communication:

1. Express concern: "Unfortunately, we are a little bit concerned about this test result."
2. Explain occupational risk: "You've been working in the building sector (e.g., as a
shipyard worker). In shipyards, they sometimes use a material called asbestos,
especially in older ships. When this material is disturbed, it can be harmful.
Unfortunately, you do have some risk for asbestos exposure or asbestosis."
3. Communicate suspicion: "I'm sorry to tell you, cancer of the lining of the lungs also
could present in this way."

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Management:

1. Two-week referral to pulmonology (chest specialist)

2. Tests to be done:
o CT scan
o Taking fluid samples
o Possibly bronchoscopy
3. Treatment:
o Main treatment: Chemotherapy
o Newer options: Immunological treatment, biological treatment

Mesothelioma Scenario 3: A&E Setting

Setting:

A&E (Emergency Department)

Patient Profile:

• Age: 60 years old

• Presenting complaint: Shortness of breath
• Observations: Low oxygen saturation, no fever
• X-ray finding: Large pleural effusion on one side

History Taking:

1. Duration of symptoms: "How long have you been experiencing shortness of breath?"
Expected response: "For the last six months, but it's gotten worse in the last two
days."
2. Inquire about cough: "Do you have a cough? If yes, is it dry or are you coughing up
anything?" Expected response: Likely to mention a dry cough
3. Ask about weight loss: "Have you noticed any unintentional weight loss recently?"
4. Get detailed occupational history: "What's your occupation? Have you worked with
buildings or ships?" Expected response: Likely to mention being a shipyard worker
or demolisher
5. Go through the "10 things" for respiratory assessment (as mentioned in previous
transcripts)

X-ray Interpretation:

• One side shows a large pleural effusion (appears white on X-ray)

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• Remember: Water/fluid is white on X-ray, air is black, blood is not visible (appears
white)

Diagnosis:

Suspect mesothelioma

Diagnosis Communication:

"Based on your symptoms, work history, and the X-ray findings, I'm concerned that this
could be a condition called mesothelioma. This is a cancer of the lining of the lungs that
could present in this way."

Management:

1. Admit patient under respiratory team (due to low oxygen saturation)

2. Immediate interventions:
o Insert chest drain to remove pleural fluid
o Explain: "We need to put a chest drain to remove the fluid from around your
lung. This should help improve your breathing."
3. Further investigations:
o Analyse drained fluid
o CT scan
4. Further management same as other mesothelioma scenarios

Key Points to Remember

1. Occupational history is crucial in all mesothelioma scenarios

2. Bilateral pleural nodular thickening on X-ray is suspicious for mesothelioma
3. Large pleural effusion with history of construction work should raise suspicion of
mesothelioma
4. Always consider patient stability (e.g., oxygen saturation) when deciding on
admission
5. Chest drain insertion is necessary for large pleural effusions causing breathing
difficulties
6. Don't forget to explain X-rays to patients in simple terms
7. Be clear and direct when communicating suspicion of cancer, but maintain empathy
8. Remember the link between asbestos exposure and mesothelioma

Things to Avoid

1. Don't forget to ask about occupational history in respiratory cases

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2. Don't ignore X-ray findings, always explain them to the patient

3. Don't use medical jargon without explanation when communicating with patients
4. Don't forget to consider mesothelioma in patients with construction-related jobs
and respiratory symptoms
5. In A&E scenarios, don't forget to check and act on low oxygen saturation

Study Tips

1. Practice explaining X-ray findings in simple terms

2. Memorize the typical occupations associated with mesothelioma risk
3. Review the "10 things" approach for respiratory assessment regularly
4. Practice communicating suspicion of cancer clearly but empathetically
5. Remember that learning is most effective when you're actively participating and
slightly anxious about missing information
6. Consider studying with people you may not get along with, as the emotional
component can enhance memory retention

Tuberculosis (TB)

I. General Characteristics of TB Presentations

• Cough (often for several weeks)

• Fever
• Streaks of blood in cough
• Weight loss
• Travel history to endemic areas (e.g., South Africa, Philippines, Thailand)
• Smoking history (present in scenarios but not a defining factor)
• Night sweats (often not given in the scenario, but should be asked about)

Note: In PLAB 2, if fever is present, it usually indicates an infectious origin.

TB Scenario 1: GP Setting (Stable Patient)

Patient Profile:

• Age: 55-60 years old

• Presenting complaints:
o Cough (for many weeks)
o Fever (for last two weeks)
o Coughing up streaks of blood
o Weight loss

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• Smoking history: Present

• Travel history: Travelled to South Africa, stayed with son

History Taking:

1. Ask about cough: "How long have you had this cough?" Expected response: "For
many weeks now."
2. Inquire about fever: "Have you had any fever?" Expected response: "Yes, for the last
two weeks."
3. Ask about blood in sputum: "Have you noticed any blood when you cough?"
Expected response: "Yes, there are some streaks of blood."
4. Inquire about weight loss: "Have you lost any weight recently?" Expected response:
"Yes, I have."
5. Ask about night sweats (even if not mentioned in scenario): "Have you been
experiencing any night sweats?"
6. Get smoking history: "Do you smoke?" Expected response: "Yes, I do."
7. Crucial: Ask about travel history "Have you travelled recently? Where did you go?"
Expected response: "I travelled to South Africa and stayed with my son."

Diagnosis:

Suspect tuberculosis

Diagnosis Communication:

"Based on your symptoms and travel history, this could be a condition called tuberculosis.
Tuberculosis is a bacterial infection. You mentioned you travelled to South Africa, which is
considered an endemic area where TB is more common. You can get it from other people
in these countries."

Management:

1. Same-day referral to TB clinic "I'm going to refer you to a TB clinic today."

2. Explain to patient about tests: "At the TB clinic, they will take a sample of your
phlegm for testing. This is called a phlegm culture. The culture takes about three
days for results to come back. They will also do an X-ray and some blood tests."
3. Explain need for self-isolation: "You'll need to self-isolate for three days until the
results come back. During this time, you can take some medication for your fever if
needed."
4. Treatment (if confirmed): "If the tests confirm TB, the treatment involves a mixture
of four different antibiotics. The treatment lasts for 6 months. For the first 2

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months, you'll take 4 antibiotics, and for the remaining 4 months, you'll take 2
antibiotics."
5. Additional information for patient:
o "TB is treatable and curable."
o "You'll have psychological support throughout your treatment."
o "A team including a social worker and a key worker will help you with taking
your medications regularly."
o "TB is what we call a notifiable condition, which means we have to report it
to public health authorities."
o "We may offer you nutritional support if needed."
o "Your son will need to be tested as well, since he lives with you."

TB Scenario 2: A&E Setting (Unstable Patient)

Patient Profile:

• Age: 40 years old

• Presenting complaints:
o Shortness of breath and cough
o Cough for last six weeks
o Shortness of breath for last two weeks
o Streaks of blood in cough
o Weight loss
o Fever
• Smoking history: Present
• Travel history: Travelled to Philippines or Thailand two months ago with girlfriend
for work
• Occupation: Hairdresser

Initial Presentation:

Patient appears unstable, having difficulty speaking due to cough and shortness of breath

Correct Approach:

1. Recognize patient's distress: "I can see that you're having trouble breathing."
2. Prioritize examination: "What I'd like to do first is check your oxygen level, blood
pressure, temperature, and breathing rate."
3. Review observations (given by examiner on paper)
4. Administer oxygen based on observations: "Your oxygen level is quite low, and your
temperature is high. I'd like to give you high-flow oxygen through a mask or non-
rebreather mask."

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History Taking (after stabilization):

1. Ask about cough: "How long have you had this cough?" Expected response: "For
about six weeks now."
2. Inquire about shortness of breath: "When did the shortness of breath start?"
Expected response: "It started about two weeks ago."
3. Ask about blood in sputum: "Have you noticed any blood when you cough?"
Expected response: "Yes, there have been some streaks of blood."
4. Inquire about weight loss: "Have you lost any weight recently?" Expected response:
"Yes, I have."
5. Ask about fever: "Have you had any fever?" Expected response: "Yes, I have."
6. Ask about night sweats (even if not mentioned in scenario): "Have you been
experiencing any night sweats?"
7. Get smoking history: "Do you smoke?" Expected response: "Yes, I do."
8. Crucial: Ask about travel history "Have you travelled recently? Where did you go?"
Expected response: "I travelled to Philippines/Thailand two months ago with my
girlfriend for work."
9. Get occupational history: "What is your occupation?" Expected response: "I'm a
hairdresser."

Diagnosis:

Suspect tuberculosis

Management:

1. Admit patient (due to instability) "We need to admit you to the hospital until you
become stable."
2. Explain tests and procedures: "We'll take a sample of your phlegm for testing. This
is called a phlegm culture and it takes about three days for results. We'll also do a
chest X-ray and some blood tests."
3. Inform about potential early treatment start: "The TB team might start you on
treatment earlier based on your X-rays and blood tests, even before the culture
results are back."
4. Explain isolation: "Your ability to pass this infection to others continues for two
weeks from the start of treatment. We advise you to avoid close contacts during this
time."
5. Duration of admission: "You'll be admitted until you become stable. When your
fever improves and your breathing is better, you should be able to go home and
continue treatment there."

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IV. Key Points to Remember

1. Always ask about travel history in suspected TB cases

2. Night sweats are important but may not be mentioned in the scenario - always ask
3. Same-day referral for all infections except STIs
4. In A&E scenarios, prioritize assessing and stabilizing the patient before taking a
detailed history
5. Stable patients can be treated at home after initial assessment and culture
6. Unstable patients need admission until stabilized
7. TB treatment typically involves 4 antibiotics for 2 months, then 2 antibiotics for 4
months
8. TB is a notifiable condition
9. Contact tracing (e.g., testing family members) is important

V. Things to Avoid

1. Don't forget to ask about travel history

2. In A&E scenarios, don't start taking history before assessing and stabilizing the
patient
3. Don't give oxygen without checking and commenting on observations first
4. Don't forget to mention the infectivity period and need for isolation
5. Don't omit information about multidisciplinary support and treatment duration
6. Don't ignore the potential need for testing close contacts
7. Don't say "isolate" for admitted patients; instead, advise to "avoid close contacts"
8. Don't mention opening windows or similar precautions in hospital settings

VI. Additional Notes

1. In PLAB 2, TB scenarios often don't mention night sweats to make diagnosis less
obvious
2. The absence of typical symptoms doesn't rule out TB
3. Both stable and unstable patients may present with similar symptoms; the key
difference is in their ability to communicate and their vital signs
4. Understanding the difference between stable and unstable patients is crucial for
determining the appropriate management plan
5. Always explain X-ray findings to patients in simple terms if an X-ray is mentioned in
the scenario
6. Remember that learning is most effective when actively participating and slightly
anxious about missing information
7. Consider studying with people you may not get along with, as the emotional
component can enhance memory retention

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Leukaemia Scenarios
Chronic Lymphocytic Leukaemia (CLL) Scenario

Setting:

GP practice, test results discussion

Patient Profile:

• Age: 65 years old

• Gender: Male
• Reason for initial test: Wife found to be pre-diabetic, patient wanted to check his
status

Test Results:

• White Blood Cell (WBC) count: 40,000 (normal range: 4,000-11,000)

• Haemoglobin: Slightly low
• HbA1c: Normal (not pre-diabetic or diabetic)
• Differential count: Lymphocytes also high

History Taking:

Start with: "Have you had any symptoms at all?"

1. Anaemia symptoms:
o "Have you experienced any shortness of breath?"
o "Do you feel more tired than usual?"
o "Have you had any episodes of light-headedness?"
2. Bleeding-related symptoms:
o "Have you noticed any bleeding from your gums?"
o "Have you had any nosebleeds?"
o "Do you bruise easily?"
3. General cancer symptoms:
o "Have you experienced any unexplained pain?"
o "Have you lost any weight unintentionally?"
o "Do you experience night sweats?"
o "Have you had any bone pain, particularly in your back?"
o "Have you had any fever?"
4. Infection-related symptoms:
o "Have you been getting more infections than usual?"

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o "Any sore throats or other throat symptoms?"

5. Swelling-related symptoms:
o "Have you noticed any swollen glands or lumps?"
o "Any swelling in your abdomen?"
6. Skin symptoms:
o "Have you noticed any rashes?"
7. Risk factors:
o "Does anyone in your family have a history of leukaemia?"
o "Have you ever undergone chemotherapy?"
o "What is your occupation?"
o "Have you ever worked in mining, particularly uranium mining?"
o "Have you worked in any radiation factories or energy sectors?"
o "Do you live near any mining areas?"
o "Have you worked in the petroleum industry?"

Physical Examination:

"I'd like to examine your abdomen, particularly to check for any enlargement of your
spleen."

Explaining Test Results to Patient:

"Let me explain the test results to you. In your blood, there are two types of cells. Some of
them are called red cells, and others are called white cells. The numbers of the white cells
have increased significantly in your blood test. Within these white cells, a type called
lymphocytes is also increased. We are a little bit concerned about these results."

Diagnosis Communication:

"Unfortunately, I'm sorry to tell you, this could be a condition called chronic leukaemia.
Chronic leukaemia is a type of blood cancer. The blood test came back like this with the
white cells increased, and also considering your age, which is a risk factor, this could
present in this way."

Management:

1. Two-week cancer pathway referral to haematology "I'm going to refer you to a blood
specialist, called a haematologist, on an urgent two-week pathway."
2. Explain further tests: "The haematologist will likely do more blood tests. They may
also perform a test called a bone marrow biopsy."

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3. Discuss potential treatments: "If the diagnosis is confirmed, the main treatment is
usually chemotherapy. There might be additional treatments like steroid treatment.
Some people might get benefit from bone marrow transplant."

Acute Leukaemia Scenario

While not currently in use, it's worth noting how acute leukaemia used to be presented:

Patient Profile:

• Young man (around 20-22 years old, less than 24)

Presenting Symptoms:

• Tiredness (often starting after physical activity like football)

• Bleeding (gum bleeding, bruises)

Physical Examination:

• Hepatosplenomegaly (enlarged liver and spleen)

III. Key Points to Remember

1. In PLAB 2, current focus is on chronic leukaemia scenarios

2. Always explain blood test results in simple terms to patients
3. When suspecting leukaemia, thoroughly ask about symptoms related to anaemia,
bleeding, infections, and general cancer symptoms
4. Don't forget to inquire about risk factors, including occupational exposures
5. Always mention the need for physical examination, especially for splenomegaly
6. Use the phrase "This could be..." when communicating potential diagnosis
7. Remember the two key questions for every scenario: "What could this be?"
(diagnosis) and "What needs to be done?" (management)

IV. Things to Avoid

1. Don't use medical terms like "CLL" when explaining to patients

2. Don't forget to mention the increase in lymphocytes when explaining test results
3. Don't omit asking about any symptom group (anaemia, bleeding, infections, etc.)
4. Don't forget to explain the referral process and potential next steps
5. Don't complicate the scenario - focus on the main issue (in this case, the high WBC
count and lymphocytes)

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V. Study Tips

1. Remember the normal range for WBC (4,000-11,000) to recognize significant

elevations
2. Group symptoms logically (anaemia, bleeding, infections, etc.) for easier recall
3. Consider the patient's age and initial reason for testing when assessing the situation
4. Practice explaining blood test results in simple terms
5. Familiarize yourself with the risk factors, especially occupational exposures
6. Study with people you may not get along with, as the emotional component can
enhance memory retention
7. Actively participate in learning rather than passively watching videos
8. Remember that in PLAB 2, if fever is present, it usually indicates an infectious
origin

VI. Sample Dialogue

Doctor: "Hello, I have your test results here. Before we discuss them, have you had any
symptoms at all recently?"

Patient: "Not really, I feel fine. I just wanted to check because my wife was found to be pre-
diabetic."

Doctor: "I see. Have you noticed any tiredness or shortness of breath?"

Patient: "Now that you mention it, I have been feeling a bit more tired lately."

Doctor: "Any easy bruising or bleeding from your gums when you brush your teeth?"

Patient: "No, nothing like that."

Doctor: "Okay. Let me explain the test results to you. In your blood, there are two types of
cells. Some of them are called red cells, and others are called white cells. The numbers of
the white cells have increased significantly in your blood test. Within these white cells, a
type called lymphocytes is also increased. We are a little bit concerned about these results."

Patient: "That sounds serious. What does it mean?"

Doctor: "Unfortunately, I'm sorry to tell you, this could be a condition called chronic
leukaemia. Chronic leukaemia is a type of blood cancer. The blood test came back like this
with the white cells increased, and also considering your age, which is a risk factor, this
could present in this way."

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Patient: "Cancer? I'm shocked..."

Doctor: "I understand this is unexpected and concerning news. We need to do further tests
to confirm this. I'm going to refer you to a blood specialist, called a haematologist, on an
urgent two-week pathway. They will likely do more blood tests and may perform a test
called a bone marrow biopsy. If the diagnosis is confirmed, the main treatment is usually
chemotherapy. There might be additional treatments like steroid treatment. Some people
might benefit from bone marrow transplant. Do you have any questions for me at this
point?"

[Address any questions or concerns the patient might have]

Prostate Cancer Scenarios

I. Introduction

• Prostate cancer scenarios come in two forms:

1. Symptomatic presentations
2. PSA test results discussions
• These scenarios are more likely to appear in exams compared to conditions like
subarachnoid haemorrhage or pericarditis

Prostate Cancer Scenario 1: History-Only

Patient Profile:

• 65-year-old man
• Presenting complaint: Back pain for more than 3 months
• Additional symptoms:
o Weight loss
o Increased frequency of urination (only one prostate symptom)
• Occupation: Postman
• No trauma history
• Patient worried about pancreatic cancer (friend had similar pain)

Key Points:

• First time experiencing this pain

• Patient was "rolling on his bed" when pain first occurred
• Only one prostate symptom present: increased frequency

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Detailed History Taking:

1. Ask about back pain: "Can you tell me more about your back pain? When did it
start?" Expected response: "It started about 3 months ago. I first noticed it when I
was rolling in bed."
2. Inquire about weight loss: "Have you noticed any changes in your weight recently?"
Expected response: "Yes, I've lost some weight."
3. Ask about urinary symptoms: "Have you noticed any changes in your urination
habits?" Expected response: "I've been going to the toilet more frequently."
4. Explore patient's concerns: "I understand you're worried about pancreatic cancer.
Can you tell me more about that?" Expected response: "My friend had similar pain
and it turned out to be pancreatic cancer."
5. Ask about all prostate symptoms (see Prostate Symptoms Checklist below)

Management:

1. Provide painkiller for back pain

2. Order PSA test
3. Order back X-ray
4. Refer to urology (2-week pathway)
5. Further tests by urology:
o MRI
o Possible biopsy
6. If confirmed: Surgery, Radiotherapy

III. Prostate Symptoms Checklist

Imagine an elderly man rushing to the toilet. Ask these questions:

1. Frequency: "Do you pass urine more frequently than usual?"

2. Urgency: "Do you need to rush to the toilet all the time?"
3. Hesitancy: "Do you need to stand a long time to start peeing?"
4. Straining: "When you pee, do you need to strain a lot?"
5. Weak stream: "How is your stream? Is it weaker than usual?"
6. Dribbling: "After passing urine, do you have any dribbling? Do you wet your pants?"
7. Incomplete emptying: "After passing urine, do you feel like you don't complete very
well?"
8. Nocturia: "Do you wake up in the night to go to the toilet?"

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Important: Ask all these symptoms, don't use medical terms like "frequency" or "urgency"
when asking the patient.

IV. Cancer Symptoms in Prostate Cancer

1. Back pain
2. Weight loss
3. Blood in urine

Prostate Cancer Scenario 2: Mannequin Scenario

Patient Profile:

• Presenting complaint: Back pain

• Multiple prostate symptoms present (e.g., hesitancy, urgency)

Key Points:

• PR (per rectum) mannequin present

• May or may not feel a lump during examination
• Presence of lump doesn't matter for diagnosis

Approach:

1. Take history as in Scenario 1

2. Ask about multiple prostate symptoms: "Have you noticed any changes in your
urination habits?" Expected response: Patient will mention multiple symptoms like
hesitancy and urgency
3. Perform PR examination on mannequin Note: Whether you feel a lump or not, it
doesn't change the management

Diagnosis:

• Suspect prostate cancer if one prostate symptom and one cancer symptom present

Management:

• Same as Scenario 1 (painkiller, PSA, back X-ray, referral)

Prostate Cancer Scenario 3: Frequency as Main Complaint

Patient Profile:

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• Presenting complaint: Increased frequency of urination

Approach:

1. Initial question: "How may I help you?" Expected response: "I'm going to the loo
more frequently."
2. Ask about all prostate symptoms (use Prostate Symptoms Checklist)
3. Explore differentials for increased frequency: "Have you noticed any burning
sensation when passing urine?" (UTI) "Have you had any recent sexual encounters?"
(STI) "Do you have any history of diabetes?" "Are you taking any new medications,
particularly water tablets?" (Diuretics) "Have you increased your intake of coffee or
tea recently?" (Caffeinated drinks)
4. Ask about cancer symptoms: "Have you experienced any back pain recently?" "Have
you noticed any unintentional weight loss?"

Examination:

• PR mannequin present

Management:

• Same as previous scenarios

VII. Key Points to Remember

1. In history-only scenarios, examination findings will be normal

2. Don't expect to be given clues about prostate involvement
3. One prostate symptom + one cancer symptom = suspect prostate cancer
4. Always consider prostate cancer in elderly men with back pain and weight loss
5. Don't be misled by patient's own worries (e.g., pancreatic cancer)
6. The starting point of scenarios may differ, but core symptoms remain similar
7. In bladder carcinoma scenarios, they might try to confuse you with prostate
enlargement

VIII. Things to Avoid

1. Don't ignore single prostate symptoms

2. Don't forget to ask about all prostate symptoms
3. Don't use medical terms when asking about symptoms
4. Don't forget to consider differentials for increased frequency
5. Don't assume prostate cancer based solely on PR examination findings
6. Don't be distracted by the patient's own diagnosis (like pancreatic cancer)

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IX. PLAB 2 Exam Tips

1. Learn to recognize different scenario types (history-only, mannequin)

2. Practice asking about prostate symptoms in patient-friendly language
3. Remember the triad: Painkiller, PSA test, Back X-ray for management
4. Be prepared for scenarios where the presenting complaint isn't obviously prostate-
related
5. Don't assume all scenarios will present the same way - pay attention to the specific
details given
6. When given a mannequin, always perform the examination, but don't base your
diagnosis solely on it
7. Remember that the scenario might start differently (back pain, urinary frequency),
but the core approach remains the same

Worried about Prostate Cancer Scenario

I. Scenario Overview

• Patient: 40-year-old man

• Reason for visit: Worried about prostate cancer
• Trigger: Father recently diagnosed with prostate cancer

II. Four-Box System Approach

Box 1: Initial Engagement

1. Opening question: "How may I help you?" Expected response: "I'm worried about
prostate cancer."
2. Follow-up: "Can I ask you why?" Expected response: "My father has been diagnosed
with prostate cancer."
3. Show empathy: "I'm sorry to hear about that. How is he doing now?" Note: Don't
dwell too much on this.
4. Transition: "Let me see what we can do for you."

Box 2: Gather Information

1. Assess prior knowledge:

o "What is your understanding about prostate cancer?"
o "Did you do any research or reading about it?"
2. Ask about specific aspects:
o "How much do you know about the prostate gland?"
o "What do you know about prostate cancer symptoms?"

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o "Do you know anything about risk factors for prostate cancer?"
3. Determine patient expectations: "Is there any particular help you're looking for
regarding prostate cancer?"
4. Assess general health:
o "Do you have any medical problems?"
o "Do you take any medications?"
5. Explore risk factors: a. Family history:
o "At what age was your father diagnosed?"
o "How was he diagnosed? Did he have symptoms?"
o "At what stage was his cancer diagnosed?"
o "Any other family members with prostate cancer?"

b. Ethnic background: "Do you have any Afro-Caribbean background?" c. Lifestyle factors:

o "Do you smoke?"

o "How much red meat do you eat?"
o "Do you exercise regularly?"
o "Do you eat a high-fibre diet?"

Note: No need to ask about prostate symptoms in this scenario due to patient's young age.

Box 3: Provide Information

Explain prostate cancer:

• "The prostate is a male gland located under the bladder, shaped like a walnut."
• "Its function is to nourish sperm."
• "Men can develop cancer in this gland."
• "Some people develop symptoms, others don't."
• "Early symptoms may include urinary frequency and urgency."
• "Late-stage symptoms can include back pain and weight loss."

Box 4: Discuss Patient's Risk and Management

1. Acknowledge risk: "Considering your circumstances, you do have some risk factors."
2. Explain risk factors:
o Family history (especially father or brothers)
o Afro-Caribbean ethnic background
o Lifestyle factors (red meat consumption, lack of exercise, low fibre diet,
smoking)
3. Discuss management:
o Lifestyle changes (exercise, healthy diet) can reduce risk

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oAnnual PSA test after age 45 if risk factors present (after 50 if no risk factors)
o Self-monitoring for symptoms
4. Conclude: "How does this sound to you?"

III. Key Points to Remember

1. This scenario is about future worry, not current symptoms

2. No need for physical examination in this case
3. Focus on risk factors and education
4. Use the four-box system approach
5. Be empathetic but don't dwell on the father's diagnosis
6. Provide clear information about the prostate and prostate cancer
7. Offer practical advice and management plan

IV. Risk Factors for Prostate Cancer

1. Family history (especially father and brothers)

2. Afro-Caribbean ethnic background
3. Smoking
4. High consumption of red meat
5. Lack of exercise
6. Low-fibre diet

V. Things to Avoid

1. Don't assume the patient's ethnicity based on appearance

2. Don't focus on current prostate symptoms (patient is too young)
3. Don't offer unnecessary examinations
4. Don't ignore the patient's level of understanding and expectations
5. Don't forget to discuss lifestyle modifications

VI. Sample Dialogue

Doctor: "How may I help you today?"

Patient: "I'm worried about prostate cancer. My father was recently diagnosed."

Doctor: "I'm sorry to hear about your father. Can you tell me more about what you know
about prostate cancer?"

Patient: "Not much, really. That's why I'm here."

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Doctor: "I see. Let me explain a bit about the prostate and prostate cancer, then we can
discuss your specific situation..."

[Provide explanation as outlined in Box 3]

Doctor: "Now, considering your family history and assuming you mentioned an Afro-
Caribbean background, you do have some risk factors. However, there are things we can
do..."

[Discuss management as outlined in Box 4]

Doctor: "How does this plan sound to you? Do you have any questions?"

[Address any concerns the patient might have]

PSA Test Consultation

"Can I have a PSA test?" Scenario

Initial Approach

• Patient typically 50+ years old (e.g., 52, 55)

• Use a four-box system for this scenario

Four-Box System

1. Ask why the patient wants the test

2. Assess prior knowledge and risk factors
3. Explain about PSA
4. Decide whether to give the test or not

Detailed Conversation

Box 1: Asking Why

Q: "Can I ask you why you want a PSA test?" Possible patient response: "One of my friends
had a PSA test. After that, he was diagnosed with prostate cancer. We used to play golf
together. He can't play golf now."

Follow-up:

• "I'm sorry to hear about your friend. How is he doing at the moment?"
• Move quickly to the next questions

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Box 2: Assessing Knowledge and Risk Factors

Q: "What is your understanding about the PSA test?" Q: "Have you done this test before?"
Expected answer: No

Q: "Did you read anything about it?" Q: "Have you ever been given any information about
the PSA test?" Q: "Do you know why doctors do this test?" Q: "Do you know what sort of
medical condition we can actually find out with this test?" Q: "Do you know the benefits of
doing this sort of test?" Q: "Do you know anything about disadvantages or drawbacks of
doing this sort of test?"

Assessing General Health

Prostate Symptoms: Q: "Do you have any problem with urination?" Ask about:

• Urgency
• Frequency
• Hesitancy
• Dribbling

Other Symptoms: Q: "Do you have any back pain?" Q: "Have you experienced any
unexplained weight loss?"

Past Medical History: Q: "Have you had any prostate conditions before?" Q: "Any infections
or treatments related to your prostate?" Q: "Are you currently taking any medications?"

Risk Factors (Ask about all five):

1. Family History: Q: "Do your brothers or father have any history of prostate
problems or cancer?"
2. Ethnic Background: Q: "What is your ethnic background?" (Note: Higher risk in
Black men)
3. Smoking: Q: "Do you smoke?"
4. Diet: Q: "How often do you eat red meat?"
5. Lifestyle: Q: "How much exercise do you do?" Q: "How would you describe your diet
in terms of fibre intake?"

Examination (if mannequin present)

• If there's a mannequin, shorten the history-taking

• Say: "I would like to examine you. Is that okay?"

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• If patient refuses: Q: "Can I ask why you're not comfortable with the examination?"
Explain: "We can ensure you don't feel any discomfort. I will try to make sure you
are as comfortable as possible."
• If still refused: Say: "That's okay. Let me explain why the examination is important.
While examining, we can find out if there are any changes in the prostate gland.
This can give us additional information."
• If patient agrees, proceed with examination
• If patient still declines, respect the decision and move on

Box 3: Explaining PSA Test

"PSA stands for Prostate Specific Antigen. It's a marker that can be increased in different
situations:

1. It can be higher while having a normal prostate

2. It can be increased during infections or inflammation
3. It can also be elevated if there's cancer

It's important to understand that PSA is not very specific to cancer, but we still use it as a
marker."

Benefits of PSA Test:

1. "We can detect cancer early and treat it early."

2. "We can monitor treatment progress."
3. "Sometimes it can give us reassurance that nothing is wrong with the prostate."

Drawbacks of PSA Test:

1. "It can lead to unnecessary testing, investigations, and treatment, especially in

elderly people. In some cases, these procedures might not prolong their life."
2. "It can give us inaccurate information. There are two types of inaccuracies: a) False
positive: This means the PSA can be elevated, but you might not have cancer. This
happens in three out of four cases. If we take four people with higher PSA, only one
will actually have cancer. b) False negative: This means while having cancer,
someone can have a normal PSA. This happens in about one in seven cases."

Box 4: Decision Making

"Doing a PSA test is an informed decision. We've explained the benefits and drawbacks.
Now it's up to you to decide if you want to proceed with the test."

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Follow-up Questions and Answers

Q: "If my PSA comes back higher, does it mean I have cancer?" A: "No, it doesn't mean
100% that you have cancer. The chances are one out of four. If we take four people with
higher PSA, only one will end up having cancer."

Q: "If my PSA is high, what will you do?" A: "If your PSA is high, we will refer you through
a cancer pathway. You'll be seen by a specialist within two weeks. The first thing the
specialist will do is an MRI. Then, if necessary, they might do a biopsy. If that confirms
cancer, you'll be offered treatment options."

PSA Test Results Scenarios

Scenario 1: Well-man Clinic Result

• Test done as part of routine check-up

• Result: PSA 20 (normal is 4)
• No symptoms reported Action: Refer through cancer pathway, regardless of
symptoms

Scenario 2: Patient Worried About Prostate Cancer

• Test done due to:

1. Family history (father had prostate cancer)
2. Patient's ethnic background: Black
• Result: PSA 3.2 (normal range up to 3) Action: Q: "Have you had any sexual
intercourse in the past few days before the test?"
• If yes: Say: "We need to repeat the test within the next 2-3 days. Please avoid any
sexual activity before the next test." If still elevated: Proceed with cancer pathway
• If no: Refer through cancer pathway

Scenario 3: Normal PSA Result

• Test done as well-man check-up or patient request

• Result: PSA normal (often given as wording, not number) Action: Say: "Your PSA
has come back normal. There's nothing to be worried about now." Advice: "Lifestyle
changes can help maintain prostate health. Regular exercise and eating a healthy
diet are beneficial."

Scenario 4: Symptomatic Patient with Normal PSA

• Test done due to symptoms (increased frequency and urgency)

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• Result: PSA normal Action:

1. Treat with medication: Prescribe alpha blockers (e.g., Tamsulosin, Alfuzosin)

2. Say: "We'll start you on medication to help with your symptoms."
3. Arrange routine ultrasound Say: "We'll also arrange a routine ultrasound to get a
better look at your prostate."

PSA First Presentation with Symptoms and Mannequin

Scenario Details

• First-time patient, around 55-60 years old

• Presenting with urinary symptoms (urgency and frequency)
• No cancer symptoms
• Mannequin present for examination

Approach

1. Take detailed history (as outlined in Section 1)

2. Perform examination
3. Order PSA test

Examination Procedure and Findings

• Explain the procedure to the patient

• Findings interpretation:
o Normal prostate: Soft, not easily felt
o BPH (Benign Prostatic Hyperplasia): Feels like the palm of your hand
o Suspicious for cancer: Rock-hard, irregular, nodular swelling

Action Plan

• If examination is suspicious (hard, irregular, nodular): Say: "I've found some

irregularities during the examination. We'll need to do an urgent ultrasound to get
a better look."
• If examination is inconclusive or normal: Say: "I'll order a PSA test to get more
information."
• Follow-up based on PSA result:
o If PSA is high: Say: "Your PSA levels are higher than expected. We'll need to
refer you through a cancer pathway for further investigation."
o If PSA is normal: Say: "Your PSA levels are normal, but given your
symptoms, we'll start you on medication and arrange a routine ultrasound."

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Important Points to Remember

1. Cancer pathway criteria (any of these):

o One prostate symptom + one cancer symptom
o Elevated PSA for age
o Suspicious ultrasound findings
2. Always do PSA test before ultrasound for symptomatic patients
3. Differentiate between "Can I have a PSA test?" and "I'm worried about prostate
cancer" scenarios
o "Can I have a PSA test?" focuses on informed decision-making
o "I'm worried about prostate cancer" focuses on risk assessment and
appropriate testing
4. Be thorough in history-taking and examination, but adapt if mannequin is present
5. Always explain benefits and drawbacks of PSA testing to allow informed decision-
making
6. Know the statistics:
o False positives: 3 out of 4 elevated PSA results
o False negatives: 1 in 7 cancer cases may have normal PSA
7. Be prepared for various result scenarios and know the appropriate next steps for
each
8. Remember that examination findings alone are not enough to initiate cancer
pathway; you need PSA, symptoms, or ultrasound evidence
9. Stay up-to-date with guidelines and best practices for PSA testing and prostate
cancer screening
10. When explaining to patients, use clear, non-technical language and be prepared to
repeat or rephrase information
11. Be sensitive to patient concerns and anxieties throughout the consultation
12. Avoid mixing up scenarios - each requires a specific approach
13. For patients over 50 requesting a PSA test, don't discourage them, but ensure they
make an informed decision
14. In cases of marginally increased PSA, always ask about recent sexual activity and
consider retesting
15. For normal PSA results, still address any existing urinary symptoms
16. Remember that PSA testing is part of a broader assessment of prostate health, not a
standalone diagnostic tool

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Colon Cancer Consultation Scenario

Setting and Patient Information

• Acute medicine department

• Elderly man, 69 years old
• Brought in by ambulance following collapse
• Tests and examinations already performed

Pre-Consultation Information

• Observations: Blood pressure, pulse, saturation (all normal)

• ECG: Normal
• Per-rectal examination: Normal
• Registrar has already reviewed the patient
• Blood tests:
o White cell count: Normal
o Haemoglobin: Normal
o Iron: Low
o Sugar: Normal
o Cardiac enzymes: Normal
• Patient unsure if passing blood
• Plan given: Discharge home, give iron tablets, arrange urgent colonoscopy

Key Elements of the Scenario

1. Angry patient management

2. Proper history taking
3. Data interpretation
4. Suspecting and discussing cancer

Detailed Consultation Approach

1. Greeting and Angry Patient Management

Initial Greeting: "Hello, Mr. Johnson. I'm [Your Name], one of the doctors."

Possible Patient Response (angry): "Why is there so much delay? I've been waiting here for
hours and hours! Why are you keeping me waiting here? My wife is waiting in the car park.
There are people waiting at my home for me to come. What have the doctors been doing
here?"

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How to Respond:

• While the patient is speaking:

o Nod your head
o Raise your eyebrows
o Make eye contact
o Show empathy
o You can tilt your head slightly
• Do not interrupt or cross-talk
• Once the patient finishes, say: "Mr. Johnson, I can see that you're quite upset/angry.
I'm extremely sorry about the delay. Let me see what we can do for you as soon as
possible. Let me tell you, I'll hurry up then."

Important things to avoid:

• Never tell the patient to calm down

• Don't say "This is the emergency department. It is quite busy."
• Don't lie about treating other serious patients
• Don't use words like "agitated" or "frustrated"

2. History Taking

Collapse Episode

"I understand you collapsed this morning. Can you tell me about that?"

• "How did you sustain the fall?"

• "How did you collapse?"
• "Did you have any symptoms before collapsing?"
• "Did you get any warning signs just before collapsing?"
• "Did you feel dizzy?"
• "Did you feel weak?"
• "Did you have any blackouts?"
• "Did you trip on something?"
• "Did you lose consciousness?"
• "How long were you unconscious for?"
• "How did you get up?"
• "What happened after you collapsed?"

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Anaemia Symptoms

"I'd like to ask you about some other symptoms you might have experienced."

• "Have you had any chest pain?"

• "Have you felt short of breath?"
• "Have you been feeling more tired than usual?"
• "Has anyone mentioned that you've been looking pale?"

Bowel Cancer Symptoms

"I've been told that your bowel habits have changed. Can you tell me about that?"

• "Have you been experiencing diarrhoea or constipation?"

• "How long have you had these changes in your bowel habits?"
• "How often do you have diarrhoea?"
• "Have you noticed anything unusual in your stools?"
• "Have you had any abdominal pain?"
• "Have you noticed any swelling in your abdomen?"
• "Have you lost any weight recently?"
• "Have you had any pain elsewhere in your body?"

Risk Factors (PMAFTOSA)

Medical history: "Have you had any bowel conditions in the past?" "Have you ever had any
polyps?"

Past medical history: "Have you had any surgeries related to your bowels?"

Treatment: "Are you currently taking any medications?"

Family history: "I'm sorry to ask about this, but has anyone in your family had any bowel
cancers?" "Have there been any other types of cancers in your family?"

Social history:

• "What do you do for a living?"

• "Do you eat a lot of red meat?"
• "Do you smoke?"
• "How much fibre do you eat in your diet?"
• "How much exercise do you do?"

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Allergies: "Do you have any allergies we should know about?"

3. Data Interpretation and Explanation

"Mr. Johnson, I understand that after you were brought in, we've done some tests and
examinations. Let me explain these to you quickly."

• "We checked your blood pressure and temperature. All came back normal."
• "We did an ECG, which also came back normal. This means there's nothing to
worry about with your heart."
• "We also did some blood tests. We checked your sugar levels and markers from your
heart, lungs, and liver. All these main organs are working fine."
• "However, your iron levels are low. Your blood levels are also low. Unfortunately,
this means you have anaemia. Anaemia means your blood levels are low, but it's not
necessarily a big concern on its own."

4. Discussing Cancer Suspicion

"Mr. Johnson, we are a little bit concerned about your test results. The reason for our
concern is that your iron levels are low, your blood levels are low, and your bowel habits
have also changed. Considering your age, I'm sorry to tell you, but cancer of your large
bowel could also present in this way."

5. Management Plan

"Here's what we're going to do:

• You'll be able to go home today.

• We're going to give you iron tablets to take to help with your anaemia.
• We've arranged for you to have a colonoscopy. This will be done within two weeks.
• After the colonoscopy, we'll be able to confirm the diagnosis and discuss any further
treatment if needed."

6. Addressing Patient Concerns

Possible Patient Response: "Doctor, I'm 69. Why should I go through all this?"

How to Respond: "Well, Mr. Johnson, it could be quite an early stage. If there are any
changes, we can detect them early. We can treat it early. There are good treatments these
days for bowel cancers. You can live longer, and your quality of life can be improved."

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Important Points to Remember

1. This scenario has four main components: angry patient management, proper history
taking, data interpretation, and suspecting/discussing cancer.
2. When the patient is angry, always acknowledge their feelings. Use phrases like
"upset," "not very happy," or "quite angry" rather than "agitated" or "frustrated."
3. Take a comprehensive history, covering the collapse episode, anaemia symptoms,
bowel cancer symptoms, and risk factors.
4. When interpreting data, explain what each normal result means (e.g., normal ECG
means heart is fine).
5. Be direct when discussing the possibility of cancer. Use the phrase "We are a little
bit concerned about your test results" before explaining why.
6. Clearly explain the management plan, including going home, iron tablets, and
colonoscopy.
7. Be prepared to address concerns about age and treatment necessity.
8. Remember not to repeat examinations that have already been done by the registrar.
9. Always suspect colonic cancer in elderly patients with iron deficiency anemia and
changed bowel habits until proven otherwise.
10. If there's a mannequin in the room, it's likely a mistake in the exam setup. Adapt by

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Hyponatremia
Overview of Scenarios

• Total of six hyponatremia scenarios

o Four in GP setting (typed in blue in the original document)
o Two in hospital setting (typed in red in the original document)
• GP scenarios:
o Information provided in the task
o Presenting complaint: Tiredness (reason for blood test)
• Hospital scenarios:
o Information provided on a table
o Presenting complaint: Confusion
o Patients are elderly and brought in by doctors
• Before entering the room, you will have hyponatremia findings:
o For GP scenarios: Incorporated in the task
o For hospital scenarios: On a table
• Main objective: Find out why sodium is low, not why the patient is tired

Classification of Hyponatremia

Normal sodium range: 135-145 mmol/L

Classification (remember as "5555"):

• Mild: 130-135 mmol/L

• Moderate: 125-130 mmol/L
• Severe: <125 mmol/L

Action based on severity:

• Moderate and severe (< 130 mmol/L):

o Send to hospital immediately, regardless of symptoms
• Mild (130-135 mmol/L):
o Send to hospital only if symptomatic
• Note: In PLAB 2, all cases are symptomatic

Hospital treatment:

• 3% saline solution (three times stronger than normal 0.9% saline)

• Administered intravenously

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• Slow infusion, followed by blood tests

• Discharge when stable
• Treated in the medical department

Important: Any symptomatic hyponatremia needs hospital treatment, regardless of severity.

Symptoms of Hyponatremia

When a patient presents with one symptom (usually tiredness), ask about other symptoms:

1. Energy-related:
o Tiredness
o Lethargy
o Loss of energy
o Drowsiness
o Fatigue
2. Muscle-related:
o Muscle weakness
o Muscle spasms
o Cramps
3. Brain-related:
o Nausea
o Vomiting
o Headache
o Irritability
o Restlessness
o Confusion
o Fits
o Coma

Rationale: Sodium is needed for action potentials, affecting energy, muscles, and brain
function.

Causes of Hyponatremia

1. Medication-related:
o SSRIs (e.g., Citalopram)
o Diuretics
o Blood pressure medications
2. Excessive fluid loss:
o Vomiting
o Diarrhoea

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3. Organ failures:
o Heart failure
o Kidney failure
o Liver failure (These retain fluids, causing sodium to move from blood to
interstitial fluid due to osmosis)
4. Cancers:
o Lung cancer
o GI tract cancers
o Lymphomas
o SIADH (Syndrome of Inappropriate Antidiuretic Hormone secretion)
5. Hormonal conditions:
o Addison's disease (lack of cortisol, a "salty hormone")

Detailed Approach to Hyponatremia Scenarios

Use a landscape-oriented paper, divided into two columns: Data and Management

Data Gathering

1. Ask about the reason for the initial test: Q: "What made you have this test in the
first place?" Expected A: Tiredness or confusion
2. Explore the presenting complaint (ODIPARA for tiredness/confusion)
o Don't focus on differential diagnosis for tiredness
o The differential should be for hyponatremia causes
3. Ask about other symptoms of hyponatremia: Q: "Have you experienced any of these
symptoms?" (list symptoms from each category)
4. Check potassium levels:
o In bulimia and Addison's disease scenarios, potassium may be affected
o If potassium is high, check for hyperkalaemia symptoms
5. Investigate causes of low sodium (differential diagnosis): Q: "Do you take any
medications, especially antidepressants or blood pressure medications?" Q: "Have
you been experiencing excessive vomiting or diarrhoea?" Q: "Do you have any
history of heart, kidney, or liver problems?" Q: "Have you been diagnosed with any
cancers?"
6. Scenario-specific questions (X):
o Addison's disease: Ask about symptoms and causes of Addison's
o Bulimia: Use SCOFF questions, ask about mood and suicidal thoughts
o SIADH: Ask about cancer symptoms
o Citalopram: Ask about depression and medication history
7. NEOM (Nominal Extragenital Oral Musculoskeletal examination)
8. Examination (important based on the scenario)

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Management

1. Explain test results: "Let me show you the test results. We found that one of the
salts in your blood called sodium is low." (If applicable: "Another salt called
potassium is also affected.") "This low sodium level is the reason for your
tiredness/confusion."
2. Provide diagnosis if applicable:
o Medication-related: "The medication you're taking, [name], can sometimes
cause sodium levels to drop."
o Addison's disease: "Based on your symptoms and test results, you may have a
condition called Addison's disease."
o Bulimia: "Your symptoms suggest you might be dealing with an eating
disorder called bulimia."
o Cancer/SIADH: "There's a possibility that this could be related to a
condition called SIADH, which can sometimes be associated with certain
cancers."
3. Explain how hyponatremia is treated: "Given your symptoms and sodium levels, we
need to treat this in the hospital. They will give you a strong salt solution through a
vein to slowly bring your sodium levels back to normal. They'll monitor your blood
closely during this treatment."
4. Explain how the underlying condition is treated:
o Medication-related: "We may need to adjust your medication or find an
alternative."
o Addison's disease: "Addison's disease is treated with hormone replacement
therapy."
o Bulimia: "Treatment for bulimia involves therapy and sometimes medication.
We'll refer you to a specialist."
o Cancer/SIADH: "If this is related to cancer, the treatment will depend on
the type and stage of cancer. We'll need to do further tests."
o Kidney problem: "We'll need to address the underlying kidney issue. This
might involve medication or lifestyle changes."

Important Points to Remember

1. Don't repeat examinations that have already been done (e.g., by the registrar)
2. Focus on finding the cause of low sodium, not the cause of tiredness
3. Be thorough in asking about all symptoms of hyponatremia
4. Consider all possible causes of hyponatremia
5. Tailor your approach based on the specific scenario (X factor)
6. Always include NEOM and appropriate examination
7. Provide clear explanations of test results, diagnosis, and treatment plans

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8. Be prepared for multiple hyponatremia scenarios in close succession

9. Remember that any symptomatic hyponatremia requires hospital treatment
10. Don't use phrases like "calm down" or make excuses about emergency department
busyness if the patient is upset
11. Acknowledge the patient's feelings if they express frustration about waiting times

Specific Scenarios to be Prepared For

1. Citalopram-related (SSRI) - two scenarios:

o Younger person
o Elderly patient
2. Bulimia (vomiting-related)
3. SIADH (cancer-related)
4. Addison's disease
5. Kidney problem

Note: There have been instances of two hyponatremia scenarios appearing in one day (e.g.,
in April/May). Be prepared for multiple hyponatremia scenarios in the same week.

General Approach to Hyponatremia Scenarios

• Use a landscape-oriented paper divided into two columns: Data and Management
• Before entering the room, you will have hyponatremia findings:
o For GP scenarios: Incorporated in the task
o For hospital scenarios: On a table

Data Gathering (Left column)

1. Reason for test

2. Explore presenting complaint (ODIPARA)
3. Other hyponatremia symptoms
4. Causes of hyponatremia
5. Scenario-specific questions (X)
6. NEOM
7. Examination

Management (Right column)

1. Explain test results

2. Provide diagnosis
3. Explain hyponatremia treatment
4. Explain treatment for underlying condition

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Hyponatremia Classification

• Normal sodium: 135-145 mmol/L

• Mild: 130-135 mmol/L
• Moderate: 125-130 mmol/L
• Severe: <125 mmol/L

Action:

• Moderate and severe (<130 mmol/L): Send to hospital immediately

• Mild (130-135 mmol/L): Send to hospital if symptomatic
• Any symptomatic hyponatremia needs hospital treatment

Hospital treatment: 3% saline solution (3x stronger than normal 0.9% saline),
administered intravenously

SIADH Scenario
Setting

• F2 in GP
• 70-year-old man
• Test results:
o Haemoglobin slightly low
o Sodium 124 mmol/L (severe hyponatremia)
• COPD for 10-15 years
• Smoker
• Coughs up blood

Approach

1. Reason for test: Q: "I understand you're here for the test results. Do you know what
tests were done and why?" A: "I was feeling tired"
2. Explore tiredness: Q: "How long have you been feeling tired?" Q: "Is it getting better
or worse?" Q: "Does anything make it better or worse?" Q: "Does rest help?"
3. Other hyponatremia symptoms:
o Energy-related: fatigue, drowsiness, loss of energy
o Muscle-related: weakness, spasms, cramps
o Brain-related: nausea, vomiting, headache, irritability, restlessness, confusion,
fits, coma

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4. Causes of hyponatremia: Q: "Do you have any heart conditions?" Q: "Any liver or
kidney problems?" Q: "Do you take any blood pressure medications?" Q: "Have you
been experiencing any vomiting or diarrhoea?"
5. COPD and cancer symptoms (X): Q: "How long have you had COPD?" Q: "How
often do you cough up blood?" Q: "Have you noticed any changes in your cough?"
Q: "Any unexplained weight loss?" Q: "Any pain in your chest or elsewhere?"
6. MAFTOSA (focus on smoking history) Q: "How long have you been smoking?" Q:
"How many cigarettes do you smoke per day?"
7. Examination:
o Check blood pressure
o Examine chest

Management

1. Explain test results: "Let me explain the test results. One of the salts called sodium is
quite low in your blood. The normal range is 135-145, and yours is 124. This low
sodium is the reason for your tiredness."
2. Discuss diagnosis: "I'm a bit concerned about these test results. Your salt levels are
low, you've had COPD for a long time, you're coughing up blood, and you've been
smoking. Unfortunately, this could be a sign of lung cancer. It seems you may have
developed a complication called Syndrome of Inappropriate Antidiuretic Hormone
secretion, or SIADH."
3. Explain SIADH: "SIADH is a condition where your body produces too much of a
hormone that affects your salt levels. This can sometimes be associated with lung
problems, including cancer."
4. Treatment plan:
o "This is an emergency situation, and you need to go to the hospital
immediately."
o "In the hospital, they will correct your salt levels by giving you a strong salt
solution through a vein."
o "You'll be seen by an endocrinologist, a hormone specialist, who will review
your case."
o "We're also going to refer you to a lung specialist to investigate the possibility
of lung cancer."
o "They may do further tests like chest X-rays, CT scans, or a biopsy."
o "If it is lung cancer, treatment options might include surgery, chemotherapy,
or radiotherapy, depending on the type and stage of the cancer."
5. Reassurance: "We'll make sure you get the care you need. Do you have any
questions about what I've explained?"

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Citalopram Scenario

Setting

• F2 in GP
• Elderly lady
• Diagnosed with depression 6 weeks ago
• Started on Citalopram
• Sodium 128 mmol/L (moderate hyponatremia)
• Patient feeling tired

Approach

1. Reason for test: Q: "I understand you're here for your test results. What made you
have this test in the first place?" A: "I was feeling tired"
2. Explore tiredness (as in SIADH scenario)
3. Other hyponatremia symptoms (as in SIADH scenario)
4. Discuss Citalopram: Q: "I see you've been taking Citalopram for your depression.
How long have you been taking it?" A: "For about 6 weeks" Q: "Do you take it
regularly?" Q: "How has it been helping with your depression?" Q: "What symptoms
of depression did you have? Are they improving?"
5. Ask about Citalopram side effects (X): Q: "Have you experienced any side effects
from Citalopram?"
o Dry eyes/mouth
o Excessive sweating
o Stomach pain
o Nausea/vomiting
o Sexual dysfunction
o Changes in libido
o Abnormal bleeding (for females)
6. NEOM
7. Examination:
o Check blood pressure

Management

1. Explain test results: "Let me explain your test results. One of the salts in your blood
called sodium is low. The normal range is 135-145, and yours is 128. This low
sodium is causing your tiredness."
2. Explain cause: "The Citalopram you're taking for depression can sometimes cause
low sodium levels as a side effect."

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3. Treatment plan:
o "Because your sodium levels are low and you're having symptoms, we need to
send you to the hospital."
o "In the hospital, they'll give you a strong salt solution through a vein to
correct your sodium levels."
o "We also need to change your antidepressant medication. A suitable
alternative is a medication called Amitriptyline."
o "I can change this medication for you today; we don't need to refer you to a
psychiatrist for this change."
4. Follow-up: "Once your sodium levels are corrected and you're on the new
medication, we'll need to see you for a follow-up to check how you're doing."

Addison's Disease Scenario

Setting

• 24-year-old patient
• Test results:
o Sodium low
o Potassium slightly high
o Other results normal
• Patient has type 1 diabetes
• Patient noticed pigmentation while in Spain

Approach

1. Reason for test: Q: "I understand you're here for your test results. What made you
have this test in the first place?" A: "I was feeling tired"
2. Explore tiredness (as in previous scenarios)
3. Other hyponatremia symptoms (as in previous scenarios)
4. Ask about hyperkalaemia symptoms: Q: "Have you experienced any irregular
heartbeats or chest pain?"
5. Investigate causes (as in previous scenarios)
6. Ask about Addison's disease symptoms (X): Q: "Have you noticed any changes in
your appetite?" Q: "Do you crave salty foods?" Q: "Have you had any abdominal
pain, nausea, diarrhoea, or vomiting?" Q: "Have you lost any weight recently?" Q:
"You mentioned noticing some pigmentation. Can you tell me more about that?" Q:
"Have you noticed any darkening of your skin, especially around scars or skin folds?"
Q: "Any changes in your hair, like hair loss?" Q: "Have you been feeling low in
mood or confused?" Q: "Any episodes of fainting?" Q: "Any muscle or joint pain?"

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7. Ask about causes of Addison's disease: Q: "Do you have any other autoimmune
conditions besides diabetes?" Q: "Have you ever had tuberculosis or any other
serious infections?" Q: "Any history of cancer or cancer treatments?" Q: "Have you
had any bowel surgeries?" Q: "Any history of bleeding disorders?" Q: "Have you ever
had a head injury?" Q: "Are you taking any antifungal medications?"
8. MAFTOSA
9. Examination:
o Check blood pressure (they may provide standing and lying down
measurements)
o Examine skin for pigmentation

Management

1. Explain test results: "Let me explain your test results. One of the salts called sodium
is low in your blood, and another called potassium is slightly high. These
imbalances are causing your tiredness."
2. Discuss diagnosis: "These results, along with your symptoms, suggest you may have a
condition called Addison's disease."
3. Explain Addison's disease: "In our body, there's a pair of glands called adrenal
glands above our kidneys. They produce two important hormones: cortisol and
aldosterone. These hormones help regulate sugar and salt levels in our body. In
Addison's disease, these glands are damaged and can't produce enough of these
hormones."
4. Treatment plan:
o "This is a medical emergency, and you need to go to the hospital
immediately."
o "In the hospital, they'll correct your salt levels and start you on hormone
replacement."
o "You'll be seen by an endocrinologist, a hormone specialist."
o "They'll run some tests to confirm the diagnosis, including:
§ An ultrasound of your abdomen
§ A CT scan
§ A hormone test called an ACTH test
§ They'll also check your hormone levels"
o "The treatment for Addison's disease is lifelong hormone replacement:
§ A medication called hydrocortisone to replace cortisol
§ Another medication called fludrocortisone to replace aldosterone"
5. Address potential questions: Q: "Why did I get this disease?" A: "Addison's disease is
often autoimmune, like your diabetes. When you have one autoimmune condition,
you can sometimes develop others. Your immune system, which usually fights off
infections, mistakenly attacks your own adrenal glands."

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Bulimia Scenario

Setting

• Patient for review

• Sodium borderline (135 mmol/L or slightly lower)
• Potassium low

Approach

1. Reason for test: Q: "I understand you're here for your test results. What made you
have this test in the first place?" A: "I was feeling tired"
2. Explore tiredness (as in previous scenarios)
3. Ask about hyponatremia and hypokalaemia symptoms
4. Investigate causes (as in previous scenarios)
5. Ask about vomiting (X): Q: "Have you been experiencing any vomiting?" If yes: Q:
"How long have you been vomiting?" Q: "Is it spontaneous or do you make yourself
vomit?" Q: "How do you make yourself vomit?" A: "I put my finger in my throat" Q:
"How often do you do this?" Q: "Why do you make yourself vomit?" A: "To lose
weight" Q: "Can I ask why you want to lose weight?"
6. SCOFF questions:
o S: "Do you make yourself Sick because you feel uncomfortably full?"
o C: "Do you worry you have lost Control over how much you eat?"
o O: "Have you recently lost more than One stone (14 lb) in a 3-month
period?"
o F: "Do you believe yourself to be Fat when others say you are too thin?"
o F: "Would you say that Food dominates your life?"
7. Ask about mood and suicidal thoughts: Q: "How has your mood been lately?" Q:
"Have you had any thoughts of harming yourself?"
8. MAFTOSA Note: Ask about past medical history Q: "Have you ever been diagnosed
with an eating disorder before?" Q: "Have you ever been diagnosed with depression?"
9. Examination:
o Check BMI (likely to be given as 22 or above 20)
o Examine hands
o Check parotid glands
o Check teeth for erosions
o Take blood pressure

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Management

1. Explain test results: "Let me explain your test results. Two salts in your blood,
sodium and potassium, are quite low. The sodium is borderline low at 135, and the
potassium is definitely low. These imbalances are causing your tiredness. The low
levels are likely due to losing these salts when you vomit."
2. Discuss diagnosis: If previous diagnosis: "The condition you had when you were
younger, bulimia, seems to have returned." If no previous diagnosis: "Based on what
you've told me, you may have a condition called bulimia nervosa. It's an eating
disorder that causes someone to eat a large amount of food and then try to get rid of
it, often through vomiting or using laxatives."
3. Treatment plan:
o "Even though your sodium is borderline, because of your symptoms and the
eating disorder, we need to send you to the hospital."
o "In the hospital, they'll correct your salt levels:
§ They'll give you saline through a vein for the sodium
§ For the low potassium, they'll give you a medication called Sando-K,
which you drink mixed with water"
o "We're also going to refer you to an eating disorder clinic. The treatment
there will involve several components:
§ Cognitive Behavioural Therapy (CBT) to help change thought
patterns
§ Nutritional advice to establish healthy eating habits
§ Medication if needed
§ Information about the condition
§ Support groups where you can meet others with similar experiences"
4. Address potential concerns: If patient says they don't eat: "I understand you might
not feel like you're eating much. We call this an eating disorder because it's related
to eating behaviours. Some people eat a lot, some don't eat at all, and some, like in
your case, eat and then try to get rid of the food. They're all related to how we
interact with food and eating."
5. Follow-up: "Once you're discharged from the hospital, we'll need to see you for
regular follow-ups to monitor your progress and adjust your treatment as needed."

Important Points to Remember

1. Always consider the severity of hyponatremia and act accordingly.

2. Focus on finding the cause of low sodium, not just the cause of tiredness.
3. Be thorough in asking about all symptoms of hyponatremia.
4. Consider all possible causes of hyponatremia.
5. Tailor your approach based on the specific scenario (X factor).

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6. Always include NEOM and appropriate examination.

7. Provide clear explanations of test results, diagnosis, and treatment plans.
8. Be prepared for multiple hyponatremia scenarios in close succession.
9. When you know the scenario, act like you're struggling to figure it out to appear
more natural.
10. Don't be robotic in your approach; adapt to the patient's responses.
11. Remember that any symptomatic hyponatremia, even border

General Approach for Hospital Scenarios

• Setting: F2 in acute medicine

• Patients: Two elderly people (not you and two daughters)
• Test results: Available outside and inside the room
• Important: Take an extra minute to read and comprehend before starting
o Even if you have less time, it's better to do an oriented job than a disoriented
one
o Scan quickly, but don't spend more than a minute reading

SIADH with Infection Scenario

Setting

• F2 in acute medicine
• 65-year-old lady brought in due to confusion
• Daughter brought her to hospital

Pre-consultation Information

• Sodium is low (important)

• CRP is high
• CT scan normal (written in the notes)
• Recent flu (last few days)
• Diagnosed with depression 3 months ago, started on citalopram
• Hypertension for 10 years, on thiazide diuretics

Approach

1. Greeting and Initial Concern:

o Be prepared for daughter to interrupt: "Doctor, is she having a stroke?"
o Response: "We've done a CT scan, which came back normal. She's not
having a stroke at the moment. I understand you brought her to the hospital
this morning. Can you tell me what happened?"

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2. Analyse Confusion: Q: "What do you mean by confused? What did you notice?"
Potential A: "She was disoriented, saying random words, yelling at me, not
recognizing me." Q: "When did you notice this? Was it just this morning?" Q: "Since
this morning until now, has it been getting better, worse, or staying the same?" Q:
"When did you last see her when she was okay? Was she okay yesterday?" Q: "Is this
the first time she's been like this?"
3. Ask about other hyponatremia symptoms:
o Energy-related: tiredness, fatigue
o Muscle-related: weakness, cramps
o Brain-related: nausea, vomiting, headache, irritability
4. Investigate Causes:
o Infections: Q: "Has she had any fever or flu-like symptoms recently?" Q: "Any
signs of chest infection or urinary tract infection?"
o Medications: Q: "What medications is she taking?" Q: "How long has she
been on citalopram? Why was it prescribed?" Q: "Is she taking any blood
pressure medications?"
o Other conditions: Q: "Any history of liver problems?" Q: "Any kidney issues?"
Q: "Any heart failure?"
5. Ask about citalopram side effects (X): Q: "Has she complained of dry mouth or dry
eyes?" Q: "Any excessive sweating?" Q: "Any stomach pain or nausea?" Q: "Any
changes in appetite?" Q: "Any abnormal bleeding?" (for females)
6. Complete MAPTOSA

Management

1. Explain test results: "One of the salts called sodium is low in your mother's blood.
This is likely causing her confusion. We also found signs of an infection, which
could be related to her recent flu."
2. Explain cause: "The low sodium could be due to a combination of factors: her
recent infection, the citalopram she's taking for depression, and the blood pressure
medication."
3. Treatment plan:
o "We need to correct her salt levels in the hospital. This will be done with a
strong salt solution given through a vein."
o "We'll also need to change her medications:
§ We'll switch the citalopram to a different antidepressant called
amitriptyline.
§ We'll change her blood pressure medication from a thiazide diuretic
to a calcium channel blocker."
o "We'll treat the infection as well, likely with antibiotics."

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4. Follow-up: "Once her sodium levels are corrected and her infection is treated, we'll
monitor her closely to ensure the confusion resolves."

Renal Failure Scenario

Setting

• F2 in acute medicine
• 70-year-old man brought in due to confusion

Pre-consultation Information

• Sodium is low
• Renal function deranged (creatinine high, urea high)
• Haemoglobin may be low (indicative of chronic renal failure)
• Patient on enalapril for blood pressure for 2-3 years

Approach

1. Analyse Confusion (as in previous scenario)

2. Ask about other hyponatremia symptoms (as in previous scenario)
3. Investigate Causes: Q: "Has he had any kidney problems in the past?" Q: "Does he
have diabetes or high blood pressure?" Q: "What medications is he taking?" Q: "How
long has he been taking enalapril?"
4. Ask about kidney failure symptoms (X): Q: "Has he had any problems with
urination? Passing too much or too little urine?" Q: "Any swelling in his legs,
abdomen, or face?" Q: "Has he been having any breathing problems?" Q: "Any
changes in appetite or unexplained weight loss?" Q: "Has he been feeling more tired
than usual?"
5. Ask about other potential causes:
o Liver problems
o Heart failure
o Cancer symptoms
6. Complete MAFTOSA

Management

1. Explain test results: "One of the salts called sodium is low in your father's blood,
which is likely causing his confusion. We've also found that his kidneys aren't
working properly."
2. Explain cause: "The kidney problem might be due to the blood pressure medication
he's been taking, although there could be other factors involved."

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3. Treatment plan:
o "We need to correct his sodium levels here in the hospital. This will be done
with a strong salt solution given through a vein."
o "We'll need to change his blood pressure medication. We'll switch from
enalapril to a different type called a calcium channel blocker, like
amlodipine."
o "We'll refer him to a kidney specialist for further tests and management."
o "The specialist will do more tests, including scans of his kidneys."
o "Depending on how severe the kidney problem is, he might need dialysis,
which is a way of filtering the blood when the kidneys can't do it effectively."
4. Prognosis: "Sometimes this kidney condition can improve with treatment, but in
some cases, long-term dialysis might be necessary. The kidney specialist will be able
to give you more information after their assessment."

Important Points to Remember for Hospital Scenarios

1. Always address immediate concerns (like stroke) promptly to alleviate anxiety.

2. Take time to read and comprehend all available information before starting the
consultation.
3. Analyse confusion thoroughly, asking about onset, progression, and previous
episodes.
4. Consider multiple causes for hyponatremia, especially in elderly patients with
multiple medications.
5. Don't forget to ask about infection symptoms when CRP is high.
6. Be prepared to explain complex concepts like kidney function and dialysis in simple
terms.
7. Always include a plan for medication changes and specialist referrals when
appropriate.
8. Remember that hyponatremia in hospital settings often requires a multidisciplinary
approach.
9. When you know the scenario, act like you're struggling to figure it out to appear
more natural.
10. Don't be robotic in your approach; adapt to the patient's responses.

General Advice for Hyponatremia Scenarios

1. Use a landscape-oriented paper divided into two columns: Data and Management.
2. Data column should include:
o Reason for test
o Explore presenting complaint (ODIPARA)
o Other hyponatremia symptoms

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o Causes of hyponatremia
o Scenario-specific questions (X)
o NEOM
o Examination
3. Management column should include:
o Explain test results
o Provide diagnosis
o Explain hyponatremia treatment
o Explain treatment for underlying condition
4. Remember, management often takes more than two minutes. The two-minute bell
is just to indicate two minutes remaining.
5. Be prepared for multiple hyponatremia scenarios in close succession, especially in
exams.
6. Always consider the severity of hyponatremia:
o Mild: 130-135 mmol/L
o Moderate: 125-130 mmol/L
o Severe: <125 mmol/L
7. Any symptomatic hyponatremia needs hospital treatment, regardless of severity.

Obstructive Sleep Apnea (OSA) Scenario

Setting

• F2 in GP
• 50-year-old man
• Type 2 diabetes follow-up
• BMI and HbA1c will be provided
• No obvious clue about OSA in the scenario

Approach

1. Paraphrase and assess understanding: "I understand you're here for a follow-up. You
also have a condition called diabetes. What is your understanding about diabetes?"
Expected A: "Diabetes means having high blood sugar."
2. Ask about treatment: Q: "Are you on any treatment for your diabetes?" A: "I'm on a
diet." Q: "Is your sugar level controlled?" A: "Yes, it's well controlled." Q: "Do you
check your sugar levels regularly?" A: "Yes, I do."
3. Ask about symptoms: Q: "How have you been feeling? Do you have any symptoms?"
Initial A: "I feel a little tired." Push for more information: Q: "Any other symptoms?
Anything else?" A: "I feel sleepy."

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4. Explore sleepiness: Q: "When do you feel sleepy?" A: "I feel sleepy all the time." Q:
"Do you feel sleepy during the daytime?" A: "Yes." Q: "On what occasions do you
feel sleepy?" Ask about specific situations: Q: "Do you fall asleep while taking rest?"
Q: "Do you fall asleep while reading a book or watching TV?" Q: "Do you fall asleep
when sitting down and talking to somebody?" Q: "Do you fall asleep after eating?" Q:
"Do you fall asleep when you sit in a vehicle as a passenger?" Q: "Do you drive?" A:
"Yes, I'm a delivery driver." Q: "Do you fall asleep while driving?"
5. Ask about other OSA symptoms: Q: "Do you wake up in the middle of the night
gasping for air?" Q: "Do you snore?"
6. Complete MAPTOSA Note: Occupation is important (patient is a delivery driver)

Management

1. Explain diagnosis: "Based on your symptoms, you may have a condition called
obstructive sleep apnea. This is when your breathing is interrupted during sleep,
which can make you feel very tired during the day."
2. Explain urgency: "Given that your job involves driving, this is an urgent situation.
We need to address this quickly for your safety and the safety of others on the road."
3. Treatment plan: "We need to refer you urgently to a sleep clinic for further
evaluation and treatment. They will likely do a sleep study to confirm the diagnosis."
4. Explain implications: "It's important to address this quickly, as sleep apnea can
affect your ability to drive safely. The sleep clinic will guide you on whether it's safe
for you to continue driving while you're being evaluated and treated."

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Hypertension Follow-up Scenarios

Scenario A: Enalapril and Cough

Setting

• F2 in GP
• 60-year-old man
• Follow-up appointment
• Admitted to hospital 6 weeks ago for cellulitis
• Diagnosed with hypertension in hospital
• Started on enalapril
• Has diabetes
• Stopped medication 2-3 weeks ago due to cough
• Blood pressure to be measured during consultation

Approach

1. Paraphrase and explore recent history: "I understand you're here for a follow-up.
You were recently admitted to the hospital. Can you tell me what happened?"
Expected A: Patient explains hospital admission and hypertension diagnosis
2. Assess understanding of hypertension: Q: "What is your understanding about high
blood pressure?" A: Patient may give a vague answer
3. Explain hypertension: "High blood pressure means the pressure inside your blood
vessels and heart has increased. This is problematic because it increases your risk of
serious medical problems like stroke and heart attack. It can also damage organs like
your eyes, heart, and kidneys. That's why it needs to be controlled."
4. Ask about medication: Q: "You were given medication for your blood pressure. Are
you still taking it?" A: "No, I stopped taking it." Q: "Can I ask why you stopped
taking the medication?" A: "I had a cough." Q: "When did you stop the medication?"
A: "About 2-3 weeks ago." Q: "Were you told that this medication could cause a
cough?" A: "Yes, they mentioned it in the hospital."
5. Explore cough: Q: "Was it a dry cough or a wet cough?" A: "It was a dry cough." Q:
"Did you have any other symptoms like fever or flu?" A: "No, just the cough."
6. Ask about hypertension symptoms: Q: "Before you were diagnosed, did you have
any symptoms like headache, tiredness, sweating, chest pain, or leg pain?"
7. Ask about complications: Q: "Have you ever had a heart attack or stroke?"
8. Complete MAPTOSA
9. Examine: "I would like to check your blood pressure." Note: Blood pressure will be
given as 160/90

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Management

1. Explain current situation: "We checked your blood pressure, and it's high today at
160/90. This is likely because you've stopped taking your medication."
2. Treatment plan: "We need to change your medication to a different one called
candesartan. This is a different type of blood pressure medication that's less likely to
cause a cough."
3. Lifestyle advice: "Apart from medication, you can improve your blood pressure by
making some lifestyle changes. This includes reducing your weight if necessary,
exercising regularly, eating a healthy diet low in salt, and limiting alcohol intake."
4. Address concerns: If asked about cough with new medication: "Unfortunately,
candesartan can cause a cough, but it's not very commonly reported. If you do get a
cough, please don't stop the medication yourself. Come back to see us instead so we
can find a solution."
5. Follow-up: "I'd like to see you again in 4 weeks to check your blood pressure and see
how you're getting on with the new medication. If you have any problems before
then, please come back to see us."

Scenario B: Amlodipine and Leg Swelling

Setting

• Similar to Scenario A, but with a female patient

• Started on amlodipine
• Stopped medication due to leg swelling
• Couldn't wear shoes due to swelling

Approach

• Similar to Scenario A, but focus on leg swelling instead of cough Q: "Why did you
stop taking the medication?" A: "My legs were swollen and I couldn't wear my
shoes."

Management

• Change medication from amlodipine to enalapril

• Explain: "Enalapril is less likely to cause leg swelling. However, it can sometimes
cause a dry cough. If this happens, please come back to see us rather than stopping
the medication on your own."

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Scenario C: Combination Therapy

Setting

• Male patient
• Started on two medications: enalapril and amlodipine
• Stopped enalapril due to cough, continued amlodipine
• Blood pressure still high at follow-up

Approach

• Similar to Scenario A Q: "I understand you were started on two medications. Are
you still taking both?" A: "I stopped the enalapril because of the cough, but I'm still
taking the amlodipine."

Management

1. Replace enalapril with candesartan "We're going to replace the enalapril with a
medication called candesartan. This is less likely to cause a cough."
2. Continue amlodipine "Please continue taking the amlodipine as well."
3. Advise patient to continue both medications "It's important that you take both
medications to control your blood pressure effectively."

Important Points to Remember

1. In the OSA scenario:

o The only clue is the BMI. There's no obvious indication of OSA in the
scenario.
o Be prepared to explore sleep-related symptoms thoroughly.
o The patient's occupation as a delivery driver makes this an urgent situation.
2. For hypertension follow-ups:
o Always measure blood pressure during the consultation.
o Explain hypertension and its risks clearly to patients.
o Be prepared to discuss medication side effects and how to manage them.
o Always provide lifestyle advice alongside medication changes.
3. In combination therapy:
o Be clear about which medication is being changed and which should be
continued.
o Explain the importance of taking both medications as prescribed.
4. General advice:
o Emphasize the importance of not stopping medications without consulting a
doctor.

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o Encourage patients to return if they experience side effects rather than

stopping medication on their own.
o Schedule follow-up appointments to monitor progress and adjust treatment
as necessary.
5. Remember to act as if you're struggling to figure out the diagnosis, especially in the
OSA scenario. This appears more natural and shows you're working through the
problem.
6. Don't be robotic in your approach. Adapt your questions and explanations based on
the patient's responses.
7. For the OSA scenario, remember that this is a diabetic follow-up that turns into an
OSA diagnosis. Be prepared to shift gears based on the patient's symptoms.

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Medical Error Scenarios

1. Introduction to Medical Errors

• Eight scenarios discussed, some common, some uncommon

• Examples include:
o Renal biopsy
o Missed blood sample
o Missed foreign body
o Missed fracture
o Missed MRI
o Mixed up glass piece
o Missed fracture in an old lady talking to the son
• Medical errors are established cases that happened in the past
• Cases are given with a story/narrative
• The task is to explain the error to the patient
• Medical error is considered news to the patient

2. AVE-Protocol (formerly EVE-Protocol)

• Used when patient shows emotions, mainly anger in PLAB 2

• A-Protocol steps:
1. Acknowledge:
§ "I can see that Mr. Johnson, you are quite upset"
§ "I can see that Mr. Smith, you are not very happy with this"
§ "I can see that you are really angry about this"
2. Validate:
§ "It is completely understandable, Mr. Johnson"
§ "Anyone in a situation would feel the same"
§ "There is no doubt about it"
3. Empathy:
§ "I'm really sorry about this"
§ "We are really sorry about this"
• Use with appropriate emotions, facial expressions, and sincerity
• Raise eyebrows, show wrinkles on forehead
• Speak from the bottom of your heart
• Always use "anyone" not "yourself" when validating
• Don't make it personal, always refer to other people

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3. Structure of Medical Error Consultation

1. Greet and Paraphrase

o Do not ask "How may I help you?"
o Explain why the patient was called
o Say: "We asked you to come because we need to discuss something"
2. Take History
o Focus on two main things: a. Current situation b. Previous visit
o Include general health if relevant (e.g., if treatment is pending)
o Ask about symptoms, diagnosis, testing, and treatment from previous visit
3. Prepare and Deliver the News
o Give a warning shot
o Narrate the story chronologically
o Deliver the news with "Unfortunately, I'm sorry to tell you..."
4. Manage Patient's Reaction
o Allow the patient to express anger
o Apply A-Protocol
o Avoid cross-talking
5. Explain Remaining Management
o What needs to be done for the patient (medical management)
o What will be done about the error (hospital protocol)
6. Address Default Questions
o Whose mistake it was
o What happens next

4. Delivering the News

1. Warning Shot
o "There is an important information that I've been asked to talk to you about
your [biopsy/test results/treatment]"
o "Unfortunately, Mr. Johnson, there is something that went wrong with your
treatment"
2. Narrative
o Start with "As we understand..."
o Present events in chronological order
o Example narrative for renal biopsy case: "As we understand, two days ago, we
have taken the biopsy. We sent it to the laboratory. We have been waiting for
the results. We didn't receive any information. We were hoping that they're
going to report to us, but they didn't report to us. So we called them."
o Use "unfortunately" for each piece of bad news
o Example: "Unfortunately, they said they didn't receive the biopsy"

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3. Final News Delivery

o "Unfortunately, I'm sorry to tell you. It seems like we have lost the biopsy"

5. Managing Patient's Reaction

• Let the patient express anger without interruption

• Do not cross-talk (avoid talking when the patient is talking)
• Apply A-Protocol
• Emphasize it's the hospital's mistake: "It is clearly a mistake on our part"
• Apologize sincerely: "Please accept our sincere apology"
• Avoid phrases like "I would like to apologize on behalf of my team"

6. Explaining Hospital Protocol for Errors

Always include these five steps:

1. Incident Reporting
o "The hospital takes this sort of incidents very seriously"
o "This will be reported as one of the significant incidents in the hospital"
2. Investigation
o "We will start the investigations"
o "We'll look into it"
o "A senior member in the department will start the investigation"
3. Taking Action
o "After the investigation, they will finalize"
o "We'll take action according to hospital policies, protocols, and guidelines"
o "We will be open and transparent about what went wrong and what sort of
action we have taken"
4. Senior Member Involvement
o "A senior member from the department also will come and speak to you"
5. Offering PALS (Patient Advice and Liaison Service)
o Must always offer, regardless of whether the patient asks
o It's the patient's right and your duty (duty of candour)
o Say: "At the meantime, if you wish to make a formal complaint, you are more
than welcome to speak to Patient Advisory Liaison Service. I can give you
information about that. I can get you in touch with them"

7. Addressing Default Questions

1. Whose mistake was it?

o If clear: "Unfortunately, it is my mistake" or "Unfortunately, it is the
department of radiology who made this mistake"

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oIf unclear: "Unfortunately, we are not really sure whose mistake this is. But
we can find out and let you know"
2. What happens next?
o Explain the next steps in patient care
o Reiterate the steps in the hospital's error protocol

8. Things to Avoid

• Don't ask "How may I help you?" at the beginning

• Avoid cross-talking when the patient is expressing anger
• Don't say "I would like to apologize on behalf of my team"
• Don't wait for the patient to ask about PALS; always offer it
• Avoid being abrupt or delivering the news without proper preparation
• Don't maintain an angry demeanour throughout the entire consultation (for role-
playing purposes)
• Don't keep asking if you need to offer PALS even if the patient is not asking

9. Sample Dialogue Structure

1. Greeting and Paraphrase: "Hello, Mr. Johnson. Thank you for coming in today. We
asked you to come because there's something important we need to discuss about
your recent renal biopsy."
2. Taking History: "Before we proceed, could you tell me how you've been feeling since
your biopsy two days ago?" (Listen to patient's response) "Have you experienced any
new symptoms or concerns since the procedure?" (Listen to patient's response) "Just
to confirm, you came in with symptoms of glomerulonephritis, is that correct?"
(Listen to patient's response) "And we performed the renal biopsy to help diagnose
your condition. Is that your understanding as well?" (Listen to patient's response)
3. Delivering the News: "Mr. Johnson, there's something important I need to tell you
about your biopsy. Unfortunately, there is something that went wrong with your test
results." (Pause to allow the patient to process this information) "As we understand,
two days ago, we took the biopsy sample and sent it to the laboratory. We have been
waiting for the results, hoping they would report back to us. However, we didn't
receive any information. So, we called the laboratory to inquire about your results.
Unfortunately, they informed us that they didn't receive the biopsy sample." (Pause
briefly) "Upon hearing this disappointing news, we conducted a thorough search
everywhere in our department. We looked in every possible location, but I'm very
sorry to tell you, it seems like we have lost your biopsy sample."
4. Managing Reaction (if patient becomes angry): (Allow patient to express anger
without interruption) "I can see that you're really angry about this, Mr. Johnson. It is
completely understandable. Anyone in your situation would feel the same way. We

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are truly sorry that this has happened. It is clearly a mistake on our part. Please
accept our sincere apology."
5. Explaining Next Steps: "Let me explain what we're going to do next, Mr. Johnson.
First, regarding your care, we will need to repeat the biopsy procedure to obtain a
new sample. We understand this is inconvenient and potentially distressing, and we
will do everything we can to make the process as smooth as possible for you.
Regarding the error itself, I want you to know that our hospital takes these sorts of
incidents very seriously. This will be reported as one of the significant incidents in
the hospital. We will start a thorough investigation immediately. A senior member
of our department will look into what happened, how it happened, and why. After
the investigation, they will finalize their findings. We'll then take action according
to our hospital policies, protocols, and guidelines. We promise to be open and
transparent with you about what went wrong and what actions we're taking to
prevent this from happening again. Also, a senior member of our department will
come to speak with you personally about this incident and the findings of our
investigation. Lastly, Mr. Johnson, if you wish to make a formal complaint, you are
more than welcome to speak to our Patient Advice and Liaison Service, also known
as PALS. This is your right, and it's my duty to inform you of this option. I can
provide you with their information or help put you in touch with them if you'd like.
Would you like me to do that?"
6. Addressing Questions: "Mr. Johnson, I understand this is a lot of information to
process. Do you have any questions about what I've just explained? Is there anything
you'd like me to clarify?" (If patient asks whose mistake it was) "Unfortunately, Mr.
Johnson, we are not really sure at this moment whose specific mistake this was. But
I assure you, we will find out during our investigation and let you know." (If patient
asks about compensation) "I understand your concern about compensation, Mr.
Johnson. While I'm not in a position to discuss that, I can put you in touch with
our PALS service, who can guide you through the process if you wish to pursue that
avenue."

Renal Biopsy Medical Error Scenario

1. Scenario Overview

• 18-year-old patient (chosen because an 18-year-old will act like an 18-year-old)

• Renal biopsy taken two days ago
• Biopsy sent to laboratory
• Report not received
• You called the laboratory
• Laboratory says they didn't receive the biopsy
• You've been asked to talk to the patient

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2. Patient Background

• GP sent patient for biopsy

• Patient had blood in urine (shown in urine test)
• Apart from this, patient didn't have any symptoms

3. Consultation Structure

3.1 Greeting and Paraphrasing

• "Are you Ben Lewis? I'm Dr. Levin, one of the doctors in this unit."
• "I understand that we have taken a biopsy" or "We have gone through a procedure"

3.2 Patient's Initial Question

• Patient likely to ask: "Doctor, they have taken the biopsy. I'm here for the biopsy.
Have you got my biopsy results with you?"

3.3 How to Respond

Do not immediately say you don't have the results. Instead, use one of these responses:

• "Actually, I've been asked to talk to you about this biopsy."

• "The reason I'm here is to talk about the biopsy."
• "I will explain to you everything about the biopsy."
• "Before I explain everything, I would like to ask you some questions about your
biopsy."
• "Unfortunately, we have got a little bit of a problem with your biopsy that I've been
asked to discuss with you. I will explain to you. Before I explain, can I please ask you
some questions?"

3.4 Taking History

1. Ask about the reason for biopsy:

o "Can you please tell me why you have taken the biopsy?"
o "What made you have the biopsy in the first place?"
2. Ask about symptoms:
o "Have you had any symptoms at all?"
o Specifically ask about kidney symptoms:
§ Problems with urination
§ Passing no urine
§ Passing a lot of urine

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§Changes in urine volume

§ Colour changes in urine
§ Swellings in legs, tummy, or face
§ Breathing problems
3. Ask about risk factors:
o Past kidney problems
o Childhood kidney conditions
o Other ongoing medical problems
o High blood pressure
o High blood sugar
o Joint problems
o Autoimmune conditions
o Skin conditions
4. Ask about medications:
o "Do you take any medications?"
o "Any over-the-counter medications?"
5. Ask about family history:
o "Does anyone in your family have any kidney problems?"
6. Ask about the biopsy experience

Remember to incorporate all these aspects: initial idea, symptoms, risk factors, general
health, and previous biopsy experience.

3.5 Telling the Error

1. Give a warning:
o "Unfortunately, there is something that went wrong."
o "There is some important information I would like to tell you."
o "Unfortunately, we have got a little bit of a problem with your biopsy."
2. Narrate the events:
o Start with "As we understand..."
o "We took the biopsy two days ago."
o "We sent it to the laboratory."
o "We have been waiting for the results."
o "We didn't receive any information."
o "We thought they would call us, but they didn't call us."
o "So we had to call them."
o "When we called them, we didn't receive very good news."
o "They said they didn't receive the biopsy."
o "Because they said they didn't receive the biopsy, we checked everywhere."
o "We couldn't locate the biopsy."

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3. Deliver the news:

o "Unfortunately, I'm sorry to tell you, it seems like we have lost the biopsy."
o "It seems like we have misplaced the biopsy."

3.6 Managing Patient's Anger

• Use the AVE-protocol (Acknowledge, Validate, Empathy)

• Say: "It is clearly a mistake on our part."
• "Please accept our sincere apology."
• "We are really sorry about it."

3.7 Explaining Next Steps

1. Talk about the hospital protocol first:

o "We will take the responsibility."
o "The hospital will take this seriously."
o "We're going to investigate."
o "We're going to find out what went wrong."
o "We are going to take necessary action."
o "At the meantime, a senior person from the department will also come and
speak to you."
2. Explain why another biopsy is needed:
o "Your biopsy was taken to find out exactly what was wrong."
o "The GP or the doctor suspected you could have a condition called
glomerulonephritis."
o "This means inflammation of the kidneys."
o "We need to find out exactly what's wrong because there are different types
of this condition."
o "Different types are treated differently."
o "The best way to find out what is exactly wrong is to have a tissue biopsy."
o "That is the reason we have taken the biopsy, to find out exactly what is
wrong."
o "In order to find the exact type and provide the treatment, we need the
biopsy results."
3. Ask for another biopsy:
o "We are just wondering if you can help us with another biopsy, please."

3.8 Handling Patient Refusal

If patient refuses, ask why:

• "Can I please ask you why?"

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• "Is there anything bothering you?"

• "Is there any other reason you're not very keen to have another biopsy?"

Possible patient responses:

• "It was very painful."

• "They put a very large needle."
• "I don't want to go through that pain again."
• "I need to go to school."
• "I don't want to stay in the hospital all the time."

How to acknowledge and negotiate:

• "It is understandable. It can be painful."

• "We are really sorry about the experience."
• "If you allow us to take another biopsy, we can ask the consultants to put a very
small needle and some numbing agent."
• "We will try and make sure you will not experience the same pain again."
• "We'll try to minimize the pain."
• "We can do this by putting you to sleep or using a numbing agent."
• "We can use a smaller needle."
• "Would that be okay?"

If patient still refuses:

• "The only worry is that your treatment is delayed."

• "If your treatment is delayed, it can cause more complications."
• "The kidney function can deteriorate and it can cause more complications."
• "That's why we wanted to do the biopsy as soon as possible."

3.9 Offering PALS (Patient Advice and Liaison Service)

• "At the meantime, if you wish to make a formal complaint, you can speak to the
Patient Advisory Liaison Service."
• "I can give you information about that."
• "I can get you in touch with them."

If patient asks how PALS works:

• "PALS are basically patient advocates."

• "They are there to advocate for patients."
• "There is somebody to represent you."

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• "There is somebody to talk on behalf of you."

• "If you make a formal complaint, they will help you to put your complaint forward."

4. Things to Remember

• Always take care to explain things thoroughly and naturally.

• Be empathetic and understanding of the patient's concerns.
• Don't immediately tell the patient you don't have their results.
• Follow the order: greet, take history, explain the error, manage reaction, explain
next steps, offer PALS.
• Be prepared to negotiate if the patient refuses another biopsy.
• Always offer PALS, regardless of whether the patient asks.
• Don't apologize by saying "I would like to apologize on behalf of my team."
• Don't maintain an angry demeanour throughout the entire consultation (for role-
playing purposes).
• Remember to raise your eyebrows and show wrinkles on your forehead when
expressing empathy.
• Speak from the bottom of your heart.

5. Sample Dialogue

Doctor: "Are you Ben Lewis? I'm Dr. Levin, one of the doctors in this unit. I understand
that we have taken a biopsy recently."

Patient: "Yes, that's right. Have you got my biopsy results with you?"

Doctor: "Actually, I've been asked to talk to you about this biopsy. There's some important
information that I need to discuss with you. Before I explain everything, I would like to ask
you some questions about your biopsy. Can you please tell me why you have taken the
biopsy in the first place?"

Patient: "Well, my GP sent me for it. I had some blood in my urine."

Doctor: "I see. Apart from the blood in your urine, have you had any other symptoms at
all? Any problems with urination, changes in urine volume, swellings in your legs or face,
or any breathing problems?"

Patient: "No, not really. Just the blood in my urine."

Doctor: "Okay. Have you had any kidney problems in the past? Or any other medical
conditions like high blood pressure or diabetes?"

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Patient: "No, nothing like that."

Doctor: "Are you taking any medications, including over-the-counter ones?"

Patient: "No, I'm not on any medications."

Doctor: "Does anyone in your family have any kidney problems?"

Patient: "Not that I know of."

Doctor: "Alright, thank you for that information. Now, unfortunately, there is something
that went wrong that I need to tell you about. As we understand, we took the biopsy two
days ago and sent it to the laboratory. We've been waiting for the results, but we didn't
receive any information. We thought they would call us, but they didn't, so we had to call
them. When we called them, we didn't receive very good news. They said they didn't
receive the biopsy. We checked everywhere, but we couldn't locate it. Unfortunately, I'm
very sorry to tell you, it seems like we have lost the biopsy."

Patient: (Angry) "What? How could you lose it? I went through all that for nothing?"

Doctor: "I can see that you're really angry about this. It's completely understandable.
Anyone in your situation would feel the same way. We are truly sorry that this has
happened. It is clearly a mistake on our part. Please accept our sincere apology."

Doctor: "Let me explain what we're going to do next. First, the hospital takes this sort of
incident very seriously. We're going to investigate to find out exactly what went wrong, and
we'll take necessary action according to our policies. A senior person from the department
will also come to speak with you about this."

Doctor: "Now, about your care. Your biopsy was taken to find out exactly what was wrong.
The doctor suspected you could have a condition called glomerulonephritis, which is
inflammation of the kidneys. There are different types of this condition, and they're treated
differently. The best way to find out exactly what's wrong is to have a tissue biopsy. That's
why we need the results."

Doctor: "Given this situation, we are just wondering if you can help us with another
biopsy, please?"

Patient: "Another biopsy? No way! It was very painful the first time. I don't want to go
through that again."

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Doctor: "I understand. It can indeed be painful, and we're really sorry about your
experience. If you allow us to take another biopsy, we can ask the consultants to use a very
small needle and some numbing agent. We'll try our best to make sure you don't
experience the same pain again. We can even put you to sleep if that would make you more
comfortable. Would that be okay?"

Patient: "I don't know... I need to go to school. I can't keep missing classes for this."

Doctor: "I understand your concern about missing school. The only worry is that if we
delay your treatment, it could cause more complications. Your kidney function could
deteriorate. That's why we wanted to do the biopsy as soon as possible. Perhaps we could
schedule it at a time that minimizes disruption to your classes?"

Patient: "I'll think about it."

Doctor: "Thank you for considering it. At the meantime, if you wish to make a formal
complaint about what happened, you are more than welcome to speak to our Patient
Advisory Liaison Service. They are there to advocate for patients and can help you put your
complaint forward. Would you like me to give you more information about this service or
put you in touch with them?"

Patient: "Yes, I think I would like to make a complaint. How does this PALS thing work?"

Doctor: "PALS are basically patient advocates. They're there to represent patients and speak
on your behalf. If you decide to make a formal complaint, they will help you put your
complaint forward. They can guide you through the process and ensure your concerns are
heard and addressed. I can give you their contact information or help arrange a meeting
with them if you'd like."

Missed Blood Sample

1. Scenario Overview

• You are an F2 doctor in the surgical assessment unit or orthopaedics

• Patient is around 50-55 years old
• Patient is going for elective knee arthroplasty (knee replacement surgery)
• You took a blood sample yesterday
• Today you got a call from the laboratory
• They have discarded the sample due to missing labels
• You need to call the patient, explain the mistake, and arrange another sample
• This is a telephone approach scenario

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2. Significance of the Error

• Missing a blood sample is not as significant as missing a renal biopsy

• It's not considered a significant event because:
o It doesn't have the potential to cause serious harm
o Blood samples are taken regularly (every day in hospitals)
• When assessing significance, consider:
o Does it have potential to cause serious harm?
o How routine is the procedure?

3. Telephone Approach Structure

1. Ask for the patient: "Are you Edward Jones?"

2. Introduce yourself: "I'm Dr. Levin, one of the doctors. I took your blood sample
yesterday."
3. State the purpose of the call: "The reason I'm calling you today is to discuss
something about the samples we took yesterday."
4. Check if it's a good time to talk: "Can I talk to you at the moment?"
5. Verify patient identity: "Before I discuss further, I wanted to make sure I'm speaking
to the right person. Can you please confirm your date of birth and first line of
address?"
o For telephone calls, check two pieces of information (e.g., date of birth and
first line of address, or hospital number if available)
o Don't check two numbers, use one number and another piece of
information
o If there's a hospital number or NHS number, you can ask for that

Important notes:

• Always introduce yourself, even if you met the patient yesterday

• Always do the formalities, especially over the phone
• Don't assume you don't need to introduce yourself because you met the patient
yesterday

4. Taking History

Even though you took the sample yesterday, you still need to take a history:

1. Ask about the surgery:

o "I understand we have taken the sample yesterday because you're going for
surgery. Can I ask you, please, what sort of surgery are you going to have?"
o "When is the surgery scheduled?"

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o"How long have you been waiting for this surgery?"

o "What was the reason for you to have this surgery?"
o "Have you been experiencing symptoms? For how long?"
o "How have these symptoms been impacting your life?"
o "How important is it for you to have this surgery?"
2. Ask about medical conditions that could cause complications during surgery:
o "Apart from that, do you have any medical problems?"
o "Do you have any long-term medical problems, like high blood pressure or
high blood sugar?"
o "Have you had any previous surgeries?"
o "Have you had any problems with wound healing in the past?"
o "Do you have any blood-related conditions or bleeding conditions?"
o "Have you had any bleeding incidents in the past?"
o "Any liver problems?"
o "Does anyone in your family have any blood-related conditions or bleeding
conditions?"
o "When was your last blood test? Was everything okay?"
o "Apart from this, have you had any blood tests in the last six months or one
year? Was everything okay?"

Remember:

• Focus on two main things: the surgery and medical/blood-related conditions that
can cause complications
• Ask about major organs like kidney and liver
• Don't feel like you know everything just because you took the sample yesterday
• You need to clearly know what you need to ask

5. Explaining the Error

1. Give a warning:
o "Unfortunately, there is some important information about your blood test
that I've been asked to talk to you about."
o "There's something that went wrong with your blood test."
2. Narrate the events:
o "As we understand, you came for a blood test yesterday."
o "I took the blood sample yesterday, and we sent it to the laboratory."
o "We have been waiting for the results."
o "Unfortunately, today I received a call from the laboratory."
3. Explain the error:
o "I'm really sorry to tell you, unfortunately, I forgot to label the sample."

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o "When a sample isn't labelled, the laboratory has to discard it."

o "They do this to prevent any mistakes happening in the future or mixing up
with other patients' information."
o "I'm really sorry to tell you, they had to discard your sample."

Remember:

• There are three pieces of bad news: you forgot to label, they discarded the sample,
and you need to ask for another sample
• All of these are equally important and severe
• Use "unfortunately" for each piece of bad news

6. Explaining the Need for Another Sample

1. Explain why blood tests are done before surgery:

o "Let me explain why we usually do a blood test before having surgery."
o "The reason we do a blood test is to check whether someone has any
possibilities of developing complications during the surgery or after the
surgery."
o "We need to check if there are any bleeding tendencies."
o "We check if there are any chances of developing infections."
o "We need to check if all the major organs are working, like kidney and liver."
o "This is all important for proper wound healing."
o "We do this to ensure you're fit for the surgery and to identify any tendencies
to develop complications."
2. Ask for another sample:
o "I'm really sorry about the inconvenience. I'm sure this can cause you some
sort of inconvenience, and we are really sorry about it."
o "We are just wondering if you can come and give us another sample, please."

7. Handling Patient Refusal

If the patient refuses, ask why:

• "Can I please ask you why?"

Possible patient responses:

• "I need to go to work, I don't have time."

• "I have already taken six weeks off."
• "I can't take time off."

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How to acknowledge and negotiate:

• "It is understandable. Sometimes it can be difficult."

• "What about coming out of hours, like after your work or before going to work?"
• "Do you think you can come to the department? I can ask somebody to collect the
sample."
• "Is it possible to give a blood sample at your GP practice? We can speak to your GP
and ask for the sample on behalf of us."
• "Is that okay?"

Explain the importance:

• "The only reason we are concerned is that if we don't have the blood sample,
unfortunately, this can delay your surgery."
• "We need to get the blood sample at the right time."
• "If we find anything in your blood test that needs to be corrected, for example, if
your blood levels are low, that needs to be corrected before the surgery, and that
needs some time."

If the patient needs time to think:

• "You can think about it."

• "Would you like to call us back, or would you prefer us to call you back?"
• "Can we call you back?"

8. Things to Remember

• Always take care to explain things thoroughly and naturally.

• Be empathetic and understanding of the patient's concerns.
• Follow the telephone approach structure.
• Take a full history even if you saw the patient yesterday.
• Explain the error clearly and apologize sincerely.
• Be prepared to negotiate if the patient is reluctant to give another sample.
• Don't say "I'm going to do this" or "I will do this". Instead, focus on what needs to
be done.
• This error is not considered a significant incident, so you don't need to mention
registering it or filling out forms.
• Don't offer to go to the patient's home to collect the sample.
• Avoid saying "I'm going to fill up a form" or similar phrases.
• Remember, it's not about what you're going to do, but what needs to be done.
• Someone in the department will handle registering significant incidents, not you.

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9. Sample Dialogue

Doctor: "Hello, is this Edward Jones?"

Patient: "Yes, speaking."

Doctor: "Hello Mr. Jones, I'm Dr. Levin, one of the doctors who took your blood sample
yesterday. The reason I'm calling you today is to discuss something about the samples we
took. Can I talk to you at the moment?"

Patient: "Yes, I suppose so."

Doctor: "Great. Before we continue, I just want to make sure I'm speaking to the right
person. Could you please confirm your date of birth and the first line of your address?"

Patient: (Confirms details)

Doctor: "Thank you. I understand we have taken the sample yesterday because you're going
for surgery. Can I ask you, please, what sort of surgery are you going to have?"

Patient: "It's a knee replacement."

Doctor: "I see. And when is the surgery scheduled?"

Patient: "It's supposed to be in three weeks."

Doctor: "How long have you been waiting for this surgery?"

Patient: "About six months now."

Doctor: "I understand. What was the main reason for you to have this surgery? Have you
been experiencing symptoms?"

Patient: "My knee has been giving me a lot of pain. It's been getting worse for about two
years now."

Doctor: "I'm sorry to hear that. How has this been impacting your daily life?"

Patient: "It's been really difficult. I can't walk for long, and it's affecting my work."

Doctor: "I see. It sounds like this surgery is quite important for you. Now, apart from your
knee problem, do you have any other long-term medical problems, like high blood pressure
or diabetes?"

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Patient: "No, nothing like that."

Doctor: "Have you had any previous surgeries?"

Patient: "No, this will be my first."

Doctor: "Okay. Do you have any blood-related conditions or bleeding problems? Or anyone
in your family?"

Patient: "No, not that I'm aware of."

Doctor: "Have you had any liver problems?"

Patient: "No, never."

Doctor: "When was your last blood test? Was everything okay?"

Patient: "I had one about a year ago for a routine check-up. Everything was fine."

Doctor: "That's good to hear. Now, unfortunately, there's some important information
about your blood test that I need to discuss with you. As we understand, I took your blood
sample yesterday and we sent it to the laboratory. We've been waiting for the results, but
unfortunately, today I received a call from the lab. I'm really sorry to tell you, but there was
a mistake and I forgot to label the sample. When a sample isn't labelled, the lab has to
discard it to prevent any mix-ups with other patients' samples. So, I'm afraid they had to
discard your sample."

Patient: "What? So what does this mean?"

Doctor: "I completely understand your frustration. Let me explain why we do these blood
tests before surgery. We need to check if there are any possibilities of developing
complications during or after the surgery. We check for things like bleeding tendencies,
infection risks, and how well your major organs like kidneys and liver are functioning. All
of this is important for proper healing after surgery.

Given this situation, we're wondering if you would be able to come in and give us another
sample. I'm really sorry about this inconvenience."

Patient: "I can't believe this. I've already taken time off work for all these appointments."

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Doctor: "I completely understand your frustration, and we're truly sorry for this mistake
and the inconvenience it's causing you. Can I please ask you why it's difficult for you to
come in?"

Patient: "I've already taken so much time off work. I can't keep asking for more time off."

Doctor: "I see. That's completely understandable. What about coming out of hours, like
after your work or before going to work? Or do you think you can come to the department,
and I can ask somebody to collect the sample? Alternatively, is it possible to give a blood
sample at your GP practice? We can speak to your GP and ask for the sample on behalf of
us. The main concern is that without this blood test, there's a risk your surgery could be
delayed. We need to get the sample in time to address any issues we might find before your
surgery date. If we find anything that needs to be corrected, for example, if your blood
levels are low, that needs to be addressed before the surgery, and that takes some time."

Patient: "I don't know. I need to think about it."

Doctor: "Of course, I understand you need time to consider this. You can think about it.
Would you like to call us back, or would you prefer us to call you back later?"

Patient: "I'll call you back."

Doctor: "That's fine. Thank you for your understanding, Mr. Jones. We're here to help, so
please don't hesitate to call if you have any questions or concerns. Once again, I'm very
sorry about this inconvenience."

Wrong Chest X-ray scenario

1. Scenario Overview

• This is a typical medical error scenario that you need to master

• You are an F2 doctor in the outpatient department
• Patient has come for follow-up
• Six weeks ago, the patient was admitted with a cough
• Patient had a chest x-ray done
• Patient was treated with antibiotics for pneumonia based on chest x-ray findings
• Patient was discharged after two days
• Later, the department received the radiology report showing the x-ray as normal
• It was discovered that the patient was treated based on someone else's x-ray
• Your task: Talk to the patient, explain the error, and address their concerns

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2. Patient Background

• Patient came with chest symptoms six weeks ago

• Was admitted and went home
• After discharge, patient was fine
• Patient might mention developing diarrhoea after taking antibiotics

3. Consultation Structure

3.1 Paraphrasing

• Always start with medical paraphrasing

• "I understand you've come for follow-up now."
• "I also understand that you were admitted about six weeks ago."

3.2 Taking History

Choose to start with either the current situation or the previous visit. In this scenario, we'll
start with the current situation.

1. Current Situation:
o "How are you doing at the moment?"
o "Are you still having any symptoms?"
o "Do you still have any cough?"
o "Do you have any chest pain?"
o "Any shortness of breath?"
o "Any wheezing?"
o "Any feeling of dizziness?"
o "Any tiredness?"
2. Previous Visit:
o "When you were admitted six weeks ago, what sort of symptoms did you
have?" (Open-ended)
o Ask closed-ended questions about specific respiratory symptoms:
§ Cough
§ Shortness of breath
§ Wheezing
§ Phlegm
o "What sort of tests did they do?"
o "Did they do a blood test on your admission?"
o "Did they do an x-ray?"
o "What did they tell you about the x-ray?" (Must ask this)
o "Did they tell you anything about the x-ray?"

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o"What did they tell you about the blood test?"

o "What did they tell you was wrong?" (Diagnosis)
o "What sort of treatment did they offer?"
o "Was it helpful?"
o "How many days were you admitted?"
o "Was the treatment working?"
o "Did you have any problems with the treatment?"
3. Additional Information (if time allows):
o Medical conditions (MMA or MAM: Medical condition, Medication,
Allergy)
o Medications
o Allergies

Note: Don't ask irrelevant questions about lifestyle, smoking, exercise, or diet. We are not
going to diagnose anything or talk about his health status. Focus on the relevant medical
history.

3.3 Explaining the Error

1. Give a warning:
o "The reason we have called you today is that there is an important
information I've been asked to talk to you about."
o "I've been asked to discuss important information about your previous
treatment because unfortunately, something went wrong with your
treatment."
2. Narrate the events:
o Start with "As we understand..."
o Formulate the narrative using four things: symptom, investigation, diagnosis,
and treatment
o "As we understand, you came to the hospital with some chest symptoms."
o "You had some fever and cough."
o "They did some tests, including an x-ray."
o "Based on your x-ray, you were diagnosed with pneumonia, which is a chest
infection."
o "You were given treatment and then discharged."
o "But later, we received your x-ray report as normal."
o "Because of that, we thoroughly checked and looked into it."
o "We were trying to look for the reason because your x-ray report was reported
as normal."

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3. Deliver the news:

o "Unfortunately, I'm sorry to tell you that you were diagnosed or given
treatment based on someone else's x-ray."
o "When you were admitted or when you were diagnosed, you didn't have
pneumonia."
o "Your x-ray report was reported as normal."

3.4 Managing Patient's Reaction

• Patient will become angry at this point

• Use the A-protocol (Acknowledge, Validate, Empathy)
• "I can see that you are quite upset."
• "It is understandable. Anyone in your situation would feel the same."
• "It's clearly a mistake on our part."
• "We should have been more careful. We should have taken extra care."
• "It is our mistake."
• "Please accept our sincere apologies."

3.5 Explaining Next Steps

1. Talk about the hospital protocol:

o "We will take this incident as a serious issue."
o "This will be reported as something significant."
o "A senior member will start investigating."
o "At the end of the investigation, we are going to take necessary action."
o "We'll be open and transparent about it."
o "At the meantime, a senior member from the department will also come and
speak to you."
2. Offer option to complain:
o "Mr. Johnson, you have a full right to make a formal complaint if you wish
to."
o "I can give you information about the Patient Advisory and Liaison Service."
o Note: You're not asking the patient if they want to complain or telling them
to complain. You're simply letting them know they have the option to
complain.
3. Explain current situation:
o "At the meantime, we don't need to do any treatment for you as you have
completed the treatment."

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4. Addressing Common Questions

1. "Will I develop any long-term complications?"

o "It is highly unlikely for you to develop long-term complications."
o "Just one shot of antibiotics or one dose of antibiotics will not cause any
long-term complications."
o "We only need to worry if you are taking repeated antibiotics or if you don't
complete the dose, which can lead to antibiotic resistance."
o If time allows, you can explain antibiotic resistance.
2. "What happened to the other person?"
o "At the moment, I'm not aware exactly how the other person was treated."
o "Whenever doctors find out that someone's treatment is missed, we
immediately call them and offer treatment."
o "Someone must have checked with the other patient, but at the moment I
don't have any information."
o "We will find out."
3. "How can you prevent this from happening in the future?"
o "The first thing we'll do is find the root cause. We're going to investigate why
this has been happening."
o "When we fix the root cause, this sort of incident is usually prevented."
o "Second, we'll be creating awareness. Whenever mistakes like this happen, we
inform everybody and discuss these cases in our training sessions, morning
meetings, and before ward rounds."
o "This continuous communication and talking makes doctors more vigilant
and careful in their day-to-day practice."
o "It will make them double-check and get a second opinion if they're not sure
about something."
o "We will take this as a serious issue, try to communicate, discuss with
everyone, inform all the staff."
o "We advise them not to hesitate to ask for a second opinion or double-check
things."

5. Things to Remember

• This scenario is considered an old scenario but keeps coming up

• It's a typical medical error that you need to master
• Always take care to explain things thoroughly and naturally
• Be empathetic and understanding of the patient's concerns
• Follow the structure: paraphrase, take history, explain the error, manage reaction,
explain next steps
• Focus on relevant medical history and avoid asking irrelevant lifestyle questions

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• Be prepared for the patient to become angry and use the A-protocol to manage this
• Always offer the option to complain, but don't ask if they want to complain or tell
them to complain
• When explaining prevention measures, focus on finding the root cause and creating
awareness, not on specific training like "x-ray courses"
• Don't say "I'm going to do this" or "I will do this". Instead, focus on what needs to
be done
• Someone in the department will handle registering significant incidents, not you
• Avoid saying "I'm going to fill up a form" or similar phrases
• Remember, it's not about what you're going to do, but what needs to be done

6. Sample Dialogue

Doctor: "Hello, Mr. Johnson. I understand you've come for a follow-up today. I also
understand that you were admitted about six weeks ago with some chest symptoms. How
are you doing at the moment?"

Patient: "I'm feeling much better now, thank you."

Doctor: "That's good to hear. Are you still having any symptoms? Any cough, chest pain, or
shortness of breath?"

Patient: "No, not really. Everything seems to have cleared up."

Doctor: "I'm glad to hear that. Now, thinking back to when you were admitted six weeks
ago, what sort of symptoms did you have then?"

Patient: "I had a bad cough and fever. I was feeling really unwell."

Doctor: "I see. And did they do any tests when you were admitted? An x-ray perhaps?"

Patient: "Yes, they did an x-ray and some blood tests."

Doctor: "What did they tell you about the x-ray results?"

Patient: "They said it showed I had pneumonia."

Doctor: "I see. And what treatment did they give you?"

Patient: "They gave me some antibiotics. I was in the hospital for two days."

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Doctor: "Thank you for that information. Now, the reason we've called you today is that
there's some important information about your previous treatment that I need to discuss
with you. Unfortunately, something went wrong with your treatment that I need to
explain."

Patient: "What do you mean? What went wrong?"

Doctor: "As we understand, you came to the hospital with chest symptoms, fever, and
cough. They did some tests, including an x-ray, and based on that x-ray, you were diagnosed
with pneumonia and given antibiotics. However, later, we received your x-ray report, and it
was reported as normal. Because of this discrepancy, we thoroughly looked into the
situation. Unfortunately, I'm very sorry to tell you, we found out that your diagnosis was
made based on someone else's x-ray. When you were admitted, you didn't actually have
pneumonia. Your x-ray was normal."

Patient: (Angry) "What? How could this happen? How can you make such a serious
mistake?"

Doctor: "I can see that you're quite upset, and it's completely understandable. Anyone in
your situation would feel the same way. It's clearly a mistake on our part, and we should
have been more careful. We should have taken extra care. It is our mistake. Please accept
our sincere apologies."

Doctor: "We're taking this incident very seriously. It will be reported as a significant event,
and a senior member will start an investigation. At the end of the investigation, we will
take necessary action. We'll be open and transparent about the whole process. A senior
member from the department will also come to speak with you about this."

Doctor: "Mr. Johnson, you have a full right to make a formal complaint if you wish to. I
can give you information about the Patient Advisory and Liaison Service if you'd like to
pursue this. At the meantime, we don't need to do any treatment for you as you have
completed the treatment."

Patient: "Will I develop any long-term complications from taking antibiotics I didn't need?"

Doctor: "It's highly unlikely for you to develop any long-term complications. Just one
course of antibiotics typically doesn't cause long-term issues. We only worry about
complications if someone is taking repeated courses of antibiotics or not completing their
prescribed course, which can lead to antibiotic resistance."

Patient: "What about the other person whose x-ray was mixed up with mine? What
happened to them?"

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Doctor: "At the moment, I'm not aware of exactly how the other person was treated.
However, I can assure you that whenever doctors find out that someone's treatment has
been missed, we immediately call them and offer treatment. Someone must have checked
on the other patient, but I don't have specific information about their case. We will find
out about this."

Patient: "How are you going to prevent this from happening again?"

Doctor: "We're approaching this in two main ways. First, we're going to find the root cause
of why this happened through our investigation. When we identify and fix the root cause,
it usually prevents this sort of incident from recurring. Second, we're creating awareness.
We'll inform all staff and discuss this case in our training sessions, morning meetings, and
before ward rounds. This continuous communication makes doctors more vigilant and
encourages them to double-check and seek second opinions when they're unsure. We'll
advise them not to hesitate to ask for a second opinion or double-check things. These steps
should significantly reduce the chance of similar errors in the future."

Missed Myocardial Infarction (MI) Scenario

1. Scenario Overview

• This is an important scenario that you need to master

• You are in the coronary care unit
• Patient was admitted two weeks ago
• Three days prior to this admission, the patient came to A&E
• In A&E:
o An ECG was done but reported as normal
o A troponin blood test was done but not checked
o Patient was sent home
• Later, a cardiologist in your department checked the initial ECG
• The ECG had a T wave inversion
• The troponin test from that day was positive
• Your task: Explain the medical error and assess for any complications

2. Patient Background

• Patient is currently receiving treatment in cardiology for two weeks

• Patient had a heart attack but doesn't know it happened on the first visit to A&E
• Patient thinks the heart attack occurred on the second visit
• Sometimes patients may act differently:
o They might act like they don't know anything about what happened

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o They might say they just had chest pain and didn't know they had a heart
attack
• Originally, the patient knew they had a heart attack, but they don't know it
happened on the first visit

3. Consultation Structure

3.1 Paraphrasing

• "I understand that you have been admitted."

3.2 Taking History

Important note: This is not a typical history taking. It should be superficial and last only
about 3-3.5 minutes. The real focus is on explaining the error.

1. Ask about patient's understanding:

o "What have you been told so far?"
o "What is your understanding about what has been going on?"
o "What is your understanding in terms of what sort of medical condition
you're having?"
o "What have you been told about your admission?"
2. Current Situation (including complications):
o "How are you doing at the moment?"
o "How are you feeling?"
o "Do you have any chest pain at the moment?"
o Ask about complications of heart attack:
§ Irregular heartbeats (arrhythmia)
§ Heart failure
§ Feeling dizzy
§ Shortness of breath
§ Swellings of the body
§ Breathing problems
§ Restlessness
§ Any fever
§ Palpitations (racing of the heart)
o "Do you have any symptoms at all at the moment?"
o "Are you feeling much better?"
3. Previous Visit to A&E:
o "I would like to know about your first visit to the A&E. I understand you
came to the emergency department about two weeks ago, prior to this
admission."

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o"What was the reason you visited the very first time?"
o If chest pain is mentioned:
§ "What sort of chest pain was it?"
§ "Was it going to the arm?" (This is important to ask because if the
pain was going to the arm, it's typical of a heart attack, so why would
they say it was musculoskeletal pain?)
o "What other symptoms did you have on that day?"
§ Ask about shortness of breath, sweating, feeling unwell, raising of the
heart, feeling dizzy
o "What sort of tests did they do on your visit?"
o "Did they do an ECG?"
o "Did they do a blood test?"
o "Any other test?"
o "What did they tell you about those tests?"
o "What did they tell you was wrong?" (Diagnosis)
o "How were you treated?"
o "How did you improve?"
o "Did you improve very well?"
o "What was the reason for you to come back to the hospital?"
4. Additional Information (if time allows):
o "Do you have any other medical problems?"

Note: Don't ask irrelevant questions about lifestyle, smoking, exercise, or diet. We are not
going to diagnose anything or talk about his health status. Focus on the relevant medical
history.

3.3 Explaining the Error

1. Give a warning:
o "Unfortunately, there is something that went wrong with the way we treated
you."
o "Unfortunately, I'm sorry to tell you that there is something that went wrong
with your treatment."
2. Narrate the events:
o Start with "As we understand..."
o "Three days prior to this hospital admission, you came to the A&E because
you had some chest pain and they did some tests for you."
o "They did an ECG, they also did a blood test."
o "They told you the ECG was normal, everything was normal, everything was
fine."

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o "They told you this was musculoskeletal pain and you were given treatment,
right?"
o "Now, the cardiologist, the heart specialist in the department, reviewed all
the tests that were done for you on your very first visit."
3. Deliver the news:
o "Unfortunately, I'm sorry to tell you, those tests revealed that on your very
first visit, you already had a heart attack."
o Pause after delivering this news
4. Explain how it was missed (if patient asks "How come?" or "How did they miss it?"):
o "They did an ECG. The ECG had some changes that are in line with a heart
attack, but they did not pick it up."
o "They could not pick this up."
o "They also did a blood test, but they didn't check the blood test before they
discharged you."
o "The blood test had some markers indicating a heart attack."

Note: Don't go into too much detail. Don't mention "T wave inversion" specifically.

3.4 Managing Patient's Reaction

• "Please accept our sincere apology."

• "We should have been very careful."
• "All these tests must have been checked properly."
• "It's clearly a mistake on our part."
• "We should have been more careful."
• "We will take this as a serious issue."

3.5 Explaining Next Steps

1. Talk about the hospital protocol:

o This is like a poem. These five things must come: (Note: The transcript
doesn't specify these five things, but based on previous scenarios, they likely
include: reporting the incident, investigating, taking action, being
transparent, and having a senior member speak to the patient)
2. Explain current situation:
o "At the meantime, we also need to run some tests in order to check whether
you're developing any complications."

4. Addressing Common Questions

1. "How did they miss it?"

o Explain as detailed in section 3.3 point 4.

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2. "Could this have been prevented?"

o "Unfortunately, this may not have been prevented."
o "When you visited the very first time, you had already developed a heart
attack."
o "You came to the hospital after the heart attack."
o "That's why the troponin was positive."
o "The test results revealed that you already had a heart attack."
o "Our mistake was that we couldn't figure it out or pick it up at the right
time."
o "The heart attack itself could not have been prevented because you already
had it when you came in."

5. Things to Remember

• This scenario is considered an important one to master

• The patient doesn't know they had a heart attack on their first visit
• Focus on explaining the error clearly
• Be empathetic and understanding of the patient's concerns
• Follow the structure: paraphrase, take history, explain the error, manage reaction,
explain next steps
• Keep the history taking brief (3-3.5 minutes) and relevant
• The real stuff is after the history
• Be prepared to explain how the error occurred and why it couldn't have been
prevented
• Don't go into too much medical detail (e.g., don't mention "T wave inversion")
• Remember to assess for complications as part of the scenario
• Don't think about whether it's a medical error when the patient asks if it could have
been prevented. It is called an error because it could have been prevented.
• The heart attack itself couldn't have been prevented, but recognizing it could have
been

6. Sample Dialogue

Doctor: "Hello, Mr. Johnson. I understand that you have been admitted here for about two
weeks now. Before we discuss further, could you tell me what you've been told so far about
your condition?"

Patient: "Well, they told me I had a heart attack when I came in two weeks ago."

Doctor: "I see. And how are you feeling now? Do you have any chest pain, shortness of
breath, or feeling of irregular heartbeats?"

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Patient: "I'm feeling much better now. No chest pain anymore."

Doctor: "That's good to hear. Are you experiencing any swelling in your body or any
breathing problems?"

Patient: "No, nothing like that."

Doctor: "Alright. Now, I'd like to ask about your first visit to the A&E, which I understand
was about three days before you were admitted here. What was the reason for that visit?"

Patient: "I had some chest pain then too, but they told me it was just muscle pain."

Doctor: "I see. Can you describe what sort of chest pain it was? Was it going to your arm?"

Patient: "It was a sharp pain in my chest, but I don't remember it going to my arm."

Doctor: "Did you have any other symptoms that day? Like shortness of breath, sweating, or
feeling unwell?"

Patient: "I was sweating a bit, but I thought it was because I was worried."

Doctor: "I understand. And what tests did they do during that visit?"

Patient: "They did an ECG and took some blood."

Doctor: "And what did they tell you about those tests?"

Patient: "They said everything was normal and sent me home."

Doctor: "How did you feel after that? Did you improve?"

Patient: "I felt a bit better, but the pain came back worse a few days later, so I came back to
the hospital."

Doctor: "Thank you for that information. Now, I'm afraid I have some important
information to discuss with you about your treatment. Unfortunately, there's something
that went wrong with the way we treated you on that first visit."

Patient: "What do you mean? What went wrong?"

Doctor: "As we understand, when you came to A&E with chest pain, they did an ECG and
a blood test. They told you everything was normal and diagnosed you with musculoskeletal
pain. However, the cardiologist in our department has now reviewed those initial tests. I'm

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very sorry to tell you, but those tests actually showed that you had already had a heart
attack during that first visit."

Patient: "What? How could they miss that?"

Doctor: "I understand your concern. The ECG actually had some changes that are in line
with a heart attack, but unfortunately, these changes weren't picked up at the time. Also,
the blood test showed markers of a heart attack, but it wasn't checked before you were
discharged. We should have been much more careful, and all these tests should have been
checked properly. It's clearly a mistake on our part, and we sincerely apologize for this
error."

Patient: "Could this have been prevented?"

Doctor: "Unfortunately, the heart attack itself may not have been prevented because you
had already had it when you first came to the hospital. Our mistake was that we didn't
recognize it at the right time. The test results revealed that you already had a heart attack
when you came in. We're taking this very seriously and will be conducting a full
investigation to understand how this happened and to prevent similar errors in the future."

Doctor: "Moving forward, we need to run some additional tests to check if you're
developing any complications from the heart attack. A senior member of our team will also
come to speak with you about this incident. You also have the right to make a formal
complaint if you wish, and I can provide you with information on how to do that."

Patient: "I see. What happens now?"

Doctor: "We'll continue with your current treatment plan, but we'll also be monitoring you
closely for any potential complications. If you experience any new symptoms like chest
pain, shortness of breath, or irregular heartbeats, please let us know immediately. Do you
have any other questions for me at this time?"

Missed Foreign Body Scenario

1. Scenario Overview

• You are an F2 doctor in the emergency department

• A four-year-old girl was brought in by her mother three hours ago following
ingestion of a foreign body
• Two possible versions of the scenario:
1. Button battery in the oesophagus
2. Lego toy in the left lung

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• You did an X-ray which was reported as normal

• Later, a radiologist reviewed the X-ray and found the foreign body
• Your task: Call the mother, explain the error, and ensure the child is brought back
to the hospital
• This is a telephone consultation scenario

Note: Button batteries can be dangerous in the oesophagus. Lego toys are made of a
specific plastic that shows up on X-rays due to legal requirements.

2. Telephone Approach Structure

1. Ask for the patient's mother: "Hello, am I speaking to Emily Jones?"

2. Introduce yourself: "I'm Dr. Levin, one of the doctors. I'm the same doctor who saw
your child earlier today."
3. State the purpose of the call: "The reason I'm calling you today is because I've been
asked to discuss something regarding your child's previous visit."
4. Check if it's okay to talk: "Do you have a minute? Can I talk to you for a while?"
(Note: In emergency situations, we don't ask if it's a good time to talk, we just ask if
we can talk for a while)
5. Verify patient identity: "Before I continue, I just wanted to check some details to
make sure I have the right information with me. Can you confirm your child's full
name and date of birth?" (Only ask for two pieces of information)

3. Taking History

Note: Even though you saw the child earlier, you still need to take a history. Don't assume
you know everything because you saw the child three hours ago.

1. Current Situation:
o "At the moment, how is your child doing?"
o Ask about respiratory symptoms and GIT (Gastrointestinal) symptoms based
on the location of the foreign body:
§ If in oesophagus (button battery), focus on GIT symptoms:
§ Any tummy pain?
§ Nausea or vomiting?
§ Diarrhoea?
§ Any chest pain?
§ Difficulty in swallowing (dysphagia)?
§ Gagging?
§ Drooling?
§ If in lungs (Lego toy), focus on respiratory symptoms:
§ Any problem with breathing?

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§ Wheezing?
§ Stridor (do you hear any noises)?
§ Coughing?
§ Choking?
§ Any bluish discoloration of the mouth or hands (cyanosis)?
o "Is the child active and playful at the moment?"
o "Is the child eating and drinking normally?"
o "Is the child just in front of you? Are you seeing the child at the moment?"
2. Previous Visit:
o "Can you tell me exactly what happened? What was the reason you brought
the child to the hospital?"
o "Did you witness the child swallowing something?"
o "How long ago exactly did this happen?"
o "When you were able to bring the child, did the child immediately develop
any symptoms like vomiting, tummy pain, or choking?"
o "Apart from me, did anyone else assess the child in the hospital? Any other
nurses or doctors? Any senior doctors?"
o "Was the child given any other treatment or tests?"
o "Apart from what you've told me, is there anything else you would like to tell
me about the visit?"

Remember: Don't close the chapter because you saw the child three hours ago. Don't
assume anything. Assuming is ignorance, and ignorance will negatively impact the
consultation.

4. Explaining the Error

1. Give a warning:
o "Unfortunately, there is something that went wrong with your child's
treatment."
2. Narrate the events:
o Start with "As we understand..."
o "You brought your child to the hospital because you witnessed or thought
the child swallowed something."
o "The child was assessed by me, and we did an X-ray."
o "You were told that everything was normal. Is that right?"
o "The same X-ray was reviewed by the radiologist. This is a normal procedure
where radiologists review all X-rays taken in the department as a backup plan
to ensure we're not missing anything."

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3. Deliver the news:

o "Unfortunately, I'm sorry to tell you, the radiologist found an object that
looks like a [Lego toy in the lungs / button battery in the food pipe]."
o "This is a medical emergency and needs to be taken out immediately."

5. Explaining Next Steps and Negotiating

1. If it's a button battery in the oesophagus:

o Ask the mother to bring the child to the hospital
2. If it's a Lego toy in the lungs:
o Tell the mother you're going to send an ambulance
o "Can you bring your child to the hospital in the ambulance?"
3. If the mother says she can't come:
o She might ask: "Is it urgent, doctor?"
o Response: "Unfortunately, this is quite serious. It is potentially dangerous
because this needs to be removed."
o "The child needs to be provided treatment as soon as possible."
4. If she still can't come:
o Ask why: "Can I please ask you why?"
o She might say: "I need to go to work. I cannot take off."
o Ask: "Is there anybody else who can bring the child to the hospital?"
5. Explain the consequences of delaying treatment:
o "This treatment should not be delayed. If there's a delay in your child's
treatment, it can cause more complications."
o If in the food pipe (button battery): "The child can cough and it can go into
the lungs. It can cause breathing problems. It can also perforate (pass
through) the tissue, causing more complications."
o If in the lungs (Lego toy): "At the moment, it's not causing any breathing
problems, but it can dislodge or move. It can cause breathing issues."
o "So it is not safe. If there's any delay in your child's treatment, this can put
your child's life in danger."

Important: Don't immediately give solutions. First, explain why immediate treatment is
necessary, then offer solutions.

6. Explain the treatment process:

o "When you bring your child to the hospital, we'll have to take another X-ray."
o "We need to find the location, then we'll use a camera test (either endoscopy
or bronchoscopy) to remove it."

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6. Addressing Hospital Protocol

• "At the same time, the hospital takes these sorts of incidents very seriously."
• "This will be reported as a significant incident."
• "This will be investigated."
• "They will take necessary action."
• "At the meantime, you will also get a chance to speak to one of the senior
members."
• "You can also speak to a Patient Advice and Liaison Service if you wish to make a
formal complaint."

7. Addressing Prevention

If asked "How are you going to prevent this from happening in the future?":

• "First, this will be investigated. After the investigation, they will give
recommendations on what I should do. I will not hesitate to follow those."
• "This has been a very good lesson for me. I've learned from this."
• "Lessons will be learned as part of the investigation."
• "Personally, if I encounter a similar situation in the future, I promise I will not
hesitate to get a second opinion."
• "So the system will do something, and at the same time, on a personal level, I will
do things differently."

8. Things to Remember

• There are two versions of this scenario (button battery in oesophagus or Lego toy in
lung). Be prepared for either.
• Keep the history taking brief (about 3-3.5 minutes) to allow time for the important
discussions.
• Don't assume you know everything because you saw the child earlier.
• Explain the urgency of the situation clearly.
• Be prepared to negotiate if the mother is reluctant to bring the child in.
• Always offer the option to complain, but don't ask if they want to complain or tell
them to complain.
• When explaining prevention measures, focus on both systemic changes and
personal learning.
• Use political-style statements like "lessons will be learned" when appropriate.
• Don't offer to go to the patient's home to collect the sample.
• Remember, it's not about what you're going to do, but what needs to be done.

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9. Sample Dialogue

Doctor: "Hello, am I speaking to Emily Jones?"

Mother: "Yes, speaking."

Doctor: "Hello Mrs. Jones, I'm Dr. Levin, one of the doctors who saw your child earlier
today in the emergency department. The reason I'm calling you is because I've been asked
to discuss something regarding your child's previous visit. Do you have a minute? Can I
talk to you for a while?"

Mother: "Yes, go ahead."

Doctor: "Thank you. Before I continue, could you please confirm your child's full name
and date of birth?"

Mother: (Confirms details)

Doctor: "Thank you. Now, how is your child doing at the moment? Any tummy pain or
difficulty swallowing?"

Mother: "No, she seems fine now."

Doctor: "Is she eating and drinking normally? Active and playful?"

Mother: "Yes, she's playing as usual."

Doctor: "That's good to hear. Now, about your visit earlier today, can you tell me exactly
what happened? What made you bring your child to the hospital?"

Mother: "I saw her put something in her mouth and I was worried she swallowed it."

Doctor: "I see. Did you witness what it was? And how long ago did this happen before you
came to the hospital?"

Mother: "It looked like a small battery. It was about three hours before we came in."

Doctor: "Did your child develop any immediate symptoms like vomiting or choking?"

Mother: "No, she seemed fine."

Doctor: "Apart from me, did any other doctors or nurses see your child?"

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Mother: "No, just you."

Doctor: "Thank you for that information. Now, I'm afraid I have some important news to
discuss with you about your child's treatment. Unfortunately, there's something that went
wrong that I need to explain."

Mother: "What do you mean? What went wrong?"

Doctor: "As we understand, you brought your child to the hospital because you thought
she swallowed something. I assessed her and we did an X-ray. You were told that everything
was normal, is that right?"

Mother: "Yes, that's right."

Doctor: "Well, as a normal procedure, all X-rays are reviewed by a radiologist as a backup to
ensure we're not missing anything. Unfortunately, I'm very sorry to tell you, but the
radiologist found an object that looks like a button battery in your child's food pipe. This is
a medical emergency and needs to be taken out immediately."

Mother: "Oh my god! Is it urgent?"

Doctor: "Yes, unfortunately, this is quite serious. It's potentially dangerous because the
battery needs to be removed as soon as possible. If there's a delay in treatment, it can cause
more complications. The battery can damage the tissue in the food pipe, and if your child
coughs, it could potentially move into the lungs, causing breathing problems. This is why
we need to act quickly. Is it possible for you to bring your child to the hospital right away?"

Mother: "I can't come right now. I have to go to work."

Doctor: "I understand this is difficult, but I must stress that this is very serious. Is there
anyone else who could bring your child to the hospital?"

Mother: "No, there's no one else available."

Doctor: "I understand this is challenging, but I need to emphasize that if we delay
treatment, it could put your child's life in danger. When you bring your child in, we'll need
to take another X-ray to confirm the location, then use a camera test to safely remove the
battery. The hospital is taking this very seriously. It will be reported as a significant incident
and investigated thoroughly. You'll also have a chance to speak with a senior member of
our team. If you wish to make a formal complaint, you can speak to our Patient Advice and
Liaison Service."

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Mother: "Okay, I understand. I'll bring her in right away."

Doctor: "Thank you for understanding. We'll be ready for you when you arrive. If you have
any questions or if your child's condition changes on the way, please let us know
immediately. Once again, I'm very sorry for this error."

Mother: "How will you prevent this from happening again?"

Doctor: "This incident will be thoroughly investigated, and I'll follow all recommendations
that come from that investigation. This has been a very important lesson for me. In the
future, if I encounter a similar situation, I promise I won't hesitate to get a second opinion.
The hospital will ensure that lessons are learned from this to improve our processes. On a
personal level, I will definitely do things differently. Do you have any other questions for
me?"

Missed Hairline Fracture Scenario

1.1 Scenario Overview

• Similar to the missed foreign body scenario

• Key differences:
1. It's a different person who made the error, not you
2. The patient has already been called to come in
• A radiologist reviewed the X-ray and found a hairline fracture that was initially
missed

1.2 Consultation Structure

• Follow the same structure as the missed foreign body scenario

1.3 Specific Question to Address

• Patient may ask: "Will my son develop any long-term complications?"

o Response: "It is highly unlikely for your son to develop any long-term
complications because hairline fractures, they don't cause any complications."
• Explanation: The son was not given any treatment for the last two days, which is
why they might ask this question

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Missed Glass Piece Scenario

2.1 Scenario Overview

• You are an F2 in orthopaedics

• A three-year-old child was brought in yesterday by the father
• Yesterday, an X-ray was done and reported as normal
• Today, a consultant reviewed the X-ray and found a piece of glass in the leg
• This is a telephone consultation
• This is a new scenario

2.2 Patient Background

• The child was playing on the beach

• The child fell down
• There was swelling and pain, so they brought him to the hospital

2.3 Consultation Structure

2.3.1 Telephone Approach

• Follow the standard telephone approach (not detailed in this transcript)

2.3.2 Taking History

1. About Yesterday's Visit:

o "I understand you brought your son yesterday. Can I ask you why?"
o "What was the reason you brought your child?"
o "What symptoms did your child have?"
§ Ask about:
§ Pain
§ Swelling
§ Redness
§ Bleeding
§ Numbness
§ Weakness
§ Ask if the child was unable to walk
o "What sort of tests did they do yesterday?"
o "Did they do an X-ray?"
o Key question: "What did they tell you about the X-ray?" (Important because
yesterday's information differs from today's)
o "What sort of treatment did they offer?"

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Ask about:
§
§ Painkillers
§ Antibiotics
§ Dressing
§ Vaccination (e.g., tetanus)
2. Current Situation:
o "How is the child at the moment?"
o "Is he having any of these symptoms now?"
o "Is it getting better or worse?"
o "Is there any swelling?"
o "Is the child able to walk?"
3. General History:
o Ask about the child's general health history
o Check vaccination status

2.4 Explaining the Error

1. Give a warning:
o "Unfortunately, there has been a mistake."
2. Narrate the events:
o Explain that a consultant reviewed the X-ray today and found a piece of glass
in the leg

2.5 Explaining Next Steps

1. Advise to bring the child back:

o "We will advise you to bring your child back."
o Important note: Don't suggest repeating the X-ray. Unlike foreign bodies in
hollow organs (like oesophagus or lungs), a glass piece in the leg won't move
with time.
2. Explain the treatment:
o "The glass piece needs to be removed."
o "The child might need some dressing."
o "We might give some antibiotics." (Explain: The glass piece is from the beach,
a potentially contaminated area)
o "We might also give some vaccinations after checking the vaccination status."
3. Ask: "Can you bring the child to the hospital?"

2.6 Addressing Hospital Protocol

• Use the "five steps" approach:

o "The hospital takes these sorts of incidents very seriously."

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o This should be like a poem, a cascade of explanation

o (Continue with the other four steps as in previous scenarios)

3. Things to Remember

• The missed hairline fracture scenario is similar to the missed foreign body scenario,
with minor differences.
• In the glass piece scenario, don't suggest repeating the X-ray. People can be robotic
about this, but it's not necessary for a glass piece in the leg.
• Be prepared to explain why antibiotics and vaccinations might be necessary in the
glass piece scenario.
• Always follow the structured approach: take history, explain the error, explain next
steps, address hospital protocol.
• Use the "cascade of explanation" for the five steps of hospital protocol consistently
across scenarios.
• In the glass piece scenario, parents are likely to agree to bring the child in without
much resistance. They will likely say "okay".
• These scenarios become medical errors because yesterday's story (everything is
normal) is different from today's story (there's a problem).
• For the glass piece scenario, imagine all the symptoms a glass piece inside the tissue,
inside the leg, could cause. It's not difficult to imagine.

4. Sample Dialogue (Glass Piece Scenario)

Doctor: "Hello, am I speaking to Mr. Johnson?"

Father: "Yes, speaking."

Doctor: "Hello Mr. Johnson, I'm Dr. Smith from the orthopaedics department. I'm calling
about your son's visit to our hospital yesterday. Do you have a moment to talk?"

Father: "Yes, go ahead."

Doctor: "Thank you. First, could you confirm your son's full name and date of birth for
me?"

Father: (Confirms details)

Doctor: "Thank you. Now, can you tell me why you brought your son to the hospital
yesterday?"

Father: "He fell while playing on the beach and his leg was swollen and painful."

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Doctor: "I see. Did you notice any bleeding, numbness, or weakness in his leg? Was he able
to walk?"

Father: "No bleeding or numbness, but he was limping. He could walk, but with difficulty."

Doctor: "And what tests did they do at the hospital?"

Father: "They did an X-ray."

Doctor: "What did they tell you about the X-ray results?"

Father: "They said it was normal and there was nothing to worry about."

Doctor: "Did they offer any treatment? Any painkillers, antibiotics, or dressing?"

Father: "They gave us some pain medicine and told us to come back if it got worse."

Doctor: "How is your son doing now? Is the swelling or pain getting better or worse?"

Father: "He's a bit better, but still limping a little."

Doctor: "I understand. Mr. Johnson, I'm afraid I have some important news to discuss with
you. Unfortunately, there has been a mistake. A consultant reviewed your son's X-ray today
and they found a piece of glass in your son's leg that was missed yesterday. I'm very sorry
about this error."

Father: "What? How could they miss that?"

Doctor: "I completely understand your concern. This is a serious error and the hospital is
taking it very seriously. We need you to bring your son back to the hospital so we can
remove the glass piece, provide proper dressing, and possibly give some antibiotics. The
glass piece is from the beach, which can be a contaminated area, so we want to prevent any
infection. We'll also check his vaccination status and may give some vaccinations if needed.
Can you bring him in today?"

Father: "Yes, of course. Should we come right away?"

Doctor: "Yes, please come as soon as you can. When you arrive, we'll assess your son and
plan the removal of the glass piece. Just to let you know, we won't need to repeat the X-ray
as the glass piece won't move in the leg tissue.

Also, I want to assure you that the hospital takes these incidents very seriously. This will be
reported as a significant incident and investigated thoroughly. You'll have the opportunity

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to speak with a senior member of our team, and if you wish to make a formal complaint,
we can provide you with information on how to do so.

Do you have any questions for me at this time?"

Father: "No, we'll come right away. Thank you for calling."

Doctor: "You're welcome. We'll be ready for you when you arrive. If you have any concerns
before you get here, please don't hesitate to call. Once again, I apologize for this error."

Missed Fracture in Elderly Patient Scenario

1. Scenario Overview

• Setting: Orthopaedics department

• Patient: 91-year-old lady
• Admitted from nursing home
• Patient fell down and is unable to walk
• Initial X-ray reported as normal by radiology department
• Physiotherapy was offered
• Patient complained of pain during physiotherapy
• CT scan was done, which showed a fracture of the femur
• After CT scan, they checked the initial X-ray again and found the fracture
• Mother has dementia
• Son has lasting power of attorney
• This scenario is likely to come up in exams, especially before Christmas

2. Why This is a Medical Error

• Yesterday's story (X-ray normal) is different from today's story (fracture found)
• They started treating as if everything was fine based on the initial report
• After CT scan, when they looked at the X-ray again, they found the fracture
• If the X-ray was still normal even after CT scan, it wouldn't be a medical error
• The error is in the interpretation, not in the inability to see the fracture on the first
X-ray

3. Consultation Structure

3.1 Preparation

• You'll have a large information sheet to read outside the room

• When you enter the room, the examiner will check your name and GMC number

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• When the examiner says "start," it means your time has started
• You can choose to read more if needed
• Tell the examiner: "I'm going to read the task again" (say it nicely)
• Read carefully and comprehend the task
• Don't start talking to the patient immediately after the examiner says "start"

3.2 Greeting and Handling Angry Patient

• Introduce yourself
• The son will be angry from the beginning because he already knows about the
fracture from nursing home staff
• Be prepared for the son to shout and say things like:
o "Why am I hearing different stories?"
o "Why haven't you told us there's a fracture?"
o "Who is telling us the truth?"
• Let him talk, nod your head
• Acknowledge his feelings: "I can see that you are quite upset/angry. It is
understandable."
• Validate: "Anyone in your situation would feel the same. There is no doubt about it,
Mr. Johnson."
• Apologize: "We are really sorry about it. We should have explained this clearly
earlier."
• Reassure: "I will explain to you everything clearly, exactly what is going on."
• Ask permission to take history: "In order for me to explain everything, I would like
to ask you some questions."

3.3 Taking History

1. Pre-knowledge:
o "Can you please tell me what have you been told so far in terms of your
mother's treatment?"
o "What is your understanding?"
o "What have you been told so far?"
o "How did you come to know about the fracture?"
o "Did you speak to any of the doctors?"
o "How did this information about the fracture reach you?"
o "Did anyone explain to you how we found out about the fracture?"
o "How did we come to know about this fracture?"
o "What did they tell you about the X-ray?"
o "Did you speak to any doctors yesterday?"
o "What have you been told about other tests or treatments for your mother?"

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o "Does she know anything about the physiotherapy that was offered?"
o "Did anyone mention anything about the CT scan?"
2. Social History:
o "I understand you have lasting power of attorney. Are you the next of kin as
well?"
o "Are there any other family members involved in your mother's care?"
o "Apart from dementia, does your mother have any other medical problems?"
o "Is there any other information we should know about your mother?"

Note: Don't spend time on irrelevant information like the mother's diet, exercise, or
detailed medical history. Focus on the relevant information to have time for the important
discussions.

3.4 Explaining the Error

• No need for a warning shot in this scenario

• Start with: "Let me explain to you what happened."
• Narrate events in chronological order:
1. Mother had a fall
2. She was brought to the hospital and admitted
3. X-ray was done (first thing we do after a fall)
4. X-ray was reported as normal
5. Started treating with physiotherapy
6. She couldn't do physiotherapy due to pain
7. We thought there might be something else, so we did a CT scan
• Deliver the news: "Unfortunately, I'm sorry to tell you, the CT scan revealed she
sustained a fracture in her hip." (You can also say "fracture of the neck of the femur"
or "fracture in the long bone of her leg")
• Explain further: "After this, we also checked the initial X-ray taken yesterday.
Unfortunately, that revealed she has sustained a fracture."
• Apologize: "It's clearly a mistake on our part. We should have been more careful.
We should have picked this up earlier. Please accept our sincere apology."

3.5 Addressing Hospital Protocol

• "We will take this as a serious matter."

• "This will be reported as a significant incident."
• "This will be investigated."
• "We'll take necessary action."
• "A senior member from the department will come and speak to you."
• "If you wish to make a formal complaint, you have full rights to do so. I can give you
information about the Patient Advisory Liaison Service."

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3.6 Explaining Treatment Plan

• "We are going to offer treatment for your mother's fracture."

• "The orthopaedics specialist advises putting on a cast."
• "She'll be admitted and treated."

4. Addressing Specific Questions

1. "Who missed this fracture?"

o If the scenario says it was the radiology department, say: "According to our
reports, it is the Department of Radiology who missed it."
o Be transparent, don't try to hide information
o You are a public servant, there's nothing to hide
o It's like when someone asks for your GMC number - you should provide it
2. "How can you prevent this from happening?"
o "This will be investigated."
o "Lessons will be learned."
o "We'll take action according to the investigation findings."
o "We'll communicate and create awareness."
o "We'll inform all doctors working in the department."
o "In day-to-day practice, they will be more careful and vigilant."
o "We'll try to prevent similar things from happening in the future."

5. Things to Remember

• Keep the history-taking focused on relevant information, don't waste time on

unnecessary details
• Always narrate events in chronological order when explaining the error
• Be transparent about who made the error if asked
• Emphasize communication and awareness creation when discussing prevention
• Take-home messages: Always paraphrase, have a proper plan to take a history
• Don't be disoriented at the start - take your time to read and understand the
scenario
• Even if you're very good, if you're disoriented, you might marginally lose the
scenario
• People can be robotic in their responses - avoid this by understanding the context
• This is not like a typical history taking with 6 minutes of history and 2 minutes for
the rest. The real stuff is after the history, which should only take about 3-3.5
minutes.

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6. Sample Dialogue

Doctor: "Hello, I'm Dr. Smith from the orthopaedics department. I understand you're here
about your mother's condition."

Son: (Angrily) "Why am I hearing different stories? Why haven't you told us there's a
fracture? Who's telling the truth here?"

Doctor: (Nodding) "I can see that you're quite upset, Mr. Johnson. It's completely
understandable. Anyone in your situation would feel the same way. There's no doubt about
it. We are really sorry about this. We should have explained things more clearly earlier. I
will explain everything to you in detail. To help me do that, may I ask you a few questions
first?"

Son: "Fine, go ahead."

Doctor: "Thank you. Can you please tell me what you've been told so far about your
mother's treatment?"

Son: "Yesterday they said everything was normal, and today I hear she has a fracture!"

Doctor: "I see. How did you come to know about the fracture? Did you speak to any of our
doctors?"

Son: "The nursing home staff told me. Why didn't you people tell me?"

Doctor: "I understand your frustration. Did anyone explain to you how we found out
about the fracture?"

Son: "No, nobody explained anything!"

Doctor: "I see. I understand you have lasting power of attorney for your mother. Are you
also her next of kin?"

Son: "Yes, I am."

Doctor: "Thank you for that information. Now, let me explain to you what happened.
Your mother was brought in after a fall, and we immediately did an X-ray, which is
standard procedure. Initially, this X-ray was reported as normal, so we started
physiotherapy. However, your mother found the physiotherapy very painful, which made
us suspect there might be something we missed. We then did a CT scan, which revealed a

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fracture in her hip. After this, we reviewed the initial X-ray again and found that the
fracture was actually visible there too, but it was missed on the first reading.

I'm very sorry to tell you that this was clearly a mistake on our part. We should have been
more careful and picked this up earlier. Please accept our sincere apology. We are taking
this very seriously. This incident will be reported as a significant event, investigated
thoroughly, and we'll take necessary action to prevent such errors in the future. A senior
member of our department will come to speak with you about this.

In the meantime, we're going to start treatment for your mother's fracture. The
orthopaedic specialist advises putting on a cast, and she'll be admitted for further care.

I want you to know that you have the full right to make a formal complaint if you wish. I
can give you information about our Patient Advisory Liaison Service if you'd like to pursue
this. Do you have any questions for me at this point?"

Son: "Who exactly missed this fracture?"

Doctor: "According to our reports, it was the Department of Radiology who initially missed
the fracture on the X-ray."

Son: "How are you going to prevent this from happening again?"

Doctor: "This incident will be thoroughly investigated, and we'll learn important lessons
from it. We'll take action based on the investigation's findings. We're also going to
communicate this incident and create awareness among all doctors in the department. This
will help ensure that in day-to-day practice, everyone is more careful and vigilant. Our goal

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Angry Patients
Introduction

There's a crucial distinction between angry patients and medical errors:

• Angry patients: It's the patient's initiative. They've learned something that upset
them and made an appointment to speak with you.
• Medical errors: It's the doctor's plan. You ask the patient to come in because you
want to discuss something with them.

This guide focuses on handling angry patients.

Common Scenarios

1. Infected cyst
2. Angry son
3. Newborn covered with poop
4. Medication change (thyroid medication)
5. Infected hernia
6. GP missed mother's diagnosis
7. Cerebral palsy and DNR (Do Not Resuscitate)
8. Rash in child given antibiotic

In all these scenarios, the patient initiates the meeting. They might provide background
(e.g., admission, treatment details), but the key is that they want to speak to you today.

The ILAR Protocol: Invite, Listen, Acknowledge, Reassure

1. Invite

Start by inviting the patient to speak. Don't paraphrase; use direct invitation:

"I understand you've been admitted with us. You're going home today, and I've been told
that you wanted to speak to one of the doctors. Is there anything in particular you'd like to
discuss?"

This invitation provokes the patient to express their concerns.

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2. Listen

Active listening is crucial and will be evaluated. There are three main reasons for checking
listening skills:

a. If you don't actively listen b. If you ask about information already provided in PLAP 2 c.
If you don't reflect on something the patient discussed

For example, in an ARMD scenario where the patient expresses worry about caring for a
wife with dementia, failing to address this concern would be problematic.

Techniques for active listening:

a. Nod your head b. Use verbal cues: "Okay," "All right," "I understand," "Mm-hmm" c.
Finish the patient's sentences (advanced technique)

Example of active listening:

Patient: "Doctor, I'm not really happy. I got this infection after the surgery. Why didn't
anyone tell me this could happen? Why do I have to suffer like this? Why didn't they
explain? Why didn't they give me antibiotics?"

Doctor: (Nodding) "I see... Mm-hmm... You weren't informed about the possibility of
infection..."

Patient: "Exactly! And now I had to be readmitted and..."

Doctor: "And you had to come back to the hospital."

3. Acknowledge

Once the patient has expressed their concerns, acknowledge their feelings sincerely:

"I can see that you're quite upset about this." "I can see that you've been affected by this."
"It's clear that you're not very happy with the situation." "I understand you're feeling
disappointed about this."

Validate their feelings:

"It's completely understandable why you feel this way." "Anyone in your situation would
feel the same, there's no doubt about that."

Apologize sincerely:

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"We're really sorry about this." "I'm truly sorry you've had to go through this experience."
"We sincerely apologize that you felt this way."

The apology must come from the heart. This acknowledgment is crucial - it's the "cry" in
the protocol.

4. Reassure

After acknowledging, offer reassurance:

"Let me see what we can do for you." "I will explain everything to you clearly." "Let me
clearly explain this situation to you."

Then, ask permission to gather more information:

"In order for me to explain, I'd like to ask you some questions." "Can I ask you some
questions to have a better understanding of the situation?" "To ensure that you and I are
both on the same page, may I ask for more details?"

Taking History

After getting permission, take a detailed history. The specific questions depend on the
scenario. You can use a four-box method if preferred:

1. Invite
2. Listen
3. Explain
4. Provide solution

Explanation and Solution

After taking the history, provide an explanation (box 3) and a solution (box 4). Sometimes
there might only be an explanation or only a solution, depending on the scenario.

Example: For the scenario of a child covered in poop, you might not be able to explain why
it happened, but you can provide a solution.

Important Points to Remember

1. Patients are typically angry for a short period; they can't sustain anger throughout
the entire conversation.

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2. When the patient starts expressing their anger, raise your eyebrows and look directly
into their eyes. This shows you're attentive and taking their concerns seriously.
3. Always approach with the mindset that the patient/customer is right, even if they're
not. Don't try to be overly logical or argumentative.
4. Your emotions and responses should always be empathetic.
5. Speak from the heart when acknowledging and apologizing.

Things to Avoid

1. Interrupting the patient while they're expressing their concerns

2. Dismissing or minimizing their feelings
3. Becoming defensive or argumentative
4. Rushing through the process without giving proper time for each step
5. Failing to provide clear explanations or solutions when possible
6. Neglecting to address all the points raised by the patient
7. Asking in PLAP 2 about information the patient has already provided
8. Failing to reflect on important points the patient has mentioned

Detailed Sample Conversation

Doctor: "Hello, Mrs. Johnson. I understand you've been admitted with us and you're going
home today. I've also been told that you wanted to speak to one of the doctors. Is there
anything in particular you'd like to discuss?"

Patient: (Angrily) "Yes, doctor. I'm not happy at all. I got this infection after my surgery,
and no one told me this could happen. Why didn't anyone warn me? Why do I have to
suffer like this? I had to be readmitted, and it's been so painful!"

Doctor: (Nodding, maintaining eye contact) "I see... Mm-hmm... You weren't informed
about the possibility of infection..."

Patient: "Exactly! And now I've had to come back to the hospital, miss work, and deal with
all this pain. It's unacceptable!"

Doctor: "And you had to come back to the hospital, causing disruption to your life."

Patient: "Yes! It's been terrible!"

Doctor: "Mrs. Johnson, I can see that you're quite upset about this situation. It's completely
understandable, and anyone in your position would feel the same way. We're truly sorry
that you've had this experience and that you're feeling this way. It's clear that this has had a
significant impact on you, both physically and in terms of disrupting your daily life."

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Patient: (Calming slightly) "Well, I'm glad someone finally understands."

Doctor: "I want to make sure I fully understand your situation so I can explain everything
clearly and see what we can do to help. Would it be alright if I asked you a few questions
about what happened?"

Patient: "Yes, go ahead."

Doctor: "Thank you. Can you tell me when you first noticed signs of the infection? What
symptoms did you experience?"

Patient: "It was about three days after I went home. My wound started to look red and felt
hot. Then I developed a fever."

Doctor: "I see. And when you noticed these symptoms, what did you do?"

Patient: "I called the hospital, and they told me to come in immediately."

Doctor: "Thank you for sharing that, Mrs. Johnson. Let me explain what might have
happened. While we take every precaution to prevent infections, sometimes they can occur
despite our best efforts. The symptoms you described - redness, heat, and fever - are indeed
signs of infection. You did the right thing by calling the hospital promptly."

Patient: "But why wasn't I warned this could happen?"

Doctor: "You're right, and I apologize that this wasn't clearly communicated to you. We
should always inform patients about potential complications, including infection. I'll make
sure to address this with our team to improve our communication in the future."

Patient: "So what happens now?"

Doctor: "Now, let's discuss what we can do to address this situation. Based on your
symptoms and our examination, we've started you on antibiotics to fight the infection.
We'll closely monitor your progress to ensure the infection clears up completely. We'll also
provide you with detailed instructions on wound care to prevent any further complications.
Additionally, I'd like to schedule a follow-up appointment in a week to check on your
recovery. Does this sound okay to you?"

Patient: (Noticeably calmer) "Yes, that sounds reasonable. Thank you for explaining
everything."

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Doctor: "You're welcome, Mrs. Johnson. Is there anything else you'd like to discuss or any
other concerns you have?"

Patient: "No, I think that covers everything."

Doctor: "Alright. Please remember, if you have any concerns or notice any changes in your
condition, don't hesitate to contact us immediately. We're here to support you through
your recovery."

Infected Cyst

Scenario Details

• Location: F2, surgical department

• Patient: 42-year-old lady
• Situation: Readmitted due to post-operative wound infection
• History: Had cyst removal three weeks ago, admitted three days ago
• Current status: Treated with IV antibiotics, now fine and going home
• Issue: Patient wants to speak to a doctor before leaving, not happy
• Note: Hospital infection rate is below the national level (specific to this scenario)

Critical Points

1. Patient has already been treated and is fine

2. She's going home today
3. Some disoriented people might readmit this lady or try to give antibiotics again
because they didn't read properly
4. You don't have previous notes in this scenario

Step-by-Step Approach

1. Invite

Start by inviting the patient to speak. Use one of these approaches:

a) Direct invitation: "I understand you wanted to speak to one of the doctors."

b) Paraphrased invitation: "I understand you have been admitted with us for the last three
days because you had some problem with your wound, and you are going home today. I've
also been told that you wanted to speak to one of the doctors. Is there anything in
particular you would like to discuss?"

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The goal is to provoke the patient to start talking.

2. Listen

The patient will likely complain about various aspects. Examples of what they might say:

• "I'm not happy I got this infection."

• "Why did I get this infection?"
• "Why did no one explain this to me?"
• "Why didn't they give me antibiotics?"
• "Why did I have to go through this?"
• "Why did I need to come back?"
• "Not everyone has to come back like this."

Listen carefully without interrupting. Use active listening techniques:

• Nod your head

• Maintain eye contact
• Use verbal cues like "I see," "Mm-hmm," "Okay"

3. Acknowledge

After the patient finishes speaking, acknowledge their feelings:

• "I can see that you are quite upset."

• "It is understandable, Mrs. Johnson."
• "Anyone in your situation would feel the same. There is no doubt about it."
• "I'm really sorry."
• "It's a very unfortunate situation that you had to go through this again."
• "We are really sorry about your experience."
• "We are really sorry to hear about what you are going through."

Important: Show empathy with energy. This demonstrates passion for your job. However,
be careful to express this energy in an "English style" to avoid appearing aggressive.

4. Transition to Questions

Transition to asking questions:

• "Let me ask you some questions."

• "Let me see what we can do for you, Mrs. Johnson."

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5. History Taking

Ask the following questions in detail:

a) Symptoms:

• "What sort of symptoms did you develop?"

• Specific closed-ended questions: "Did you develop any swelling?" "Was there any
redness?" "Did you experience pain?" "Was there any pus or discharge?" "Did you
notice any fluid leaking?" "Did you have any fever?"
• "When did you develop these symptoms?"

b) Reason for hospital visit:

• "What made you come to the hospital this time?"

• "Were you feeling really unwell?"

c) Risk factors for infection:

• Before surgery: "Were you ever told that you had an infection before the surgery?"
• During surgery: "Did you have any complications during the surgery?" "Was there
any bleeding during the procedure?"
• After surgery: "Were you taking care of your wound properly?" "Do you do regular
dressing?" "Do you do the dressing by yourself or do you go somewhere else?" "Were
you given enough training on how to do the dressing?" "Did anyone explain to you
how to do the dressing?" "Were you given any medication?" "Did you keep your
wound open?" (Note: Keeping the wound open is a risk factor) "Was there any
contamination after the surgery, like with water?" "Was there any contamination
with seawater?"

d) Medical history:

• "Do you have any ongoing medical problems, like diabetes?"

• "Do you take any medications, like steroid medication?"
• "Are you on any antibiotics?"
• "Do you take any other medications?"

e) Occupation and lifestyle:

• "What do you do for a living?"

• "Have you started working?"
• "What sort of instructions were you given in terms of your work?"

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• "Do you smoke?" (Note: Smoking is a risk factor)

• "Were you mobile after the surgery?"

f) Patient's perspective:

• "What do you think might be the cause of this infection?"

• "Are you concerned about anything in particular?"
• "Is there anything worrying you?"

g) Expectations:

• "I understand you want to speak to the doctors regarding this. Is there anything in
particular you're hoping that we should do about this?"
• "Is there any particular way that you expect us to help regarding this?"

Note: The last question is a polite, technical way of asking "What do you want?" without
being rude.

6. Explanation

After gathering information, provide an explanation:

• "From the information I've gathered, it's not very clear why you got this infection."
• "You don't seem to have any risk factors for infection."
• "In some small proportion of people, however much we try, they tend to develop
infections without having any risk factors. It's a very unfortunate situation."
• "I don't have your notes at the moment, but I can go and find out whether there's
anything that was missed in your treatment, or if there were any risk factors you had
already. Then I can come back and discuss this with you."
• Regarding antibiotics: "You mentioned antibiotics. Antibiotics are not given
routinely after every surgery. They are only given if someone has a risk of infection.
From the information I've gathered, it doesn't seem that you had any known risk
factors. That's likely the reason you weren't given antibiotics, but I can go and find
out for sure."

7. Offer Solutions

• "Is there anything I can do for you?"

• If the patient is still angry, you can offer to help them make a formal complaint:
"Would you like to make a formal complaint?"

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8. Patient Advocacy and Liaison Service (PALS)

• If the patient says they want to complain or seems very unhappy, offer PALS.
• It's acceptable to offer PALS; don't think of it as detrimental or something to avoid.
• You should offer PALS in two situations:
1. If you hear the word "complain"
2. If the patient is really not happy

9. Closing

• "I'm really sorry, Mrs. Johnson, that this has happened to you. Is there anything else
I can do for you?"

Key Points to Remember

1. Read the scenario carefully to avoid mistakes like readmitting a patient who's ready
for discharge.
2. Show empathy with energy, but be careful to express it appropriately in an "English
style."
3. Take a thorough history, focusing on symptoms, risk factors, and the patient's
perspective.
4. Provide a clear explanation, acknowledging when you don't have all the
information.
5. Offer solutions, including the option to make a formal complaint if the patient is
still unsatisfied.
6. Always maintain a respectful and understanding demeanour throughout the
interaction.
7. Don't be afraid to offer PALS if the patient is very unhappy or wants to complain.
8. Remember that the goal is to address the patient's concerns and ensure they feel
heard and respected.

Infected Hernia
Scenario Details

• Location: A&E (Accident and Emergency)

• Patient: 45-year-old man
• Situation: Patient had hernia repair three weeks ago
• Issue: Patient has some concerns and is angry

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Initial Interaction

1. When you approach the patient and say "Hello," the patient may respond
aggressively:
o "I don't want to speak to you."
o "Where is your senior?"
o "Is there anybody above you?"
o "I don't want to speak to you. I'm not doing anything."
o "I don't like that."
2. How to respond:
o "I'm so sorry."
o "Unfortunately, the senior doctors are not here at the moment."
o Important: Don't say they are busy or doing something else.
o "I've been actually asked to come and assist you."
o "Let me introduce myself. I'm Dr. [Your Name]. I'm one of the doctors."
o "Can I know your name, please?"
o "Can you confirm your age as well?"
o "Thank you. So, what can I do for you? How can I help you?"

Patient's Complaints

The patient may express anger and concerns such as:

• "Look, I had this surgery."

• "After that, I got this infection, not infection."
• "I got this, you know, the pus is coming."
• "It's smelling."
• "No one is coming around me."
• "Why did this happen to me?"

ILAR Protocol (Invite, Listen, Acknowledge, Reassure)

Listen

• Allow the patient to express their concerns without interruption.

Acknowledge

After the patient finishes speaking:

• "I can see that you are quite upset."

• "It is understandable."

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• "Anyone in your situation would feel the same."

• "I'm really sorry you have to go through this."

Reassure

• "I will explain everything to you."

• "Let me see what I can do for you."
• "Let me ask you some questions."

History Taking

Ask the following questions:

1. Symptoms:
o "What sort of symptoms are you experiencing?"
o Ask about infection symptoms (same as in previous scenarios)
o "When did you first start experiencing these symptoms?"
o "When was the first time you noticed these issues?"
2. Systemic Symptoms:
o Ask about fever
o Inquire about fast breathing
o "Are you feeling unwell in general?"
3. Surgery Details:
o "What sort of surgery did you have?"
o "When did you have the surgery?"
o "Was everything okay with the surgery?"
4. Risk Factors for Infection: a. Before the surgery:
o "Did you have any problems before the surgery?"

b. During the surgery:

o "Were there any complications during the surgery?"

c. After the surgery:

oAsk about wound care (same as in previous scenarios)

oInquire about wound dressing
o Ask about any contamination
5. Medical History:
o "Do you have any ongoing medical problems?"
o "Do you have a chronic cough?" (This is a risk factor)
6. Medications:

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o "Are you taking any medications?"

7. Occupation:
o "What do you do for living?"
o "Have you started working?"
o "What information were you given in terms of working?"
o If the patient says they were told to take six weeks off: "May I please ask why
you were not able to follow that?"
o Note: The patient may mention financial constraints as a reason for
returning to work early.
8. Social History:
o "Do you smoke?" (Smoking is a risk factor)

Important: The patient has three risk factors:

1. Started working early (occupation-related)

2. Chronic cough (medical problem)
3. Smoking (social history)

Examination

• Mention that you would like to examine the patient: "I would like to examine you,
if that's okay."
• Note: This is the second scenario where examination is crucial. The first scenario
requiring examination is when a patient asks for antibiotics for viral infection where
the patient had come back again.

Interpreting Examination Results

You will be presented with a picture showing:

• A cut wound over the hernia repair site

• Some signs of infection (not very severe)

Observations to make:

• Look at the wound characteristics

• Note any signs of infection
• Check the patient's vital signs (observations)

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Explanation and Plan

After examining:

• "Unfortunately, it seems like there is some infection."

• "The risk factors such as going back to work early, having a chronic cough, or
smoking could be contributing to this."

Proposed plan:

1. "We need to admit you under the surgery department."

2. "We'll take a swab of the wound."
3. "We'll also do some blood tests."
4. "We will do proper dressing of the wound."
5. "I'll give you some antibiotics through the vein."
6. "When we see signs of healing, you should be able to go home."

Key Points to Remember

1. Handle the initial rejection calmly and professionally.

2. Use the ILAR protocol to manage the angry patient.
3. Take a thorough history, focusing on symptoms, risk factors, and the patient's
circumstances.
4. Always mention the need for examination in this scenario.
5. Provide a clear explanation of the situation and a comprehensive plan for
treatment.
6. Be prepared to see and interpret an image of the infected wound.
7. Emphasize the impact of risk factors like early return to work, chronic cough, and
smoking on wound healing.
8. This scenario involves an infected hernia, which requires admission and treatment.
9. The examination will involve looking at a picture of the wound.

Heart Failure Mother

Scenario Details

• Location: F2 in Acute Medicine

• Patient: 65-year-old lady
• Situation: Admitted due to angina and losing blood in urine (haematuria)
• Issue: Son is here to talk, has some concerns and is angry

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Important Notes on Approach

• Don't create extensive notes as it creates pressure and takes too much time.
• Understand the concept and deal with it naturally, maintaining authenticity.
• Formulate your approach based on your understanding of the scenario.

Initial Interaction

When you approach the son, use the following opener: "I understand your mom has been
admitted with this. I've also been told that you wanted to speak to one of the doctors. Is
there anything in particular you would like to speak about?"

Son's Complaints

The son is likely to express three main concerns. Listen carefully to identify all three:

1. Difficulty reaching doctors:

o "I've been calling the hospital all the time."
o "I've been visiting the hospital many times."
o "Whenever I visited, there are no doctors, only nurses."
o "Whenever I call on the phone, always nurses answer."
o "They say there is no doctor to talk. Why is there no doctor to talk to me
about my mother?"
2. Negative interaction with a doctor:
o "Last week I came to the hospital and met one of your colleagues."
o "That person was very rude and didn't explain anything to me."
o "He said the consultant would come and explain, but I never met a
consultant."
3. Lack of information about mother's condition:
o "Why has no one explained to me what is wrong with my mother?"
o "I've been hearing there is heart failure, haematuria. What is all this?"
o "Why has no one explained to me what is going on with my mother?"

ILAR Protocol (Invite, Listen, Acknowledge, Reassure)

Listen

• Allow the son to express his concerns without interruption.

• Listen carefully to identify all three main issues.

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Acknowledge

After the son finishes speaking:

• "I can see that you are a little bit disappointed."

• "I can see that you are not very happy."
• "I can see that you're quite angry about this."

Validate

• "It is understandable."
• "Anyone in your situation would feel the same."

Reassure

• "I'm really sorry you felt this way."

• "I can explain things to you."
• "Let me see what we can do for you."

Transition to Questions (Signposting)

• "In order for me to help you, I would like to ask you some questions to have more
understanding about this."
• "Can I please ask you some questions?"

History Taking

Ask the following questions about each of the three main concerns:

1. Regarding phone calls and visits:

o "How long have you been visiting or calling?"
o "How many times have you visited the hospital or called?"
o "Do you call at any specific time?"
o "What happened with your calls?"
o "What is the reason you called?"
o "What sort of things did you want to speak to doctors about?"
o "What sort of information have they given you so far?"
2. Regarding the interaction with the colleague:
o "You mentioned an interaction with one of my colleagues. Would you like to
tell us a little bit more?"
o "Do you know their name?"
o "Is there anything particular my colleague said that made you upset?"

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o"Would you like to tell exactly what happened?"

o "Was the doctor helpful at all?"
o "What did they tell you?"
o "Have they done anything particularly that made you upset?"
o "Have they said something that made you upset?"
o "Why are you really disappointed about the meeting?"
o "How much have they been helpful?"
3. Regarding the mother's condition:
o "Can you tell me what were the reasons she was admitted?"
o "What sort of symptoms did she have?"
o "What sort of tests have they done?"
o "What have you been told so far?"
o "Do you know what sort of treatment she is receiving right now?"
4. Expectations:
o "I understand you wanted to speak to one of the doctors regarding this, but
is there anything in particular you are hoping that we should do regarding
this?"

Explanation and Solutions

Provide explanations and solutions for each concern:

1. Difficulty reaching doctors:

o Explain: "Doctors are not always present in the ward. In the morning,
doctors go for ward rounds with consultants to see what needs to be done.
Once they finish the ward round, they do different duties - some arrange
patients' treatment, some take patients to treatment, some go for training,
some go for clinics. So it may not be possible for them to be in the ward all
the time."
o Solution: "Nurses are always there in the ward. They are knowledgeable
about the patients and should be able to help you. Alternatively, why don't
you leave your number? We would like to have your number in our records
so if there's anything important that we think we should talk to you about,
we can discuss it with you. What do you think about that?"
2. Negative interaction with a doctor:
o "I'm really sorry to hear about the interaction you had with my colleague. I'm
disappointed to hear this, and I will speak to my colleague. I'm sure they will
be disappointed to hear this as well, as this is not our standard of care."
o "I will ask my colleague to come and speak to you."
o Important: Do not say you will ask your colleague to apologize to the patient.
3. Lack of information about mother's condition:

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o "At the moment, I don't have much information about your mother. But I
can find out. When we have a discussion over the phone, I can discuss this
with you. I would like to check your mother's records."
o "You mentioned heart failure and bleeding. Sometimes, when someone has
severe heart failure, due to blood pressure irregularities, they might lose some
blood. The kidneys may not filter properly, which can cause blood in the
urine (haematuria)."

Handling Specific Requests

If the son says he doesn't want a particular doctor to treat his mother:

• Respond: "I'm sorry you feel this way. I will pass this information to my seniors. I
will also let all my colleagues know about this."
• Important: Do not encourage refusing specific doctors. This is not related to patient
autonomy and is not encouraged in the system.
• Explain: "This is not a personal process where you can choose a particular doctor to
treat your mother. It's not related to patient autonomy."
• Do not forcefully insist on treating if they refuse, but remember it's not encouraged.

Key Points to Remember

1. This scenario is more about communication and customer service than medical
details.
2. Show empathy with energy. This demonstrates passion for your job.
3. Be careful to express this energy in an appropriate way to avoid appearing aggressive.
4. Listen carefully to identify all three main concerns of the son.
5. Use the ILAR protocol to manage the angry son.
6. Take a thorough history, focusing on the son's experiences with calls, visits, and
interactions.
7. Provide clear explanations for why doctors might not always be available.
8. Offer solutions, such as leaving a contact number for future communications.
9. When addressing the negative interaction with a colleague, express disappointment
but do not promise an apology.
10. Provide a basic explanation about the mother's condition based on the information
available.
11. If the son refuses a specific doctor, handle it professionally without encouraging
such behaviour.
12. Remember that patients cannot refuse doctors based on personal preferences (e.g.,
race or religious symbols).

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Closing

• "Is there anything else I can do for you?"

• If all concerns have been addressed, thank the son for his time and reassure him
that you will follow up on the discussed matters.

Child Covered with Poo and Vomit

Scenario Details

• Location: F2 in Paediatrics
• Patient: 5-month-old child (with maturity of 3-months-old or 2-months-old)
• Situation: Child in incubator, less maturity, covered with poo, feeding tube out
• Issue: Mother has concerns and wants to speak to a doctor

Initial Interaction

Approach the mother with: "I understand your child has been admitted with us. We've also
been told that you wanted to speak to one of the doctors. Is there anything in particular
you would like to discuss?"

Mother's Concerns

The mother is disappointed (not really angry) and may say: "Doctor, I'm not happy. Why
has no one changed my child's nappy? Today when I came to see the child, they were
covered with poo and the nasogastric tube or feeding tube was out. Why is no one
changing? Why is no one looking after my child?"

ILAR Protocol (Invite, Listen, Acknowledge, Reassure)

Acknowledge and Validate

• "I'm sorry to hear about that."

• "I can see that you are concerned."
• "You're worried."
• "It is understandable."
• "Any mother seeing their child in this situation would feel the same."
• "I'm really sorry about this."
• "I'm really sorry you feel this way."
• "I'm really sorry about the incident."

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Reassure and Transition

"I would like to ask you more questions to understand your situation better. Can I ask you
some questions?"

History Taking (Incident History)

Ask about the incident (before, during, and after):

1. "When did this happen? How long ago?"

2. "What did you exactly notice? You mentioned the child was covered with poo, but
could you tell me a little bit more detail?"
3. "Was it a lot of poo or just a little?"
4. "Was there anything else? Was there any vomit?"
5. "You mentioned the nasogastric tube was out. Was it completely out?"
6. "What happened after that? Did you speak to anybody?"
7. "Did you ask someone to change the nappy? Has it been changed, or is the child still
in the same situation?"
8. "Has this happened before?"
o If yes: "What happened yesterday? Did you speak to anybody yesterday? Did
they change the nappy? Did you speak to any doctors yesterday?"

Note: The mother might mention that yesterday the child was covered with vomit.

Additional Questions

1. Concerns:
o "Are you concerned about anything?"
o "Are you worried about anything?"
o If infection is mentioned: "Why do you think the child might have an
infection? Is there anything you've noticed, like a fever?"
2. Child's birth:
o "Can you tell me about the child's birth?"
o "At what age did you deliver? How many weeks along in your pregnancy were
you?"
o "Was there any problem during the pregnancy?"
o "Was there any problem during the delivery?"
o "Do you know what was the reason for the early childbirth or premature
birth?"
3. Medical conditions:
o "After the child was born, was the child diagnosed with any medical
condition?"

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o"The child may have some serious medical problem. For example, was the
child diagnosed with anything like cystic fibrosis?"
o "Is the child on any medications?"
4. Expectations:
o "Is there anything in particular you want us to do about this?"
o "Is there anything particularly you wanted us to do about this?"

Note: Always ask about expectations last.

Explanation and Action Plan

1. Apologize again: "I'm really sorry to hear about this. It's very disappointing for us to
hear as well."
2. Propose immediate actions:
o "We will take immediate action."
o "I will go and check the child immediately and we will take necessary action
to change the nappy first."
o "I'll ask nurses to change it immediately and I'll also ask for an explanation."
o "I'll speak to the particular nurse responsible for your child and ask why this
is happening."
o "I'll come back and speak to you afterwards."
3. Inform about further steps:
o "I will speak to my seniors regarding this."
o "I will inform the nurse in charge."
o "I will personally document this in the child's records."
o "I will ask for this to be put in the nurse's documents as well."

Addressing Additional Concerns

1. If asked about keeping the child in the neonatal unit:

o Explain that the child has passed the neonatal period (first four weeks).
o The child has grown and it's not possible to keep them in the neonatal unit.
o Neonatal units can provide one nurse per child as it's a small, more
sophisticated unit.
o Paediatric wards are larger with many patients and nurses working in
rotation.
o Nurses work in 8-12 hour rotations.
2. If asked about agency nurses:
o Explain that agency nurses are used in emergency situations if a regular nurse
can't come.
o Agency nurses are not low-income nurses, but nurses sent through an agency.

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o Reassure that all nurses, including agency nurses, have the same
qualifications and can provide necessary care.
o "We have to fill up that gap with agency nurses in emergency situations if
somebody cannot come."
o "Whoever comes, we will provide the accurate care, the necessary care."
o "We will make sure they have the same qualifications."
3. If the mother wants to take the child to a private hospital:
o The answer is no.
o Don't give weak arguments like "it's not safe to travel now."
o Explain: "It is not necessary to take your child to a private hospital."
o "We're sorry about the incident, but in the future, we will try to ensure this
doesn't happen again."
o "We don't think it is necessary to move your child."
o "We don't think that you need to take your child to a private hospital."

Key Points to Remember

1. This is not a significant incident for reporting, but it should be documented in the
child's notes and nurse's documents.
2. For children, elderly, or those without capacity, doctors make decisions, not parents
or relatives. Discuss with them, but you know what's best.
3. All children belong to the state, and you work for the state. Have this
understanding when making decisions.
4. Don't encourage or allow parents to make decisions about moving the child to a
private hospital. The answer is no, and it's not necessary.
5. Always apologize for the incident and validate the mother's feelings.
6. Take a thorough incident history.
7. Propose immediate actions and follow-up steps.
8. Explain why the child can't be in the neonatal unit if asked.
9. Clarify the use of agency nurses if questioned.
10. Document everything in both the child's records and the nurse's documents.

Medication Change Not Informed to Daughter

Scenario Details

• Setting: F2 in GP (General Practice)

• Patient: 75-year-old lady
• Situation: Routine blood test for hypothyroidism, medication changed without
informing daughter
• Issue: Daughter is upset about not being informed of the medication change

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Initial Information

• Patient had a routine blood test for hypothyroidism

• Test results: TSH and T4 levels mimicking hypothyroidism
• GP reduced Levothyroxine to 50 micrograms following the blood test
• There was a prior agreement to inform the family about medication changes, but it
wasn't done

Initial Interaction

Approach the daughter with: "I understand that you wanted to speak to one of the doctors
regarding your mother's treatment. Is there anything in particular you would like to talk
about?"

Daughter's Concern

The daughter may say: "Doctor, why did you change my mother's medication and not
inform me?"

ILAR Protocol (Invite, Listen, Acknowledge, Reassure)

Acknowledge and Validate

• "I can see that you are not very happy."

• "I can see that you're quite upset."
• "I can see that you seem to be a little bit disappointed."
• "I'm sorry about this."
• "It is understandable. We do understand why you feel this way."

Reassure and Transition

• "I will explain everything to you."

• "I understand that this must have been explained to you, but I will explain it to
you."
• "Before I explain everything about what has really happened, I would like to ask you
some questions."

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History Taking

1. Discovery of medication change:

o "Can I please ask you, how did you come to know that your mother's
medication has been changed?" (Possible answer: "I went to the nursing
home, and the nursing home staff told me.")
2. Prior knowledge about mother's condition:
o "What is your prior knowledge or understanding about the type of medical
condition your mother is having?"
o "Do you know what sort of medical problems she has been experiencing?"
(Possible answers: dementia, fracture, hypertension)
o "Do you know what sort of medication she's taking?"
o "Do you know she takes a medication called Levothyroxine?"
o "May I know, do you know why she's taking this medication? For what reason
she's taking this Levothyroxine?"
3. Communication with doctors:
o "I understand doctors usually discuss with you about your mother's treatment
and medication changes time to time. How do they discuss this with you?"
o "Do they meet you in person, or do they write to you, discuss over the phone,
or send text messages?"
o "How often do these discussions happen? Do you have any regular meetings?"
o "Does it happen after your mother's appointments?"
o "What sort of information do they discuss? Is it only significant changes or
every other change?"
o "When was the last meeting with the doctors? What was that about?"
o "Has this happened previously? Have they previously missed informing you?
Did it happen before?"
4. Family involvement:
o "Are you the next of kin?"
o "Who are the members involved in your mother's treatment?"
o "Has your mother appointed anyone as her lasting power of attorney?"

Explanation

1. Why the medication was changed:

o "Let me explain to you why the doctors have changed the medication."
o "Your mother has a condition called hypothyroidism. This means her thyroid
glands are underactive."
o "In order to treat this, we offer a medication called Levothyroxine."
o "We did a blood test. What we have done is we did the blood test, and the
blood test shows the hormone levels are high."

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o"If somebody's hormone levels are high, or thyroid hormone levels are high,
they can develop some symptoms."
o "They can have some raising of the heart rate, sweating, losing weight,
diarrhoea. This can disturb the sleep."
o "Unfortunately, she has been over-treated."
o "So, in order to prevent that, we have reduced the dose."
2. Why they didn't explain:
o "I'm really sorry. This must have been explained to you."
o "But I'm really sorry we didn't discuss this with you."
o "I'm not really sure why this was not discussed with you."
o "But what we can do is we can find out. I will find out with the doctors that
have changed this medication and come back to you. Would that be okay?
Are you okay with that? Are you fine with that?"

Follow-up Actions

1. Communication method:
o "What is the best way to communicate with you?"
o "Can we call you, or can I call you? Or we can write to you? How would you
like to make an appointment?"
2. Preventing future occurrences:
o "How can you make sure this will not happen again?"
o "First thing, I will document in your mother's notes. I will put a note on that
so whenever doctors open next time, they will find out about this. So they
will be careful."
o "Second thing, I'm going to write this to all the doctors in this practice."
(Explain that a GP practice is not one person. It's a group of doctors. There
are different levels of people - someone on GP training, someone has F2 GP
training like a registrar level, someone completed the training, or some GPs
with some special interests.)
o "So, next time, whenever whoever sees your mother, they will be more
careful."
3. Complaint option:
o "Is that okay with you?"
o "Or would you like to make a formal complaint to the practice manager?"

Key Points to Remember

1. Always acknowledge the daughter's feelings and validate her concerns.

2. Take a thorough history, focusing on the daughter's understanding of her mother's
condition and the usual communication process.

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3. Provide a clear explanation of why the medication was changed and why there was a
failure in communication.
4. Offer to investigate why the communication breakdown occurred.
5. Propose concrete actions to prevent similar incidents in the future.
6. Give the option to make a formal complaint if the daughter is not satisfied with the
explanation and proposed actions.
7. Document the conversation and inform all doctors in the practice about the
incident to prevent future occurrences.
8. Remember that this is an angry patient scenario, so use the appropriate
communication techniques throughout.
9. Be prepared to explain the structure of a GP practice, including the different levels
of doctors who may be involved in a patient's care.

GP Missed Mother's Diagnosis

Scenario Details

• Setting: Respiratory unit

• Patient: 72-year-old lady
• Situation: Admitted two days ago with cough, now diagnosed with lung cancer
• Past Medical History: COPD, smokes 40 cigarettes a day
• Issue: Son wants to speak to you, believing GP missed the diagnosis

Critical Understanding of the Scenario

1. This is NOT a medical error scenario. Do not treat it as such.

o Medical error example: Giving penicillin to a patient with known penicillin
allergy.
o Medical negligence example: Not giving antibiotics when needed, leading to
sepsis.
2. This is potentially a medical negligence claim, which is more complex.
3. You don't have enough information to determine if there was an error or
negligence.
4. You don't know how the lady presented to the GP or what the GP's impression was.
5. You don't have information about what tests were done or how she was treated by
the GP.

Things to Avoid

1. Do not treat this as a medical error scenario.

2. Do not defend the GP (e.g., don't say COPD and lung cancer can be similar).

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3. Do not blame the GP either.

4. Do not say you will contact the GP.
5. Don't make conclusions about what went wrong.

Initial Interaction

Approach the son with: "I understand your mother has been admitted with this condition.
I've also been told that you wanted to speak to one of the doctors. Is there anything in
particular you would like to discuss?"

Son's Likely Concern

The son may say: "Yesterday, she was diagnosed with lung cancer. Why was this missed?
Why is there a delay in her diagnosis? Why didn't the GP pick this up?"

ILAR Protocol (Invite, Listen, Acknowledge, Reassure)

Acknowledge and Validate

• "First of all, I'm really sorry that your mother has been diagnosed with cancer."
• "This must have been very difficult for you and your family."

Reassure and Transition

"Let me ask you a few questions in order to understand your situation better."

History Taking

Always signpost: "I would like to ask you some questions to understand your situation
better."

1. Reason for suspicion:

o "What made you think that the GP missed a diagnosis?"
o "What made you think the GP could have picked this up earlier?"
o "Is there anything particular you've noticed about her symptoms?"
2. GP visits and symptoms:
o "What was the reason your mother has been seeing the GP?"
o "How long has she been seeing the GP?"
o "What sort of symptoms has she been experiencing?"
3. Specific symptoms (closed-ended questions):
o "Has she had any cough?"
o "Was she coughing up any blood?"

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o "Has she been losing weight?"

o "Any body pain?"
o "Any shortness of breath?"
o "Was she feeling unwell in general?"
4. GP's actions:
o "What did the GP do?"
o "What sort of tests did they do?"
o "Have they done any x-rays?"
o "Have they done a CT scan?"
o "Any camera test arranged?"
o "What did they tell you was wrong?"
o "Did they say she was having a chest infection?"
o "Did they do any testing for chest infection, like taking a phlegm sample?"
5. Treatment:
o "How was she treated?"
o "Was she given antibiotics?"
o "Was it helpful? Did she improve?"
6. Risk factors:
o Ask about smoking history
o "How long has she been diagnosed with COPD?"
o "Any other medical problems?"
o "Any other lung conditions?"
o "Was she working in any building sector, mining sector, or petroleum
sectors?"
7. Social history:
o "Who is she living with?"
o "Who are the important family members involved in her care?"
o "Are you the next of kin?"
o "Has she appointed anyone as lasting power of attorney?"
8. Concerns and expectations:
o "What are you concerned about?"
o "Is there anything in particular you're hoping that we should do about this?"
o "Is there anything in particular you wanted us to do regarding this?"

Explanation

1. Lack of information:
o "I'm really sorry, but at the moment, I don't have much information
regarding your mother's condition."
o "We don't have information from the beginning about how your mother
presented to the GP."

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o "We don't know what the GP's impression was or what they were thinking
about."
o "We don't have much information about what sort of tests they've done."
o "We don't know whether they've done any tests to check for lung cancer."
o "We don't know how she was being treated or what the GP's impression was."
2. Next steps:
o "Because you've raised this concern, and your concern is quite valid, I'm
going to escalate this to the seniors."
o "Here's what will happen next:" a. "Someone senior in the department, like a
consultant or registrar, will look into this." b. "They will conduct a
preliminary investigation, collecting all your mother's records from the GP
and everywhere else." c. "They'll check if there's anything significantly missed
in your mother's treatment." d. "The senior person may speak to you to
collect more information." e. "They'll determine whether this needs to be
investigated further." f. "If they find something significant, the hospital
administration may start a formal investigation." g. "If they find something
significantly wrong in the investigation, they may refer it to the General
Medical Council (GMC)." h. "The GMC is the regulatory body for doctors."
i. "The GMC will do their own investigation. They might call the GP for
investigation and ask for their statement." j. "If they find any wrongdoing in
your mother's treatment, they will take necessary action."
3. Potential outcomes:
o "Taking action against the GP is based on the GMC's investigations."
o "After the investigation, if there is wrongdoing, they can give a formal
warning, temporarily suspend someone's registration, or permanently erase
them from the registration."
4. Legal action:
o "In this situation, I cannot tell you to take legal action, nor can I tell you not
to take legal action."
o "I cannot prevent you from taking legal action."
o "You have some questions and concerns about your mother's treatment that
need to be answered."
o "If you'd like to take legal action, you can do so on your own."
o "In the meantime, the hospital can help you. There's a department that
advocates for patients called the Patient Advice and Liaison Service (PALS)."
o "You can speak to them and make a formal complaint. They will help you get
answers to your questions."

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Handling Specific Questions

1. If asked "Will the GP be punished?":

o "The punishment or taking action is done by the medical council when they
do their investigation."
2. If asked "Can I take legal action against the GP?":
o "I cannot say yes or no. I cannot tell you to take legal action, and I cannot
prevent you from taking legal action."
o "You do have some questions and concerns about your mother's treatment
that need to be answered."
o "If you'd like to take legal action, you can do so on your own."
o "In the meantime, you can speak to the Patient Advice and Liaison Service
(PALS) in the hospital. You can make a formal complaint to them, and they
will help you get answers."

Key Points to Remember

1. This is not a confirmed medical error scenario. Treat it as a potential negligence

claim.
2. Do not defend or blame the GP.
3. Focus on gathering information and explaining the process of investigation.
4. Be clear about the roles of the hospital, GMC, and PALS.
5. Do not promise specific outcomes or encourage legal action.
6. Show empathy throughout the conversation.
7. Stick to the information provided in the scenario and don't make assumptions.
8. The main objective is to explain the process and show what steps will be taken next.
9. Document the conversation in the patient's records.

Cerebral Palsy
Case Overview

• Location: A&E (Accident and Emergency)

• Patient: 17-year-old boy with cerebral palsy
• Brought by: Father
• Reason for visit: Follow-up from previous week's visit
• Previous visit: One week ago, due to falling from sofa
• Current visit: Father raising concerns about previous treatment

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Detailed Case History

Previous Visit (One Week Ago)

• Incident: Child fell from sofa

• Assessment:
o Doctors examined and assessed the patient
o No bony tenderness found
o X-ray not performed
• Diagnosis: Ankle sprain
• Treatment: Given, but specifics not mentioned in transcript

Current Visit

• Father's concerns:
o Dissatisfaction with previous treatment
o Suspicion of discrimination due to cerebral palsy
o Belief that doctors rushed the examination
o Questioning why x-ray wasn't performed

Approach for Consultation

Initial Interaction

1. Greet the father and son

2. Open-ended question: "How can we help you today?"

Listening to Father's Concerns

Anticipated responses from father:

• "My son is still having pain."

• "He cannot walk."
• "Last time, the doctor rushed everything."
• "They didn't look at him properly."
• "They didn't do an x-ray."
• "Is it because my son has cerebral palsy?"

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Acknowledging Concerns

Appropriate responses:

• "I can see that you are quite upset."

• "I'm sorry you feel this way about your experience."
• "Let me see what we can do for you."
• "Let me ask you some questions to understand your son's current situation better."

Important Note on What to Avoid

Do NOT say: "Anyone in your situation would feel the same." Reason: This implies all
parents of children with cerebral palsy would feel this way, which could be perceived as
discriminatory.

Detailed Questioning

1. About the Initial Incident:

o "Can you tell me what happened when your son fell from the sofa to the
wheelchair?"
o "What sort of symptoms did he have initially?"
o "Was there any swelling?"
o "Did you notice any redness?"
o "Were there any bruises?"
o "What kind of pain was he experiencing?"
o "Is he able to walk?"
o "Can he put weight on his leg?"
o "Does he usually walk?"
2. About the Previous Visit:
o "What exactly did they do for your son last time?"
o "Did they examine him? How did they examine him?"
o "Did they perform any tests?"
o "Did they do an x-ray?"
o "Did anyone explain to you why they haven't done an x-ray?"
o "What did they tell you was wrong with your son?"
o "What sort of treatment did they offer?"
o "Was the treatment helpful?"
3. About the Current Situation:
o "What made you bring him back today?"
o "What sort of symptoms is he having at the moment?"
o "Is there any swelling now?"
o "Is he experiencing pain? If so, where and how severe?"

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o"Are there any bruises or redness?"

o "Are the symptoms getting worse, staying the same, or getting better?"
4. Medical History:
o Ask about relevant past medical history (Note: The transcript doesn't provide
specific questions for this section)

Examination

• Inform the father: "I would like to examine your child."

• Perform a thorough examination
• Note: The transcript states that the examination findings will be similar to the
previous visit
• Key point to check and communicate: Presence or absence of bony tenderness

Explaining the Findings

Script for explaining: "We've just examined your son. The examination findings are similar
to the previous visit. Importantly, there is no bony tenderness. This suggests that your child
most likely has sustained an ankle sprain. An ankle sprain is basically an overstretching of
the ligaments, which is a soft tissue injury."

Treatment Plan

1. Continue with previous treatment:

o Painkillers
o Cold compression
o Elevating the leg
2. Explain PRICE principle: Protection, Rest, Ice, Compression, Elevation

Addressing X-ray Concerns

Explanation script: "I understand you're concerned about why an x-ray wasn't done. Let me
explain our approach. We do an x-ray when we suspect a fracture. We suspect a fracture if
there is any tenderness over the bones. We've examined his bones thoroughly, and they are
healthy and fine. We're not clinically suspecting a fracture, so an x-ray isn't necessary in this
case. If we do an x-ray when it's not clinically indicated, it would be unnecessary radiation.
Unnecessary radiation, especially in children, is not recommended because of potential
side effects and harmful effects."

Addressing Discrimination Concerns

Key points to communicate:

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• "I can reassure you that your son was treated properly."
• "This is how we would treat anyone with a complex ankle sprain or ankle injury."
• "I'm sorry you felt that your son was treated differently because he has cerebral
palsy."
• "I want to assure you that we don't treat people differently because of their medical
problems or whoever they are."
• "For us, everyone is the same. We treat everyone fairly and equally."
• "What we take into consideration is their presentation - that is, the signs and
symptoms they have."
• "We have certain guidelines and rules to follow according to these signs and
symptoms. Based on these, we determine the necessary tests and treatment."

Closing the Consultation

• Apologize for any misunderstanding: "I'm sorry if you felt this way. We should have
explained this to you more clearly earlier."
• Offer opportunity for questions: "Do you have any other questions or concerns I
can address?"
• Provide clear follow-up instructions (Note: Specific follow-up instructions not
provided in the transcript)

Things to Avoid

1. Don't use phrases like "you people" or imply all parents of children with cerebral
palsy would react the same way.
2. Don't dismiss the father's concerns or rush through the examination.
3. Avoid medical jargon without explanation.
4. Don't perform unnecessary tests (like x-rays) just to appease the father's concerns.
5. Never imply or admit to any form of discrimination in previous treatment.
6. Don't say "anyone in your situation would feel the same" as it could be interpreted
as discriminatory.

Key Points to Remember

• Treat the patient and family with respect and empathy

• Perform a thorough examination and explain findings clearly
• Justify medical decisions (like not performing an x-ray) with clear, understandable
reasons
• Address discrimination concerns directly and reassure about equal treatment
• Document the consultation thoroughly, including examination findings and
explanations given

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Additional Notes

• The transcript emphasizes the importance of mentioning the examination and

reassessment of the child.
• The explanation about x-rays and radiation is crucial for addressing the father's
concerns.
• The consultation should focus on addressing both the medical concerns and the
perceived discrimination.
• Clear, empathetic communication is key throughout the entire interaction.

Antibiotic-Related Scenario in Pediatrics

Case Overview

• Setting: F2 Pediatric, Emergency Department

• Patient: 4-year-old female child
• Accompanying adult: 42-year-old lady (mother)
• Reason for visit: Rash development after antibiotic administration
• Previous visit: Yesterday, due to chest infection

Detailed Case History

Previous Visit (Yesterday)

• Location: Emergency Department

• Reason: Chest infection
• Action taken: Child was examined
• Treatment: Prescribed amoxicillin
• Outcome: Discharged home

Current Visit

• Chief complaint: Child developed rash all over her body after taking amoxicillin
• Mother's concern: Potential adverse reaction to antibiotic

Approach for Consultation

Initial Interaction

1. Enter the room

2. Mother's likely first question: "Where is the doctor?"
3. Appropriate response:

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o "I'm sorry, you must be looking for one of my colleagues."

o "My colleague is not here."
o "Let me introduce myself. I'm Dr. [Your Name], one of the doctors in this
pediatric department."
o "May I know your name, please?"
o "Unfortunately, my colleague is not here. So what can I do for you?"

Listening to Mother's Concerns

Anticipated statement from mother:

• "Doctor, they gave an antibiotic to my child. My child has a rash now."

Acknowledging Concerns

Appropriate response:

• "I'm sorry to hear about that."

Important Notes

• Do not immediately jump to conclusions about medical error

• First, take a history and establish the problem
• This is a history scenario, so focus on gathering information

Detailed History Taking

1. About the Rash:

o "Tell me about the rash, please."
o Analyze the rash using the following framework: a. Morphology:
§ "What sort of rash is it?"
§ "What part of the body is affected?"
§ "What is the color of the rash?"
§ "What shape are the rash spots?"
§ "How is it distributed on the body?" b. Evolution:
§ "How did the rash start?"
§ "Is it getting better, getting worse, or staying the same?" c. Symptoms:
§ "Is the rash itchy?"
§ "Is it painful?"
§ "Are there any blisters?"
§ "Is there any burning sensation?"
§

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2. Check for Signs of Anaphylaxis:

o "Has your child experienced any breathing problems?"
o "Any wheezing?"
o "Any swelling of the lips, mouth, or tongue?"
o "Any swelling of the face or eyes?"
o "Any dizziness or fainting?"
3. About the Medication:
o "What sort of medication was given?"
o "When was it given?"
o "How many times have you given this medication?"
o "How long after taking the medication did the rash appear?"
4. Allergy History:
o "Is your child allergic to this medication?"
o "Do you know if your child is allergic to penicillin?"
o "Did anyone ask you about allergies during your visit yesterday?"
o "Did you tell anyone about any allergies?"
o "Is your child allergic to any other medications?"
o "Does your child have any food allergies?"
5. Previous Occurrences:
o "Has this happened previously?"
o If yes: "How long ago did it happen?"
o "What happened last time?"
o Anticipated response: "This happened last year also. When the child was
given [medication], the same problem happened."
o Follow-up: "I'm sorry to hear about that. Can you tell me more about what
happened last year?"
6. Medical Records:
o "Do you know if this allergy information is in your child's record?"
o "Was this documented after the incident last year?"

Examination

• Inform the mother: "I would like to examine your child."

• Note: The mother will show you a picture of the rash
• Observation: The picture shows urticaria rash

Explaining the Findings

Script for explaining: "Thank you for showing me the picture. It seems like your child is
developing an allergic rash. We call this urticaria. I'm sorry, but it appears that your child
was given an antibiotic that she's allergic to. Amoxicillin is a type of penicillin medication."

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Treatment Plan

1. Stop the current antibiotic (amoxicillin)

2. Prescribe a different antibiotic: clarithromycin
3. Prescribe an allergy medication: chlorpheniramine

Explanation to the mother: "Here's what we need to do. First, we'll stop the amoxicillin
immediately. We'll give you a different antibiotic called clarithromycin, which is safe for
people allergic to penicillin. We'll also give an allergy medication called chlorpheniramine
to help with the rash."

Addressing the Incident

• "We will report this as a significant incident."

• "We are going to start an investigation to understand why this happened."
• "After the investigation, we'll let you know about the findings."

Answering Mother's Questions

1. Q: "If you give a different antibiotic, will the infection go away?" A: "Yes, if we
change the antibiotic, the infection will still be treated. Clarithromycin is the
antibiotic we give to people who are allergic to penicillin. It's effective against the
same types of infections."
2. Q: "Will the rash disappear?" A: "Yes, the rash will disappear. It's not a permanent
rash. This sort of rash, called urticaria, will go away when we stop the antibiotic and
with the help of the allergy medication we're prescribing. It may take a few days, but
it should resolve completely."

Things to Avoid

1. Don't jump to conclusions about medical error before establishing the facts.
2. Avoid medical jargon without explanation.
3. Don't dismiss or minimize the mother's concerns.
4. Avoid making promises about the investigation outcome.
5. Don't say "anyone in your situation would feel the same" as it could be interpreted
as dismissive.

Key Points to Remember

• Always invite and listen to the patient/parent carefully.

• Acknowledge their feelings: "I'm sorry you feel this way." "I'm sorry this has
happened to you." "It is understandable and upsetting, Mrs. Johnson."

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• Have a plan for exploring every scenario.

• The typical exploration areas are: incident, history, current situation, previous visit.
• After exploration, provide explanation and solution.
• Always ask if they're okay with the proposed plan: "Are you okay with that?"

Additional Notes

• This scenario emphasizes the importance of thorough history taking, especially

regarding allergies.
• The consultation should focus on addressing both the medical issue (rash and
infection) and the mother's concerns about the medication error.
• Clear, empathetic communication is key throughout the entire interaction.
• Reporting the incident and initiating an investigation are crucial steps in addressing
medication errors.
• The lack of ideas to explore is often the main challenge in these scenarios.
• It's important to study all scenarios, as any of them could appear in the exam.
• The day before the exam, focus on reviewing the structure of these consultations
rather than detailed content.

PCP (Pneumocystis Pneumonia) Scenario

Key Points about PCP

1. PCP stands for Pneumocystis pneumonia

2. Associated with two main patient groups:
o Recreational drug users and homeless individuals
o Men who have sex with men (MSM)
3. Currently, only one main scenario is used for assessment

Detailed PCP Scenario

Patient Presentation

• Main symptoms: Shortness of breath and dry cough

• Presenting to A&E (Accident and Emergency)
• May mention previous hospital visit where antibiotics were given (ineffective)
• Current symptoms:
o Fever
o Shortness of breath
o Cough
• Patient is typically a homeless man

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• Rarely, weight loss may be mentioned

• No blood in cough

Scenario Setup

• Previously: Patient dressed as homeless

o Hairstyle: Unkempt, "hair is like this"
o Clothing: Old, faded jacket
o Appearance: Bearded
o Sitting on couch with oxygen cannula
• Current setup: "Patient is homeless" written outside the room
• Note: "They have become a bit lazy. They have come with a different idea. Let's
write it down."

Additional Patient Information

• One of the patient's sexual partners may have had a similar cough
• Exact quote: "One of his sexual partners also had this... They also had a similar
cough."

Approach to PCP Scenario

Initial Assessment

• Read information outside the room: "Patient is homeless"

• Enter the room and greet the patient

History Taking

1. Present Illness:
o Ask about shortness of breath
o Inquire about dry cough
o Check for fever
o Ask about weight loss (though rarely mentioned)
2. Past Medical History:
o Ask about previous hospital visits
o Inquire about previous treatments (e.g., antibiotics)
o Possible patient response: "I was given antibiotics earlier. It didn't work."
3. Social History:
o Ask: "What do you do for a living?"
o Note: If they do something for a living, they will live in a house

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o Important context: In the UK, homelessness often associated with drug

abuse
o Quote: "We are not judgmental but until proven otherwise, they are drug
abusers... They abuse drugs. That's why they lose the address. They don't
have address."
4. Sexual History:
o Must ask about sexual history "robotically"
o Ask about sexual partners
o Inquire if any partners had similar symptoms
5. Drug History:
o Ask about recreational drug use

Physical Examination

• Mention: "I would like to examine you."

• Follow the "ten things" approach:
o "Five upper muff to stop, five lower muff to stop"
o Complete "muff to sir" (exact meaning unclear from transcript)
• After examination, mention observations

Observations

• Check and report on:

o Oxygen saturation (will be low)
o Temperature (there will be a temperature)

Diagnosis

• State: "This could be a condition called Pneumocystis pneumonia (PCP)"

• Explain: "Pneumonia is a chest infection. PCP is caused by a bug called
Pneumocystis jirovecii"

Management Plan

1. Admission to medical team

o Note: "Any atypical pneumonia admission"
2. Chest X-ray
3. Arterial blood gas
4. LDH (Lactate Dehydrogenase) marker
5. CT scan to check for lung damage
6. Lung function test to check the function of the lung
7. Lavage (taking fluid from the throat) for PCR test to confirm PCP

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oRemember: "PCP is for PCR, TB is for culture"

o "PCR test is to confirm. You need to know that how it is confirmed."
8. Treatment: Cotrimoxazole for 21 days
o "You need to know how long is the treatment"

HIV Testing

• Initiate discussion about HIV testing

• Script: "We would advise you to do an HIV test. The reason is that this type of
infection, pneumocystis infection, is common in people with HIV infection."

Additional Scenarios Mentioned

1. Homeless lady scenario:

o Associated with Pulmonary Embolism (PE)
o Always involves female patients
o To be discussed with chest pain scenarios
o Quote: "Whenever they bring PE, PE is going to be always ladies"

Things to Remember

• Always ask about sexual history in these scenarios

• Be aware of the association between homelessness and drug use in the UK context
• Don't use terms like "beggar" - "homeless" is the preferred term
o Quote: "We don't call beggars in this country. Okay, beggars is different. I
beg you. You understand, that is different. That's polite."
• Be non-judgmental in your approach
• Familiarize yourself with the "ten things" examination approach mentioned
• Know the difference in diagnostic tests: PCP uses PCR, TB uses culture

Exam Preparation Tips

• Study all scenarios thoroughly

• Some students score very high on PCP/TB scenarios
o Quote: "There are a lot of students to get 12. TB PCP my students. They
really seriously get 12. Because sometimes they fail the scenario, but some
scenario they get 12."
• Focus on understanding the structure of these consultations

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Abdominal Scenarios
Overview of Abdominal Pain Scenarios

Types of Scenarios

1. Abdominal pain without mannequin

2. Abdominal pain with mannequin

Focus on PID (Pelvic Inflammatory Disease)

• Three PID scenarios in PLOP2:

1. GP setting - history scenario (no mannequin)
2. GP setting - with abdominal mannequin
3. A&E setting - with abdominal mannequin

Detailed PID Scenarios

PID in GP Setting (No Mannequin)

Scenario Setup

• F2 in GP
• 32-year-old lady with abdominal pain
• No mannequin in the room
• Additional information: Patient diagnosed with depression a few months ago, on
sertraline

Patient History

• Abdominal pain for 3 months

• Foul-smelling discharge
• Belt-like tummy pain (Note: "Belt-like" indicates bilateral pain)
• Sexual history:
o Patient says, "I don't sleep around"
o Divorced 2-3 years ago
o Some casual sexual encounters
o In a stable relationship for the last 3 months
o Doesn't practice safe sex
o Takes mini pill (progesterone-only pill)
o No periods due to the pill

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Approach

1. Take detailed history (SOCRATES for pain)

2. Consider differential diagnoses:
o Stomach problems
o Gallbladder issues
o Bowel-related issues
o UTI
o Pregnancy (always consider in females of reproductive age)
3. Ask about sexual history
o If patient seems offended, apologize: "I'm sorry. I don't mean to give you that
impression."
4. Inquire about STI symptoms
5. Mention desire to examine the patient
o Note: No temperature will be provided
o May have some tenderness in the abdomen

Diagnosis and Explanation

• Suspect PID (Pelvic Inflammatory Disease)

• Explain: "PID is inflammation of your womb, your vagina, and the tube that is your
fallopian tube, and your glands which are ovaries."
• Usually caused by sexually transmitted infection

Management

1. Refer to GUM clinic

o Ask patient: "Are you okay to go there?"
o Explain: "Going to GUM clinic is a self-referral. You don't need a referral.
You don't need an appointment. Just walk in there."
2. Explain GUM clinic process:
o "They will do some tests. They could take a blood, they could take a swab
from vagina, they take a swab from your cervix. Then they test for the
sexually transmitted infections."
3. Treatment:
o Single injection of ceftriaxone
o Two antibiotics for two weeks: doxycycline and metronidazole
o Remember as "PID DM":
4. Discuss other STI-related information

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PID in GP Setting (With Abdominal Mannequin)

Scenario Setup

• Patient with lower abdominal pain for 1-2 weeks

• Belt-like pain
• Has a partner but doesn't practice safe sex
• Discharge present

Examination

• Use abdominal mannequin (torso)

• Examiner will report bilateral adnexal tenderness
• Check temperature (normal or less than 38°C in this scenario)

Diagnosis

• PID

PID in A&E Setting (With Abdominal Mannequin)

Scenario Setup

• Patient with severe abdominal pain

• Wincing in pain, holding abdomen
• Discharge present
• Sexual history: casual encounters, recent trip to Spain

Approach

1. Offer painkiller (but don't spend too much time on this)

2. Take detailed history: "Can I ask you some questions to understand you better?"
3. Check temperature (will be high in this scenario)
4. Suspect PID
5. Mention need for ultrasound
o Any female having severe pain belt like pain you must think of a
reproductive area.

Examination and Findings

• Use abdominal mannequin

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• Ultrasound results (provided by examiner): tubo-ovarian abscess and bilateral

adnexal tenderness
• "Bilateral adnexal means it is related to womb, tube and the glands.

Management

1. Keep patient nil by mouth

2. Insert cannula for fluids and painkillers
3. Admit under gynecology
4. Explain possibility of emergency surgery: "In order to drain the pus, you may have to
go for emergency surgery. You may need to go for keyhole surgery."
5. Antibiotic treatment: ceftriaxone injection, doxycycline, and metronidazole

Other Abdominal Pain Scenarios with Mannequin

1. Intestinal obstruction (3 different scenarios)

2. Ovarian cancer
3. Alcohol liver disease
4. Confusion
5. Heart failure
6. Cholecystitis
7. Cholangitis

Teaching Scenarios with Mannequin

Five key scenarios to master:

1. Abdominal examination teaching

2. BLS (Basic Life Support) teaching - adult
3. BLS pediatrics
4. Male urogenital/pelvic examination
o "Okay, male pelvic is basically this mannequin."
5. Female pelvic examination (speculum teaching)

Additional common scenario (no mannequin):

• Urine dipstick teaching

Important Notes

• Temperature > 38°C in PID requires ultrasound (acute abdomen)

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Abdominal Examination Teaching

Introduction and General Guidelines

1. Proper Introduction
o Introduce yourself by name and position Example: "I'm [Your Name], one of
the F2s in the surgical department."
o Never introduce yourself as a doctor to colleagues, students, or hospital staff
o Only use the doctor title when treating patients or filling out forms
o You are not a doctor to the village or colleagues
2. Building Rapport
o Start with casual conversation: "How have you been? How has your day been?
How is medical school going? How are your studies?"
o Avoid asking about challenges
o Be genuinely nice but don't overdo it
o Don't be too friendly or nice as it may seem suspicious
o Avoid phrases like:
§ "Is there any particular reason you want to learn about abdominal
examination?"
§ "Do you have any challenges?"
§ "I'm here to help you"
3. Avoid Theoretical Questions
o Don't ask about regions, muscles, or other theoretical knowledge
o Refrain from asking students to repeat information
o Even in BLS scenarios, only ask students to perform if the scenario
specifically requires it
4. Teaching Approach
o Focus on showing and telling
o Use a mannequin for demonstration if available
o If using a mannequin, say: "We have a mannequin on the table. I will train
on the table with the mannequin. Is that okay?"

Basic Steps Before Examination (WICCE)

1. Wash hands (W)

o Use alcohol-based sanitizer
o Follow seven-step WHO recommended hand washing technique
o Crucial for scenarios like urine dipstick tests
o Demonstrate proper technique, avoiding common mistakes: "People often
apply alcohol like face cream, but that's not correct. You need to cover all
surfaces thoroughly."

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2. Introduce yourself (I)

o As mentioned in the introduction guidelines
3. Get Consent (C)
o Explain the procedure before asking for consent
o "I'd like to perform an abdominal examination. This will involve looking at,
touching, and listening to your abdomen. Are you comfortable with this?"
4. Provide Chaperone (C)
o Offer a chaperone, preferably of the same sex as the patient
o "Would you like a chaperone present during the examination?"
5. Expose adequately (E)
o Expose the area to be examined
o Avoid unnecessary exposure
o Ensure good lighting
o "I'll need to expose your abdomen for the examination. I'll make sure to keep
you covered as much as possible. Let me know if you're uncomfortable at any
point."

Abdominal Examination Steps (IPPA)

1. Inspection

a. Stand at patient's foot end

• Assess general state: "I'm going to start by looking at your overall appearance. Are
you comfortable?"
• Check skin: Look for paleness, jaundice, or redness
• Observe for signs of weight loss or gain
• "I'm looking at your overall appearance and skin color. Have you noticed any
changes in your weight recently?"

b. Move to patient's side

• Inspect hands:
o Palm: "Can you show me your palms? I'm checking for any redness or muscle
wasting."
o Nails: "Now, let's look at your nails. I'm checking their shape, size, and
color."
o Check for asterixis: "Please close your eyes and stretch out your hands like
this. Hold them steady."
• Inspect eyes: "I'm going to look at your eyes now. Can you look straight ahead?"
• Inspect mouth: "Could you open your mouth wide for me?"
• Inspect chest: "I'm just going to have a quick look at your chest area."

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c. Inspect abdomen (DR. TRIBULUS)

• D: Distention - "Does your abdomen feel more swollen than usual?"

• R: Redness - Look for any areas of redness or discoloration
• T: Scars from previous surgery - "Have you had any surgeries on your abdomen
before?"
• R: Look for any visible pulsations or movements
• I: Check for any visible masses or irregularities
• B: Look for any bulges or hernias
• U: Umbilicus - Check for any abnormalities around the belly button
• L: Look for any visible veins or skin changes
• U: Check for any asymmetry
• S: Swellings - "Have you noticed any lumps or swellings in your abdomen?"

2. Palpation

a. Superficial palpation

• Check temperature in all four quadrants: "I'm going to gently place my hand on
your abdomen. Let me know if you feel any tenderness."
• Check for tenderness: "Does this cause any discomfort?"

b. Deep palpation

• Check for organs and swellings: "Now I'm going to press a bit deeper. Tell me if you
feel any pain."
• Palpate systematically through all four quadrants

3. Percussion

• "I'm going to tap gently on your abdomen. This helps me assess the organs
underneath."
• Percuss systematically through all four quadrants

4. Auscultation

• "Now I'm going to listen to your abdomen with my stethoscope. This might feel a
bit cold."
• Listen for bowel sounds in all four quadrants

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Additional Examinations

• Per rectal examination: "To complete the examination, I may need to perform a
rectal exam. We can discuss this further if necessary."
• Check for pitting edema in liver disease: "I'm going to press on your ankles to check
for any swelling. Let me know if this is uncomfortable."

Important Points to Remember

1. McBurney's point
o Location: "If we draw a line from your belly button to your right hip bone,
McBurney's point is about two-thirds of the way along this line."
o Significance: "This point is important because it's where we often find
tenderness in appendicitis."
2. Causes of left hypochondriac pain
o When discussing with patients: "Pain in the upper left part of your abdomen
could be due to several reasons. It could involve your spleen, the tail of your
pancreas, or parts of your large intestine."
3. Rigidity vs. Guarding
o Rigidity: "Sometimes, the abdomen feels hard all the time, even when you're
relaxed. This is called rigidity."
o Guarding: "If you tense up when I press on a certain area, that's called
guarding. It's your body's way of protecting a painful area."
4. Proctitis
o Definition: "Proctitis is a condition where the lining of your rectum becomes
inflamed or irritated."

Time Management

• Aim to complete examination within 3.5 minutes

• Allocate time as follows:
o History taking: 3.5 minutes
o Physical examination: 3.5 minutes
o Diagnosis and management discussion: 50 seconds
• Always state the diagnosis
• Discuss management points, even briefly

Practice Tips

1. Use a pillow with a t-shirt as a mannequin

2. Practice examination 20 times before assessment
3. Set a timer for 3.5 minutes for each practice session

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4. Focus on time management during practice

Things to Avoid

1. Don't ask if there's a particular reason for learning abdominal examination

2. Avoid laughing too much or acting weird
3. Don't be overly friendly or nice
4. Avoid asking theoretical questions or requesting students to repeat information
5. Don't use the term "tummy" - use "abdomen" instead
6. Avoid giving too many examples for each point
7. Don't provide lengthy explanations or definitions during management discussion
8. Avoid starting responses with "Certainly!", "Of course!", "Absolutely!", "Great!",
"Sure!", etc.

Key Reminders

• Poor time management is a common reason for failure

• Practice with a timer to improve time management skills
• Avoid omitting diagnosis or management discussion
• Be confident in your knowledge
• When it comes to teaching the factual information, it has to be correct.
• Combined scenarios come with the mannequin and a history. All of these scenarios,
what is important is time management.
• If you don't tell the diagnosis, management is zero. If you don't talk something
about the management, management is zero.
• Abdominal examination, you need to master them. That is the primary examination
you, most of you might get on your day.

Intestinal Obstruction Scenario

Patient Presentation

• 50-year-old man in A&E

• Abdominal pain started this morning
• No stool passage for 4 days
• No gas passage for 2 days
• Experiencing nausea and vomiting
• Patient appears to be in pain, but not extreme
• Patient is sitting, with a mannequin available for examination

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History Taking

1. Use SOCRATES approach for pain assessment

o Site: "Where exactly is the pain?"
o Onset: "When did the pain start?"
o Character: "How would you describe the pain?"
o Radiation: "Does the pain spread anywhere else?"
§ Ask specifically: "Does it go to the tip of your shoulder?"
§ "Does it go to your back?"
§ "Is it like a belt-like pain?"
o Associated symptoms: "Are you experiencing any other symptoms?"
o Time course: "How has the pain changed since it started?"
o Exacerbating/relieving factors: "Does anything make the pain better or
worse?"
o Severity: "On a scale of 1-10, how severe is the pain?"
2. Ask about GI symptoms
o "Have you been feeling nauseous?"
o "Have you been vomiting? If so, how often and what does it look like?"
o "Have you had any diarrhea?"
o "When was the last time you passed stool?"
o "When was the last time you passed gas?"
3. Inquire about other symptoms
o "Have you had any fever?" (for appendicitis)
o "Any pain in your shoulder?" (for cholecystitis)
o "Any pain in your back?" (for pancreatitis)
4. Ask about possible causes of intestinal obstruction
o "Have you ever been diagnosed with colon cancer?"
o "Have you had any previous abdominal surgeries?"
o "Do you often have trouble with constipation?"
o "Are you taking any medications, such as antidepressants or strong
painkillers?"
5. Time management
o Limit history taking to 3.5 minutes
o Use a timer on your phone for practice
o Don't be greedy with questions, stick to the time limit

Physical Examination

1. Inform the patient: "I would like to examine your abdomen. This includes checking
your hands, eyes, mouth, and abdomen. Is that okay?"
2. Inspection

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o Observe the abdomen for distension, visible peristalsis, scars

3. Palpation
o Perform superficial palpation: "I'm going to gently press on your abdomen.
Let me know if you feel any pain."
o Attempt gentle deep palpation: "Now I'm going to press a bit deeper. Tell me
if this causes any discomfort."
o Note: Patient will show signs of pain during palpation, saying "I'm in pain,
doctor."
4. Auscultation
o "I'm going to listen to your abdomen with my stethoscope."
o Listen for bowel sounds
o In this scenario, you will hear increased bowel sounds

Note: Skip percussion in this scenario due to patient discomfort

Diagnostic Tests

1. Radiology
o Order abdominal X-ray: "We need to do an X-ray of your abdomen."
§ When you mention X-ray, an image will be provided
§ Interpret: "Based on this X-ray, it looks like you could have a large
bowel obstruction."
o Order CT scan: "We also need to do a CT scan for a more detailed look."
§ When you mention CT scan, an image will be provided
§ Interpret: "The CT scan confirms that you have a large bowel
obstruction."
2. Blood tests
o Mention the need for blood tests without elaborating

Management

1. Initial stabilization
o "We need to start treatment right away. Here's what we're going to do:"
o Insert IV cannula: "We'll put a small tube in your arm to give you fluids and
medication."
o Administer fluids: "We'll give you some fluids to help with dehydration."
o Provide pain relief: "We'll give you something for the pain."
o Administer antiemetics: "We'll give you medication to help with the nausea
and vomiting, such as ondansetron or cyclizine."
o Insert nasogastric tube: "We need to put a tube through your nose and into
your stomach. This will help remove fluids and gas from your stomach and
make you more comfortable."

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o Keep patient nil by mouth: "For now, you shouldn't eat or drink anything."
2. Explain to the patient
o "Based on the examination and tests, you likely have a large bowel
obstruction. This means something is blocking your intestines."
o "We need to stabilize your condition and prepare for possible emergency
surgery."
o "I will refer you to the surgical team for further management. They will
decide if you need surgery and when."
3. Refer to surgical team for emergency surgery evaluation

Practice Tips

1. Time management is crucial

o Use a timer for 3.5 minutes during history taking
o Practice giving management plans in 1 minute
2. Create and practice with multiple scenarios
o Write down 20 different scenarios
o Practice giving management plans for each in 1 minute
3. Don't be afraid to challenge yourself
4. Focus on efficient, targeted questioning and examination
o Avoid asking about unlikely causes (e.g., body packing)
5. Be prepared for the mannequin's features
o Understand that the mannequin may have speakers for bowel sounds
o Be ready to interpret provided images (X-ray, CT scan)
6. Practice makes perfect
7. Remember, this is one of three or four acute abdomen scenarios you might
encounter. Others include cholecystitis/cholangitis and possibly a female PID
scenario. Mastering abdominal examination and management of conditions like
intestinal obstruction is crucial. Practice regularly and challenge yourself to improve
your skills and time management.

Scenario 2: Female Patient with Mannequin

Patient Presentation

• Female patient
• Didn't pass stools for 2 days
• Didn't pass gas for 1 day

Examination

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• When examining a female patient with a mannequin:

o Say: "I'd like to examine your abdomen now. Is that okay?"
o The examiner will verbally tell you: "There are increased bowel sounds"
• Important note: No X-ray will be provided in this scenario

Key Points

• Be prepared for verbal feedback about bowel sounds

• Don't expect or ask for an X-ray image
• When discussing examination with the patient, say: "I'm going to listen to your
abdomen with my stethoscope"

Scenario 3: Real Human Patient

Patient Presentation

• Real human patient to examine

• Patient will have some pain

History Taking

• Ask about current symptoms:

o "When did you last pass stools?"
o "When did you last pass gas?"
o "Are you experiencing any pain? Can you describe it?"
• Ask about previous surgeries:
o "Have you had any surgeries in the past?"
• Patient response: "I had an appendectomy about 10 years ago. It was a ruptured
appendix."

Examination

• Inform the patient: "I need to examine your abdomen now. This might cause some
discomfort. Please let me know if the pain becomes too severe."
• When you examine the patient, the examiner will tell you: "The patient has a silent
abdomen"

Diagnostic Tests

• Suggest blood tests: "We need to run some blood tests to get more information."
• Specifically ask for lactate levels: "I'd like to check the patient's lactate levels"

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• Interpretation: "An elevated lactate can be a sign of ischemia, which can occur in
intestinal obstruction. This is particularly concerning given the silent abdomen on
examination."

Key Points

• This is still a case of bowel obstruction

• The past history of ruptured appendix is significant and should be noted in your
assessment
• Silent abdomen is a critical finding and may indicate a late-stage or complicated
obstruction
• Elevated lactate suggests possible ischemia, which is a surgical emergency

General Notes for All Scenarios

1. Be prepared for different examination methods:

o Mannequin with audio (Scenario 1 - covered in previous notes)
o Mannequin with verbal feedback (Scenario 2)
o Real human patient (Scenario 3)
2. Adapt your approach based on the scenario presented:
o For mannequins, be ready to interpret audio cues or verbal feedback
o For real patients, conduct a careful physical examination, being mindful of
patient comfort
3. Always take a thorough history, especially regarding:
o Duration of symptoms (stool and gas passage)
o Previous surgeries, particularly abdominal surgeries
4. Be aware of the diagnostic tests available in each scenario:
o X-ray may or may not be provided (not provided in female mannequin
scenario)
o Blood tests, especially lactate levels, can be crucial in real patient scenario
5. Interpret findings in context:
o Increased bowel sounds in early obstruction (Scenario 2)
o Silent abdomen in late or complicated obstruction (Scenario 3)
o Elevated lactate suggesting ischemia (Scenario 3)
6. Remember the link between past surgical history and current presentation:
o Previous abdominal surgeries (like appendectomy) increase the risk of
adhesions, which can cause bowel obstruction
7. Practice all three scenarios:
o Master each scenario thoroughly
o Be prepared to adapt your approach based on the specific scenario presented
8. Time management:

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Although not explicitly mentioned in this transcript, remember to manage

o
your time effectively across all scenarios
9. Communication:
o Explain your findings and next steps to the patient in clear, understandable
terms
o For example: "Based on my examination and the tests we've done, I'm
concerned you may have a bowel obstruction. This is a serious condition that
may require surgery. I'm going to consult with the surgical team right away."

Ovarian Cancer Scenario

Patient Presentation

• 69-year-old lady in GP setting

• Presenting complaint: Bloating
• Reason for visit: "My husband asked me to see the doctor because I'm having some
bloating."
• Additional symptoms:
o Some weight loss
o Some tenderness
o Some abdominal pain ("tummy pain")

Similar Scenario Note

• There was another scenario with a man presenting with bloating

• The man's scenario was colonic cancer with weight loss

History Taking

1. Bloating Assessment
o Ask: "How often do you get bloating?"
o Key point: Frequency should be assessed
o Important to note: "Is it more than 12 times in a month?"
o Guideline: More than 12 times a month (more than 3 times a week) is
significant
o Explain to patient: "It's important to know how often you experience
bloating. If it's happening more than 12 times a month, or more than 3
times a week, it's something we need to look into further."
2. Family History
o Critical question: "Does anyone in your family have a history of cancer?"
o Key information: Patient's mother had breast cancer

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Note: Missing this information is crucial. If you miss this, you may need to
o
be more systematic in your approach.
o Explain to patient: "Family history is very important in assessing your risk.
You mentioned your mother had breast cancer. This information helps us
determine what tests we might need to do."
3. TOSAR Approach
o Go through the TOSAR approach for a comprehensive history
o This includes asking about Timing, Onset, Severity, Associated symptoms,
and Relieving/aggravating factors of the bloating and other symptoms

Physical Examination

1. Inform the patient: "I need to examine your abdomen now. Is that okay?"
2. Possible Findings: a. Balloon simulation:
o A balloon may be inserted in the mannequin and inflated
o This simulates abdominal distension

b. Fluid bag simulation:

o A fluid bag may be inserted in the mannequin

o This simulates ascites or abdominal fluid
3. Palpation:
o Note any tenderness
o Assess for any masses or fluid
o Say to patient: "I'm going to gently press on your abdomen. Please let me
know if you feel any pain or discomfort."

Diagnosis and Management

1. After examination, sit down with the patient

2. Explain findings:
o "Based on the examination, I've found some fluid/bloating in your
abdomen."
o "There's also some tenderness when I press on certain areas."
3. Discuss potential diagnosis:
o "I'm concerned about these findings, especially given your symptoms and
family history."
o "I'm sorry to tell you, but these findings, especially considering your mother's
history of breast cancer, raise concerns about the possibility of ovarian
cancer."

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4. Explain next steps:

a. Blood tests:

o "We need to do some blood tests. This will include routine blood tests and a
special test called CA125, which is a cancer marker."

b. Imaging:

o "We'll also arrange an abdominal ultrasound to get a better look at what's

causing the bloating."

c. Referral:

o"I'm going to refer you urgently to a gynecologist through what we call the
cancer pathway. This doesn't mean you definitely have cancer, but it ensures
you'll be seen quickly by a specialist."
5. Further management (to be done by specialists):
o Biopsy: "The gynecologist will likely perform a needle biopsy. This involves
taking a small sample of tissue to examine more closely."
o Treatment options:
§ Surgery: "If cancer is confirmed, surgery is often part of the
treatment."
§ Chemotherapy: "This uses drugs to kill cancer cells throughout the
body."
§ Radiotherapy: "This uses targeted radiation to destroy cancer cells in a
specific area."
o Treatment order may vary:
§ "Sometimes, doctors give chemotherapy first to shrink the tumor
before surgery."
§ "After surgery, you might have more chemotherapy or radiotherapy."
§ "The exact order and combination of treatments will depend on your
specific situation."

Key Points to Remember

1. The frequency of bloating (more than 12 times a month) is a red flag

2. Family history of breast cancer (especially in mother) is crucial for ovarian cancer
risk assessment
3. Be prepared for different examination simulations (balloon or fluid bag)
4. Deliver the potential diagnosis with empathy but clarity
5. Explain the urgency of the referral and next steps

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6. Brief overview of treatment helps prepare the patient for what's to come

Remember, this scenario tests your ability to pick up on subtle clues (like family history)
and your communication skills in delivering potentially distressing news. Practice
explaining the findings and next steps clearly and compassionately.

Additional Notes

• There was mention of a scenario with a man presenting with bloating, which turned
out to be colonic cancer with weight loss. Be aware that bloating can be a symptom
in various conditions and in both genders.
• The importance of the mother's breast cancer history was heavily emphasized. Make
sure to always ask about family history, especially of cancers, in cases of unexplained
symptoms like persistent bloating.

Alcohol Liver Disease Scenario

Patient Presentation

• Setting: GP office
• Age: 55-60 years old
• Chief complaint: "My tummy started to swell up, so I have come"
• Background: Drinks half a bottle of vodka every day

History Taking

1. Tummy Swelling Assessment

o Ask about onset: "When did you first notice the swelling?"
o Persistence: "Does the swelling come and go, or does it stay there all the
time?"
§ Note: Swelling that stays is more indicative of ascites than bloating
o Progression: "Is it getting better or worse?"
2. Causes of Tummy Swelling
o Recent weight gain: "Have you gained weight recently? Any changes in your
diet?"
o Fluid retention causes:
§ Heart failure: "Do you have any heart problems?"
§ Renal failure: "Have you had any kidney issues?"
§ Liver failure: "Have you had any liver problems?"
o Liver conditions:
§ "Have you had any previous liver infections?"
§ "I'm sorry to ask, but have you ever been diagnosed with liver cancer?"

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"Does anyone in your family have liver conditions?"

§
3. Alcohol History
o Don't jump immediately to alcohol questions
o Ask: "Do you drink alcohol?"
o If yes, take a detailed alcohol history:
§ "What sort of alcohol do you drink?"
§ "How much do you drink?"
§ "How long have you been drinking?"
§ "Has the amount you drink changed over time?"
§ "Do you drink anything else besides vodka?"
4. Associated Symptoms
o Breathing problems: "Do you have any trouble breathing because of the
tummy swelling?"
§ If yes, consider immediate hospital referral
§ If no, patient is stable and can be managed in primary care
5. Avoid
o Don't use CAGE or AUDIT questionnaires at this stage
o Don't spend more than 3.5 minutes on history taking

Physical Examination

1. Inform the patient: "I would like to examine your abdomen now. Is that okay?"
2. Examination steps:
o Inspection
o Palpation
o Percussion
o Auscultation
3. Specific findings:
o Enlarged liver: When you palpate, you'll feel the liver jutting out below the
rib cage
o Fluid: You'll feel fluid in the abdomen
o Shifting dullness: Ask "Can you please roll on one side?" (Examiner will
verbally confirm shifting dullness)
4. Examination technique:
o Engage with the patient throughout:
§ "I'm just going to have a look at your tummy."
§ "Now I'm going to touch your tummy to check the temperature."
§ "I'm going to press on your tummy. Let me know if you have any
pain."
§ "I'm going to press a little bit deeper. Tell me if you have any pain
anywhere."

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§ "I'm going to tap on your tummy."

§ "Can you please roll on this side? Now the other side?"
§ "I'm going to listen to your tummy."
o Provide encouragement: "You're doing very well. Excellent. Thank you."
o Don't announce findings during examination
o Don't run a commentary: Avoid saying things like "There is no discharge,
there is no sinus, there is no swelling" etc.
o Don't "dance in front of the mannequin" or appear disoriented

Diagnosis and Management

1. After examination, sit down with the patient

2. Explain findings:
o "Based on the examination, I believe you could have a condition called
alcohol liver disease."
o "This means that excessive intake of alcohol has started affecting your liver."
3. Explain next steps:

a. Blood tests:

o Liver function tests

o Kidney function tests
o Blood sugar levels
o Salt levels
o Inflammatory markers

b. Referral:

o "I'm going to refer you to a liver specialist (hepatologist) or a

gastroenterologist."
4. Specialist management:
o Paracentesis: "They may need to drain fluid from your abdomen. They'll send
this fluid for analysis."
o Medication: "You might be given some water tablets to help with the fluid."
o Imaging:
§ "They'll do some scans of your liver."
§ "This includes something called a fibroscan to check how well your
liver is functioning."
5. Treatment:
o "The main part of your treatment will be to quit drinking alcohol."
o "We can offer support to help you with this."
o "You may also be given some medications to help protect your liver."

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Key Points to Remember

1. Differentiate between bloating (comes and goes) and ascites (persistent)

2. Take a thorough alcohol history without jumping to it immediately
3. Check for breathing problems as a sign of urgency
4. Engage with the patient during examination, but don't announce findings
immediately
5. Explain the condition, tests, and treatment plan clearly
6. Emphasize the importance of quitting alcohol

Additional Note for Acute Abdomen Scenarios

For acute abdomen or intestinal obstruction scenarios, remember to mention blood tests:

• Complete blood count

• Inflammatory markers (ESR, CRP)
• Special markers: lipase, amylase
• Clotting factors
• Electrolytes (salt levels)
• Blood sugar
• Kidney function tests
• Liver function tests

Remember, this scenario tests your ability to take a sensitive history, perform a thorough
examination, and communicate findings and next steps clearly. Practice delivering the
information in a non-judgmental, supportive manner.

Confusion Related to Prostate Issues Scenario

Patient Presentation

• Setting: A&E, F2 in the hospital

• Patient: 65-year-old man
• Brought by: Daughter
• Chief complaint: Confusion
• Note: There is a mannequin on the table, but no father mannequin

History Taking (Speaking to the daughter)

1. Initial Approach
o "Understand you brought your father today. Can you tell me what
happened?"

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o Daughter's response: "He's confused today."

2. Confusion Assessment
o "What do you mean by he's confused? What did you notice?"
§ Potential response: "He's speaking some random words. He couldn't
recognize me."
o "When did you notice these changes?"
o "Since you noticed till now, would you say it is getting worse, still the same,
or getting better?"
o "When did you see him last time? Was he okay yesterday?"
o "Does he get confused like this sometime, time to time? Has he ever been like
this?"
§ Expected response: "No."
3. Potential Causes
o Infection:
§ "Any chest symptoms?"
§ "Any problem with the urination?"
§ Daughter's response: "Sometimes he rushed to the toilet."
o Past Medical History:
§ Ask about prostate problems
§ Daughter's response: "He had some prostate surgery."
o Other causes to inquire about:
§ Dementia
§ Heart problem
§ Liver issues
§ Electrolyte imbalances
§ Falls

Physical Examination

1. Observations
o Check temperature (patient will have a fever)
2. Abdominal Examination (using mannequin)
o Inspection
o Palpation:
§ Superficial palpation: You'll feel something in the lower abdomen
§ Deep palpation: Go around the border of what you feel
§ Note: Bladder is usually not palpable, but if enlarged, you'll feel it
o Percussion
o Auscultation
3. Important Notes:
o Don't tap on the bladder

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o A palpable bladder means it's full of urine, nothing else

o No need to assess if it's "stony hard"
o Don't do any "drama" or unnecessary actions
4. Digital Rectal Examination
o Mention: "I need to do a back passage examination."
o Examiner will tell you the prostate is enlarged
5. Urine Dipstick
o Mention it, but note that it's not usually provided nowadays

Diagnosis and Management

1. Explain findings to the daughter:

o "So we checked and examined your father. He's running a temperature."
o "We checked his bladder. The bladder is enlarged. There is a urine
collection."
o "The prostate is also enlarged. He's having some prostate enlargement."
2. Summarize the situation:
o "Due to the prostate enlargement, he's not able to pass urine."
o "So the urine stays in the bladder."
o "If the urine stays in the bladder for longer than usual time, that causes
infection."
3. Management plan:
o "What do we need to do? First thing, we need to admit him under the
medical team."
o "We need to put a catheter."
o "We need to take a urine for analysis and culture and sensitivity. We need to
send it to the laboratory to see if there are any bugs."
o "He will be given fever medication and antibiotics through the vein."
o "We also assess for sepsis as well."
o "We'll run some tests like a blood culture."
o "We'll check a marker called lactate."
o "We'll measure urine output."
o "We'll give him oxygen if necessary."
o "We'll give him fluids."

Key Points to Remember

1. Take a thorough history from the relative, focusing on the onset and progression of
confusion
2. Consider multiple causes of confusion, but pay attention to urinary symptoms and
prostate history

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3. During abdominal examination, focus on palpating the bladder

4. Don't forget to mention digital rectal examination
5. Explain findings and management plan clearly to the relative
6. Be concise in your explanation - "Don't be greedy. You cannot talk much."
7. This scenario is related to hyponatremia, as mentioned in the transcript
8. The mannequin has a rubber part in the lower abdomen to simulate the enlarged
bladder

Heart Failure Scenarios

Scenario 1: Heart Failure in A&E (With Mannequin)

Patient Presentation

• Setting: A&E
• Patient: 60-70-year-old man
• Chief complaints: Shortness of breath and swellings of the body
• Background (given outside): Had a heart attack twice
• Note: There is a mannequin on the table with abdominal swelling

History Taking

1. Initial Approach
o "How may I help you?"
o Patient's response: "I have shortness of breath and swellings in the body."
2. Swelling Assessment
o "Where do you have swellings?"
o Patient's response: "Everywhere. I have leg swelling, testicular swelling,
tummy swelling, I have swelling everywhere."
3. Differential Diagnosis Approach
o Focus on conditions causing both shortness of breath and swelling (fluid
accumulation)
o Ask about:
§ "Do you have any kidney problems?"
§ "Any liver problems?"
§ "Any heart problems?"
4. Heart Attack History
o Ask about previous heart attacks
o "Did you take any medication after your first heart attack?"
o "What happened the second time?"
o Patient will mention: Didn't take medication after first attack, started taking
after second but doesn't take water tablet

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5. Reason for not taking water tablet

o Patient's response: "I have to go to the toilet."
6. Heart Failure Symptoms
o "Do you experience racing of the heart?"
o "Do you feel dizzy?"
o "Do you feel tired?"
o "Do you have problems lying down?"
o "Does your shortness of breath get worse when you lie down?"
7. Complete MAFTOSA approach

Physical Examination

1. Chest Examination
o "I would like to examine your chest."
o Findings: Bilateral bi-basal crackles (fluid in lungs)
2. Abdominal Examination
o Findings: Fluid with shifting dullness
o "Can you please roll to one side?"
o Examiner will confirm positive shifting dullness
3. Other Examinations
o Mention: "I would also like to examine the back passage."
o Findings (given by examiner):
§ Enlarged prostate (due to age)
§ Testicular swelling
o Leg examination: Bilateral pitting edema

Diagnosis and Management

1. Explain findings:
o "I've just examined you. There's some fluid collection in your lungs, in your
tummy, in your testes, and your legs."
2. Diagnosis:
o "You could be having heart failure."
3. Explain heart failure:
o "Heart failure means the heart is a muscular pump. It is like a pump."
o "If you have a heart condition, like heart attack, this pump may fail to pump
the blood sufficiently throughout the body."
o "The heart muscle can become weaker. They may fail to pump the blood
sufficiently throughout the body."
o "This can happen. That is heart failure."
4. Management plan:

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o "We need to admit you to the hospital."

o "We need to run some tests:"
§ ECG
§ "We need to do an x-ray."
§ "We need to arrange an ultrasound of your heart, called an Echo."
§ Blood tests: "We need to check all the markers in the blood - sodium,
potassium, kidney, liver, and a marker called BNP."
o Treatment:
§ "Your main treatment is water medication."
§ "We're going to put a cannula and give you medication through the
vein."
o Address patient's concern about frequent urination:
§ Patient may ask: "What about me going to the toilet?"
§ Response: "We can put a catheter for you. Is that okay?"

Scenario 2: Heart Failure (Without Mannequin)

Patient Presentation

• Similar to Scenario 1: Shortness of breath and swelling

• Background: Had a heart attack seven years ago
• Note: No mannequin present, just history taking

Key Differences

• When mentioning abdominal examination, examiner will indicate liver

enlargement
• Include management of the liver in the treatment plan

Examination and Management

• Follow the same approach as Scenario 1

• Additional finding: Liver enlargement
• Include liver management in the treatment plan

Key Points to Remember

1. In mannequin scenarios, don't waste time on unnecessary differentials

2. Part of the data gathering is examination too
3. Be careful not to be too politically correct in mannequin scenarios
4. Don't run a commentary during examination
5. Be concise in explanation - "Don't be greedy. You cannot talk much."

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6. Focus on conditions causing both shortness of breath and swelling

7. Address patient concerns about medication side effects (e.g., frequent urination)
8. Be prepared for slight variations in scenarios (e.g., presence of liver enlargement)

Heart Failure Scenario 3: GP Setting

Patient Presentation

• Setting: GP office
• Patient: 80-year-old lady
• Chief complaint: Shortness of breath
• Background:
o Never had any conditions
o Never had any heart problem or heart attack
o Nothing in the family history
o Does not smoke
o No cough
o No fever
o May have a little tiredness
o Takes Omeprazole for stomach issues (noted as irrelevant)

History Taking

1. Initial Approach
o "What brings you in today?"
o Patient's response: "I'm having some shortness of breath."
2. Further Questions
o "Have you ever had any heart problems before?"
o "Has anyone in your family had heart issues?"
o "Do you smoke?"
o "Do you have any cough?"
o "Have you had any fever?"
o "Are you feeling more tired than usual?"
3. Medication History
o "What medications are you currently taking?"
o Patient's response: Takes Omeprazole for stomach issues

Physical Examination

When you mention examination, the examiner will tell you:

1. JVP (Jugular Venous Pressure) is elevated

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2. There is pitting edema

3. Chest is clear

Note: This scenario is described as confusing because the chest is clear, which is atypical for
heart failure.

Diagnosis

Suspect heart failure despite atypical presentation

Explanation to Patient

"Based on my examination, I suspect you might have a condition called heart failure. Let
me explain what that means:

• Heart failure doesn't mean your heart has stopped working.

• The heart is like a muscular pump.
• If you have a heart condition or due to old age, the muscle can become weaker.
• Then they may not be able to pump the blood sufficiently.
• This can lead to accumulation of fluids in your body.
• In your case, this might be age-related changes rather than a specific heart
condition."

Management Plan

1. Tests to Run:
o ECG
o Chest X-ray
o Blood analysis
o Urinalysis
o Peak flow measurement
o Spirometry (measuring breathing)
o BNP (Beta Natriuretic Peptide or Brain Natriuretic Peptide) test
2. Explain BNP test: "We need to do a special blood test called BNP. This will help us
determine how urgently you need to see a heart specialist."
3. Referral Process based on BNP results:
o If BNP is more than 2,000: Refer within two weeks
o If BNP is less than 2,000: Refer urgently to be seen within six weeks
4. Explain to patient: "Based on the results of this test, we'll refer you to a specialist. If
the level is very high, you'll be seen within two weeks. If it's lower, but still
concerning, you'll be seen within six weeks. Either way, we're treating this urgently."

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Key Points to Remember

1. This is a rare scenario of heart failure presentation

2. Patient has no typical risk factors (no smoking, no previous heart issues)
3. Chest is clear, which is unusual for heart failure
4. Focus on JVP elevation and pitting edema as key findings
5. Suspect heart failure despite atypical presentation
6. Emphasize the importance of the BNP test in determining urgency of referral
7. Be prepared to explain heart failure in the context of age-related changes

Things to Avoid

1. Don't dismiss the possibility of heart failure just because the presentation is atypical
2. Don't forget to mention the BNP test and its importance in determining referral
urgency
3. Avoid using complex medical terminology when explaining to the patient

Cholecystitis Scenario

Patient Presentation

• Setting: A&E, F2
• Patient: Man (noted as unusual, as typical case is female)
• Chief complaint: Pain on the right side
• Patient behavior: May be holding hand on right side or pointing to right side

History Taking

1. Pain Assessment
o Ask: "Where is the pain?"
o Patient response: "On the right side"
o Ask: "Does the pain go anywhere else?"
o Patient response: Pain goes to the tip of the shoulder
2. Other Symptoms
o Yellowish discoloration of the eye and skin (not really yellow, but will be
mentioned)
o Ask: "Have you noticed any changes in your urine color?"
o Patient response: Urine is dark
o Ask: "Have you noticed any changes in your stool color?"
o Patient response: Stool is pale
3. Potential Confounding Factor
o Patient may mention drinking alcohol

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oNote: This is to confuse with pancreatitis. Don't get confused.

4. Important Note
o No fever in cholecystitis

Physical Examination

• Perform confident examination

• Murphy's sign:
o On the right side, mid-clavicular line, just under the rib cage
o Say to patient: "I'm going to press on your abdomen. Can you please take a
deep breath in?"
o Press halfway through, patient will catch their breath and show pain
o Note: No need to verbally state "Murphy's sign positive"

Diagnosis and Explanation

• Say to patient: "Based on your symptoms and examination, you may be having a
condition called cholecystitis."
• "You may have gallstones."
• Explain cholecystitis: "Cholecystitis means inflammation of the gallbladder."
• Explain gallbladder: "The gallbladder is a pouch under your liver that collects a
pigment called bile."

Management

1. Investigations:
o Say: "We need to do some tests, including imaging of your abdomen and
blood tests."
2. Treatment:
o Explain: "We'll give you medication for pain control."
o "We'll need to admit you under the surgical team for further testing and
treatment planning."
o "The main treatment for this condition is usually surgery to remove the
gallstones, but this is typically done after the inflammation settles down."

Cholangitis Scenario
Key Differences from Cholecystitis

• Presence of fever (temperature will be given as 37.8°C)

• Murphy's sign may be negative

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Examination

• When you examine, Murphy's sign might be negative

• Look for temperature on observation chart: 37.8°C indicates cholangitis

Explanation to Patient

• "Based on your symptoms and the fever, you may have a condition called
cholangitis."
• "Cholangitis is inflammation of the gallbladder channels."
• "The gallbladder is a pouch that collects a pigment called bile."

Management

• Same acute abdomen approach as cholecystitis

• Additional treatment: "We'll need to start you on strong antibiotics to treat the
infection."
• Mention antibiotic options: "We might use medications like Augmentin, also called
co-amoxiclav, or other antibiotics like penicillin or ciprofloxacin."

PID (Pelvic Inflammatory Disease) Scenario

Key Points

• Consider in females with abdominal pain

• Pain characteristics:
o Ask: "Can you describe where the pain is?"
o Expected response: Lower abdominal pain or belt-like pain
o Note: Not pain everywhere (differentiates from intestinal obstruction)

Important Notes

• Cholecystitis vs. Cholangitis:

o Key differentiator is fever (present in cholangitis, absent in cholecystitis)
• Don't confuse alcohol consumption with pancreatitis in these scenarios
• Stick to 3.5 minutes for history taking
• Be confident in examination
• No need to verbalize "Murphy's sign positive" during examination
• PID is not a mannequin scenario
• For cholecystitis and cholangitis, it's an acute abdomen scenario
• In cholecystitis, pale stool indicates obstruction

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• Don't forget to mention admission under surgical team for cholecystitis

• In cholangitis, emphasize the need for antibiotics
• For PID, remember it's a belt-like pain in the lower abdomen, not pain everywhere

Pancreatitis Scenarios
Scenario 1: Acute Pancreatitis in A&E

Patient Presentation

• Setting: A&E, F2
• Patient: 55-year-old man
• Chief complaint: Epigastric pain (note: when written as epigastric pain, suspect
pancreatitis)

History Taking

1. Pain Assessment
o Ask: "Where is the pain?"
o Patient will point to epigastrium
o Ask: "Is it a belt-like pain? Does it go to your back?"
2. Alcohol History
o Patient drinks alcohol
o Last night's consumption: Gin and tonic (a spirit, strong alcohol), two pints
of beer
o Has been drinking for quite a long time
3. Other Questions
o Ask about gallbladder-related conditions
o Inquire about medications (some can cause pancreatitis, e.g., carbamazole)

Physical Examination

• Note: This is not a mannequin scenario, no actual examination

• Examiner will tell you: "Generalized abdominal tenderness"
o Be careful: Don't confuse this with peritonitis

Diagnosis and Explanation

• Say to patient: "You could be having a condition called pancreatitis."

• Explain pancreatitis: "Pancreatitis is inflammation of the pancreas."
• Explain pancreas: "The pancreas is an organ that is part of the bowel system. It helps
with the digestion of food."

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• Cause: "Excessive intake of alcohol can cause inflammation of the pancreas."

Management

1. Admit under surgery

2. Initial treatment:
o Nil by mouth
o Nasogastric tube
o Painkiller: Pethidine (remember P for P - Pethidine for Pancreatitis)
§ Explain: "We'll offer a painkiller called pethidine. It's given as an
injection in your muscle."
3. Run tests (same as acute abdomen)
4. Fluids through IV
5. Monitor salt levels
6. Explain to patient:
o "Pancreatitis is a self-limiting condition. It will settle on its own."
o "It doesn't need any treatment usually, but it needs regular monitoring and
fluids."
7. Discuss alcohol reduction: "The mainstay of your treatment is to cut down on
alcohol."
8. Warn about potential complications:
o "In unfortunate situations where it gets worse, you may need to be admitted
to the intensive care unit."
9. Discharge plan:
o "You'll be discharged home once your condition improves."

Scenario 2: Acute on Chronic Pancreatitis in A&E

Key Differences from Scenario 1

• Pain has been present for six months, on and off

• Patient didn't come earlier because he thought it wasn't a big deal
• Pain has worsened recently, prompting hospital visit
• Patient has diabetes
• Patient reports bulky stools recently (important symptom for this scenario)

Diagnosis

• Acute on chronic pancreatitis

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Management

• Same as Scenario 1
• Additional steps:
o Refer to diabetic clinic
o Refer to diabetic nurses
o Review diabetes treatment
o Discuss sugar control

Scenario 3: Pancreatitis in GP Setting

Patient Presentation

• Setting: GP office
• Chief complaint: Epigastric abdominal pain, belt-like pain
• Patient drinks alcohol for a long time
• Patient is experiencing stress in life, drinks alcohol to cope

Management

1. Advise patient to go to the hospital

2. Patient's likely response: "I don't want to go to the hospital, doctor. Give me some
painkiller. I will be fine."
3. Explanation to patient:
o "Unfortunately, pancreatitis is a serious condition."
o "It's self-limiting, but quite serious."
o "When you have pancreatitis, you have to avoid eating and drinking because
it can irritate the bowel system and prolong recovery."
o "We need to check your salt levels, sugar levels, and give you fluids."
o "There's a possibility of bleeding inside your tummy."
o "Some people need emergency surgeries."
o "It can become severe and sometimes life-threatening."
4. Negotiate with patient to go to hospital:
o "It's not safe for you to stay at home."
o "We strongly advise you to go to the hospital for treatment."
o "This is not a condition that can be safely managed at home with just
painkillers."

Key Points to Remember

1. Epigastric pain + alcohol history = suspect pancreatitis

2. Pethidine is the painkiller of choice for pancreatitis

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3. Pancreatitis is self-limiting but can be serious

4. Bulky stools can indicate chronic pancreatitis
5. Always advise hospital admission for suspected pancreatitis
6. Be prepared to negotiate with patients who refuse hospital admission
7. Stick to 3.5 minutes for history taking
8. In A&E scenarios, remember to mention admission under surgical team
9. For chronic pancreatitis, don't forget to address diabetes management
10. In GP scenario, emphasize the potential serious complications to convince patient
to go to hospital

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Headache
Headache Presentations

Headache as a presenting complaint appears only in these scenarios:

1. Hangover
2. Meningitis
3. Migraine
4. Sinusitis
5. Menstrual migraine
6. Subarachnoid hemorrhage
7. GCA (Giant Cell Arteritis)
8. Carbon monoxide poisoning
9. Tension headache
10. Intracranial hypertension

Important distinctions:

• Glaucoma presents as eye pain and redness in the eye, not headache.
• Optic neuritis presents as eye pain and blurry vision.

SOCRATES Approach for Headache

The SOCRATES questions should flow naturally, like a river. Don't try to learn them in
the exam setting. Practice until they become second nature.

S - Site

• Ask: "Can you please point out with one finger where you feel the pain?"
• This question helps identify if the pain is on the left, right, or another specific
location.

O - Onset and Duration

• Begin with: "How long have you had these symptoms?"

• Follow up with: "Is this continuous or does it come and go?"
• If intermittent: "How many episodes have you had?"
• "How long does each episode last?"
• "How did it start? Suddenly or gradually?"

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C - Character

• Don't ask: "What is the character of the pain?"

• Instead, ask: "What type of pain is that?"
• Provide options immediately: "Is it a dull pain? Sharp pain? Throbbing pain? Aching
pain?"
• Remember, patients haven't been to medical school and may struggle to describe
pain without prompts.

R - Radiation

• Don't ask: "Does it radiate anywhere?"

• Instead, ask: "Does it go anywhere?"
• Provide specific examples: "Does it go to your neck? Your eyes? Your jaw?"

A - Aggravating and Alleviating Factors

Ask two separate questions:

1. "Is there anything that makes it better?"

o Immediately provide examples: "What about painkillers?"
2. "Is there anything that makes it worse?"
o Provide examples: "What about leaning forward? Coughing and sneezing?"
o For potential carbon monoxide poisoning: "Do you notice any difference
when you go out of your buildings?"

Remember: Always give samples and use closed-ended questions. Don't wait for the patient
to volunteer information.

T - Timing

• Ask: "Do you get this headache at a particular time?"

• Examples: "Morning headache? Evening headache? After work? When you go to
work?"

S - Severity

• Ask: "How bad is the pain?"

• Follow up with: "Can you please score your pain on a scale of 0 to 10, where 0 is no
pain and 10 is the worst pain you've ever experienced? What would you score?"

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• If the patient appears to be in pain: "I can see you're in pain. Would you like to
score your pain on a scale of 0 to 10, where 0 is no pain and 10 is the worst pain
you've ever experienced? What would you score?"
• If the patient scores high (e.g., 7, 8, or 9): "Oh, that is quite high. Would you like a
painkiller?"
• If they decline: "No, doctor, I'm fine." - Respect their decision and move on.

Differential Diagnosis

Approach each potential diagnosis efficiently:

• Ask key questions for each differential

• Make quick decisions based on responses
• Don't ask five questions for one differential and only one for another

Examples:

• For meningitis:
o "Do you have fever?"
o "Do you have any rash?" If both answers are no, it's likely not meningitis.
Move on.
• For migraine:
o "Have you had previous episodes like this?"
o "Do you experience any warning signs before the headache, like visual
disturbances?" If there's no previous episode and no aura, it's likely not
migraine. Move on.

Be decisive and efficient in ruling out differentials.

Additional Important Questions

IDEA (Ideas, Concerns, Expectations, and Affect)

Always ask about the patient's ideas, concerns, and expectations. This is crucial because:

1. It's in the examiner's guidelines.

2. It shows you're considering the patient's perspective.
3. It can reveal important information about the patient's understanding and worries.

Example questions:

• "What do you think could be causing this headache?"

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• "Is there anything specific you're worried about?"

• "Do you think it might be a brain tumor? Do you think you need a CT scan?"

Note: Patients often ask about brain tumors or request CT scans. Be prepared for these
questions.

Effect of Symptoms

Always ask: "How has this headache been affecting your life in general? Your work? Your
studies?"

This question is important because:

1. It's in the guidelines that examiners review.

2. It shows you're considering the impact on the patient's quality of life.
3. It can reveal the severity and nature of the headache.

Examination

Based on the presenting symptoms and differential diagnosis, consider:

• Eye examination
• Cranial nerve examination
• Head and neck examination
• Examining the scalp

General Consultation Tips

1. Structure is crucial. Follow a logical order in your questioning.

2. Ask one question at a time. Never combine questions like "Do you smoke or drink?"
This can lead to confusing responses.
3. Always provide samples or options when asking about pain characteristics or
aggravating/alleviating factors.
4. Be thorough but efficient in your questioning.
5. Pay attention to the patient's non-verbal cues.
6. Offer pain relief if the patient reports high pain levels, but respect their decision if
they decline.
7. Be prepared for patients to ask about serious conditions like brain tumors or
request specific tests like CT scans.
8. Always inquire about the patient's ideas, concerns, and expectations (IDEA).
9. Assess the impact of symptoms on the patient's daily life.

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10. Be decisive when ruling out differential diagnoses based on key symptoms or their
absence.

Common Mistakes to Avoid

1. Neglecting to use the SOCRATES approach systematically

2. Forgetting to ask about the patient's ideas, concerns, and expectations
3. Not providing options or examples when asking about pain characteristics
4. Asking multiple questions at once
5. Spending too much time on one differential diagnosis while neglecting others
6. Failing to assess the impact of symptoms on the patient's life
7. Not offering pain relief when appropriate
8. Forgetting to examine the patient after taking the history
9. Neglecting to ask about aggravating or alleviating factors
10. Failing to provide a clear structure to the consultation

Exam Preparation and Mindset

1. Practice SOCRATES questions until they flow naturally. Don't try to learn them
during the exam.
2. Remember, the exam is about demonstrating basic competence. If you avoid major
mistakes, you're likely to pass.
3. Examiners often start with a baseline score (e.g., 2-2-2) and adjust based on
performance.
4. Examiners categorize candidates as: A. Excellent/Good (definite pass) B. Borderline
(pass depends on overall performance) C. Poor (unlikely to pass) D. Definite fail
5. The pass mark is often around 6, but this can be adjusted based on overall
candidate performance.
6. Focus on delivering the key elements examiners expect to see. This is often enough
to pass.
7. Remember, if you cause no harm and demonstrate basic competence, you're likely
to pass.

Hangover Headache

Scenario Identification

• Setting: Student Health Center

o Note: Only two scenarios typically occur in this setting - measles and
hangover headache
• Patient: Young adult, typically 19 years old

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• Chief complaint: Headache

Initial Observations and Potential Confounding Factors

1. Patient may be wearing sunglasses

o Don't confuse with glaucoma (unusual in young adults)
§ Remember: "What glaucoma for 19 years old? Can 19 years old
develop glaucoma?"
o Don't confuse with ocular herpes
§ Note: Ocular herpes presents with eye pain, not headache
2. Patient may mention roommates having headaches
o Caution: This might lead you to think about carbon monoxide poisoning
o Remember: This is likely a red herring in this scenario
3. Patient may report high pain levels (e.g., 8 out of 10)
o Be cautious in interpretation
o This is likely to confuse you, but remember the context

History Taking

Headache Characteristics

• Ask: "Where is the headache? Is it all over or in a specific area?"

o Expect: Headache is likely to be "everywhere" (widespread)
• Ask about onset: "When did the headache start?"
o Expect: "I woke up with this headache this morning"
o Note: This is an acute headache that just started today
• Ask about duration: "How long have you had this headache?"
o Expect: Acute onset, started this morning

Recent Events

• Ask: "Did anything happen today or yesterday? Have you had any injuries?"
o Potential response: "Yesterday I won a rugby match"
o Follow-up: "Did you play in the match?"
o Expect: Patient didn't play, but supported the team
o Patient will likely say: "The team I supported won the match, so we
celebrated"

Alcohol History (Critical component)

• When the alcohol story comes up, explore thoroughly

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• This is a crucial part of the scenario - you are expected to take a detailed alcohol
history
• Remember: Most alcoholics start drinking at this age (19)

Ask the following:

• "Did you drink alcohol during the celebration?"

• "How often do you drink?"
• "Do you drink every day?"
• "How much did you drink yesterday?"
• "What type of alcohol did you consume?"
• "At what age did you start drinking?"

Assess for Alcohol Poisoning

Patient's concern: "Is it alcohol poisoning?" You need to know and ask about the features of
alcohol poisoning:

Ask about these symptoms:

• "Have you experienced any confusion?"

• "Do you have any difficulty speaking clearly?" (slurred speech)
• "Have you had any vomiting?"
• "Are you having any balance problems?"
• "Are you having any breathing difficulties?"
• "Do you feel unusually cold?" (hypothermia)
• "Have you lost consciousness at any point?"

Note: These symptoms are primarily related to cerebellum and medulla functions

Differential Diagnosis

Primary suspicion: Hangover headache or simple headache

Explanation to patient: "Based on your history, this could be a hangover headache. When
you drink alcohol excessively, it can cause you to urinate more frequently, leading to
dehydration. This dehydration can cause a headache."

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Treatment Plan

First-line Treatment

Recommend:

1. Take over-the-counter pain relievers like paracetamol

2. Drink plenty of water

Say to the patient: "As a first line of treatment, I recommend taking some paracetamol and
drinking plenty of water."

Expected patient response: "I'm already trying this. I took paracetamol and I'm drinking
lots of fluids, but it doesn't go away."

Second-line Treatment

The patient is looking for a second line of treatment. Recommend:

1. Consume foods high in sugar:

o Say: "You can eat something with high sugar content, like chocolate bars,
biscuits, or other sugary foods"
o "You could also have sweet drinks or fruit juices"
o "Other options include pasta or sandwiches"
o Note: Don't specifically mention brand names like Coca-Cola
2. Consider bouillon soup:
o Say: "You might want to try bouillon soup. It's a vegetable broth that you can
buy from supermarkets in cans or packets. Just warm it up and drink it."
3. Continue hydration:
o "Keep drinking lots of water and soda water"
4. Avoid "hair of the dog":
o "It's important to avoid drinking more alcohol as a remedy. This won't help
and could make things worse."

Prevention Advice

When the patient asks how to prevent future hangovers, advise:

1. "Don't drink more than you can handle"

2. "Avoid drinking on an empty stomach"
3. "Drink water or non-fizzy drinks between alcoholic drinks"
4. "Drink a pint of water before going to bed after drinking"

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Important Notes for the Clinician

1. This scenario is designed to test your ability to recognize a hangover headache in a

young adult population.
2. Be prepared for potential red herrings like the sunglasses or mention of roommates'
symptoms.
3. Taking a thorough alcohol history is crucial in this scenario.
4. Demonstrating knowledge of alcohol poisoning symptoms is expected.
5. Be prepared to offer both immediate treatment advice and prevention strategies.
6. Remember to maintain a non-judgmental, supportive approach throughout the
consultation.
7. The scenario is structured to lead you through first-line treatment to second-line
options.
8. Be aware that the patient may report high pain levels, which could be misleading.
9. The mention of rugby is a narrative device to introduce the drinking scenario, not a
source of injury.
10. Always consider the potential for alcohol use disorders in young adults presenting
with such symptoms.

Meningitis
Scenario Identification

• Setting: GP (General Practitioner's office)

• Patient: 21-year-old
• Chief complaint: Headache
• Additional symptoms: Fever (sometimes with rigors and chills)
• Past medical history: Type 1 diabetes

Patient Behavior and Communication

Important note: The patient in this scenario is not fully cooperative and may be difficult to
handle.

• Answers may be confusing or inconsistent

• May say yes or no randomly to questions
• Not necessarily fully confused, but not pleasant to handle
• This behavior is part of the condition - do not be alarmed or frustrated

Example of patient behavior: Q: "Do you have a fever?" A: "Yes... no... I'm not sure."

Q: "Have you noticed any rash?" A: "Maybe... wait, what did you ask?"

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Remember: You may need to ask about key symptoms (especially fever and rash) multiple
times due to the patient's inconsistent responses.

Key History Points

1. Recent travel to Kenya with girlfriend

o Q: "Have you traveled recently?"
o A: "Yes, I went to Kenya with my girlfriend."
2. Presence of headache
o Q: "Can you tell me about your headache?"
o A: (Patient may give unclear or contradictory responses)
3. Presence of fever
o Q: "Have you had a fever?"
o A: (May need to ask multiple times due to inconsistent answers)
4. Presence of rash (this may be revealed during examination)
o Q: "Have you noticed any unusual marks or rash on your skin?"
o A: (Patient may not give a clear answer)

Examination Findings

When you mention that you would like to examine the patient, you will be given a paper
with the following findings:

1. Rash on the leg

2. Positive neck stiffness

These findings, combined with the history, should be sufficient to diagnose meningitis.

Diagnosis

Based on the history and examination findings, the diagnosis is meningitis.

Management

1. Immediate action in GP office:

o Administer antibiotic injection immediately
§ Preferred: Benzyl penicillin
§ Alternative: Ceftriaxone
o Explain to patient: "We need to give you an antibiotic injection in your thigh
immediately. This is very important for your treatment."
2. Arrange immediate transfer to hospital:
o Call an ambulance

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oExplain to patient: "We'll call an ambulance to send you to the hospital right
away. This condition requires immediate hospital care."
3. Inform the patient about what will happen in the hospital:
o Blood tests: U&E, CRP, clotting factors, blood culture
o PCR test (can be done on blood or CSF from lumbar puncture)
o CT scan
o Lumbar puncture Explanation to patient: "At the hospital, they'll do several
tests including blood tests, a special test called PCR, a CT scan, and possibly
a procedure called a lumbar puncture. These will help confirm the diagnosis
and guide your treatment."
4. Hospital treatment:
o IV benzyl penicillin
o Steroids (to reduce inflammation)
o Supportive treatment:
§ Fever medication
§ Painkillers (including morphine)
§ Fluids Explanation to patient: "In the hospital, you'll receive
intravenous antibiotics, medications to reduce inflammation, and
treatments to manage your symptoms like fever and pain. They'll also
make sure you're getting enough fluids."
5. Additional actions:
o Notify relevant authorities (meningitis is a notifiable condition)
o Inform senior medical staff
o Arrange prophylaxis for girlfriend: Ciprofloxacin Explanation to patient:
"We'll need to inform some health authorities about your condition, as it's a
requirement for this illness. We'll also need to give your girlfriend some
preventive medication."

Important Notes

1. Meningitis is a serious condition that has caused deaths in the UK due to late
diagnosis and treatment, especially in people who have traveled abroad.
2. Quick diagnosis and immediate treatment are crucial.
3. PCR test is the confirmatory test for meningitis and will identify the specific
pathogen.
4. The girlfriend needs prophylactic treatment even if she's asymptomatic.

Differential Diagnosis: Malaria

While not the focus of this scenario, be aware that malaria is another possibility in patients
with fever who have traveled to endemic areas.

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Key points for malaria:

• Recent travel history now mentions Uganda instead of Kenya

• If suspected, send the patient to the hospital immediately
• If a patient asks about quarantine for their girlfriend who didn't travel: Q: "Does my
girlfriend need to quarantine?" A: "No, she doesn't need to quarantine or any
treatment. Malaria is transmitted by mosquito bites, and the specific mosquito that
carries malaria isn't found in our country."

Migraine
Importance and Common Pitfalls

• Migraine is one of the most misdiagnosed headache scenarios

• Particularly challenging for male candidates
• Many students miss this diagnosis (around 15 mentioned in the transcript)
• It's a confusing presentation that requires careful attention
• Headache is the most misdiagnosed scenario because candidates don't study
according to what will come in the exam

Scenario Presentation

• Can have male and female versions

• Patient presents with headache
• May not clearly state it's a one-sided headache
• Some patients might simply say "one side headache," but it's often not that
straightforward

Key History Points

1. Location of Pain
o Ask: "Can you point out with one finger where you feel the pain?"
o Patient response may be vague: "over here"
o Patient may indicate multiple areas: "here, here, here, here"
o Be prepared for the patient to indicate the front, side, or corner of the head
o Don't assume it's clearly one-sided
2. Previous Episodes
o This is not the first occurrence
o Ask: "Have you had headaches like this before?"
o Patient might say: "Yes, I had one about a month ago"
3. Aura
o Critical to ask about aura

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o Most common presentation: Blurry vision (not flashes of light)

o Ask: "Did you experience any symptoms before the headache started?"
o Follow up with: "Did you have any blurry vision, pins and needles, see any
zigzag lines, or have any speech problems?"
o Be prepared for the patient to say "blurry vision" rather than textbook
symptoms like flashes of light
4. Severity
o Often reported as severe (8-10 out of 10)
o Ask: "On a scale of 1 to 10, where 10 is the worst pain you've ever
experienced, how would you rate this headache?"
o Patient might respond: "It's very severe, maybe 8 or 9 out of 10"
5. Stress
o Male scenario: May mention relationship stress
§ Ask: "Have you been under any stress recently?"
§ Patient might respond: "Well, I've been having some problems with
my girlfriend"
o Female scenario: May mention work-related stress
§ Ask: "How have things been at work lately?"
§ Patient might respond: "There's been a lot of stress at my job"
o Note: Stress can trigger migraine, but not all stress-related headaches are
tension headaches
o Be careful not to automatically assume stress means tension headache
6. Duration
o Can last 24-48 hours continuously
o Ask: "How long does the headache typically last?"
o Patient might say: "It can go on for a whole day, sometimes even two days
straight"
7. Frequency
o Ask: "How often do you get these headaches?"
o Ask: "How many episodes have you had in total?"
o Patient might respond: "This is my second episode in a month"
8. For Female Patients
o Ask about contraception, especially combined pills
o Ask: "Are you using any form of contraception?"
o If yes: "Are you using combined oral contraceptive pills?"
o Important because migraine patients shouldn't take combined pills
o Explain: "It's important to know about contraception because some types can
affect migraines"

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Diagnosis

• State: "Based on what you've told me, this could be a migraine type of headache"
• Define migraine: "Migraine is a type of headache that typically affects one side of the
head, but can be more widespread"
• Note: No need to give vascular explanations

Management

1. Emphasize that migraine is diagnosed and treated by GPs

o No need for routine blood tests
o Do not refer to neurology unnecessarily
o Do not call for senior review (this is emphasized strongly in the transcript)
o Explain: "Migraines are typically managed by GPs like myself, and we don't
usually need to do additional tests or refer to specialists for typical cases"
2. Medication
o First, check what the patient has already tried
o Ask: "Have you tried any medication for these headaches? Did anything
work?"
o Patient has likely already tried NSAIDs
o Patient might say: "I've tried ibuprofen, but it didn't help much"
3. Prescribe three medications: a. Sumatriptan tablets
o Instruct: "I'm going to prescribe a medication called Sumatriptan. Take this
whenever you have a headache" b. Metoclopramide
o Offer regardless of presence of nausea or vomiting
o Explain: "I'm also prescribing a medication called Metoclopramide. This can
help with any nausea you might experience and may improve the
effectiveness of the pain medication" c. Discuss prophylaxis (preventive
medication)
o Explain: "There's also something called preventive medication. In the future,
if you get more than one episode in a week, it's better to take a preventive
medication called propranolol. We don't need to start this now, but it's good
for you to be aware of this option"

Addressing Patient Concerns

• If patient asks, "Is it a brain tumor, doctor?"

• Response: "From what you've told me, this doesn't appear to be a brain tumor.
Migraines are much more common and can explain your symptoms"
• Do not provide safety netting for brain tumor

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• Instead, emphasize: "It's important to understand that while migraines are not
dangerous in the way a tumor would be, they can severely impact someone's life.
Some people find that migraines significantly affect their daily activities"

Important Notes

1. Be careful not to miss this diagnosis

2. Pay attention to the subtle differences between male and female presentations
3. Remember that stress can trigger migraines, but not all stress-related headaches are
migraines
4. The aura is typically blurry vision, not the textbook "flashes of light"
5. Don't unnecessarily involve senior doctors or make referrals
o Calling seniors unnecessarily can lead to delays in treatment, especially in a
GP setting
6. Be prepared for the patient to indicate pain in multiple areas of the head
7. Always consider contraception in female patients with migraines
8. Emphasize the potential severity and impact of migraines on quality of life

Cluster Headaches

1. General Information:
o Not currently a scenario in PLAB 2 exams
o May be introduced in future exams as all other headache types have been
covered
2. Key Characteristics:
o Can change sides (unlike migraine, which is always on one side)
o Symptoms include:
§ Water running from eyes and nose
§ Redness in the eye
o Patients may have difficulty opening eyes on the affected side
3. Presentation:
o Patient may present with one-sided redness and inability to open eye
4. Note: While not currently tested, be prepared to discuss as a differential diagnosis

Sinusitis

1. Patient Profile:
o Typically, a 60-year-old lady
o Presents with headache
2. Key History Points:
o Headache duration: 4 weeks
o Recent history of flu (risk factor)

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o Nasal blockage
o May have facial pain or pain around eyes (not always present)
3. Critical Symptoms:
o Leaning forward makes headache worse
o Greenish nasal discharge
4. PLAB 2 Focus:
o Only one type of sinusitis in PLAB 2: Acute bacterial sinusitis
o Characterized by greenish discharge
o Treatment: Phenoxy methyl penicillin (not amoxicillin)
5. Diagnosis:
o Acute bacterial sinusitis (less than 3 months duration)
o Do not consider viral vs. bacterial differentiation in PLAB 2 context
6. Patient Concerns:
o Patient may ask, "Is it a brain tumor?"
o Response: "It doesn't look like a brain tumor."
o Explain: "Brain tumors typically cause morning headaches and neurological
symptoms like weakness in the body."
7. Examination:
o Examine nose, ear, and throat
o Examine facial nerves
o If brain tumor concern, conduct relevant neurological examination
8. Treatment:
o No testing required (no swabs, blood tests, or X-rays)
o No referrals
o Two main management steps:

a. Phenoxy methyl penicillin for 5 days

b. Nasal steroid (not salt water)

o Additional: Pain killers like ibuprofen

9. Follow-up:
o No routine follow-up needed
o Advise patient: "If there's no improvement after 48 hours of antibiotics,
make an appointment to come back. If you get better, you don't need to
return."

Important Notes:

1. Cluster Headaches:
o While not currently tested, be prepared for potential inclusion in future
exams

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o Key differentiating factor from migraines: can change sides

2. Sinusitis:
o Focus on acute bacterial sinusitis for PLAB 2
o Key symptoms: headache worsening on leaning forward and greenish
discharge
o Remember the specific antibiotic: Phenoxy methyl penicillin
o No testing or referrals needed
o Be prepared to address brain tumor concerns
o Emphasize the importance of returning if no improvement after 48 hours of
antibiotics

Allergic Rhinitis

Patient Profile

• 40–45-year-old man in GP setting

• Presenting complaint: "I sneeze a lot. I'm sneezing. I'm coughing."

Key History Points

1. Family History:
o Son with asthma
o Brother with eczema
o Note: Eczema, dermatitis, asthma, and nasal polyps often run in families
2. Occupation:
o IT work
3. Effect on daily life:
o Patient may say: "I need to keep rubbing my nose, doctor. I cannot work."
o Appropriate response: "I'm sorry to hear about that."

Differential Diagnosis for Sneezing

Ask about:

• Common flu
• Sore throat
• Fever
• Any growth in the nose
• Sniffing substances
• Nasal polyps
• Smoking
• Any other causes of sneezing the patient can think of

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Examination

When you mention "I would like to examine", you will be told:

• There is inflammation of the lining of the mucosa

Diagnosis

• Allergic Rhinitis

Explanation to Patient

"Based on your symptoms and the examination, you may have allergic rhinitis. This means
you may have some allergies. Due to these allergies, you may have some swelling of the
lining of your nose. Having family members with asthma or eczema, as you do, increases
the risk of allergic rhinitis."

Treatment

1. Antihistamine medication
o Patient may ask: "Can you give me a medication that doesn't cause
drowsiness?"
o Response: "Yes, we can offer a medication called loratadine or cetirizine.
These are less likely to cause drowsiness."
2. Avoiding triggers: Explain to the patient: "There are several ways to avoid triggers
that can worsen your symptoms:
o Close windows, especially during high pollen seasons
o Avoid air drying clothes outside
o Avoid working outdoors in parks, around bushes and trees, especially in the
morning
o Close windows when driving
o It's also important to identify any food allergies you might have and avoid
those foods"
3. Additional advice: "It would be helpful to find out if you have any other allergic
items and avoid those as well."

Unilateral Nasal Polyp

Patient Profile

• 60+ year old man

• Presenting behavior: Sitting with a tissue and continuously wiping the nose

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Key History Points

1. Patient's initial statement:

o "I have hay fever."
o Note to clinician: Hay fever is a type of allergic rhinitis specifically caused by
pollen from trees or plants.
2. Symptoms:
o Patient may say: "I have a runny nose. I took medication for hay fever, so all
the runny nose from the eye stopped, but the nose is still running."
3. Critical Questions:
o Ask: "Have you ever seen any blood?"
o If no response, be more specific: "Have you seen any drops of blood at all?"
o Patient response: May mention seeing one or two drops of blood in the last
two weeks
o Note: Always ask about blood, even if not volunteered by the patient. If you
don't ask, you won't get this critical information.
4. Additional Symptom (sometimes included):
o Ask about weight loss: "Have you noticed any changes in your weight
recently?"
o Potential response: "Yes, my clothes have become loose."

Examination Findings

• You will be given a picture showing a polyp

• Note: This is not a deviated septum, which is not relevant for PLAB 2

Diagnosis

• Suspected cancer (unilateral nasal polyp is a guideline-based scenario for suspected

cancer)

Explanation to Patient

"Based on your symptoms and the examination, we've found a growth on one side of your
nose, which we call a unilateral nasal polyp. Given your symptoms, including the blood
you've noticed, we need to investigate this further to rule out any serious conditions."

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Management

• Two-week referral pathway to ENT (Ear, Nose, and Throat specialist)

• Explain to patient: "I'm going to refer you to a specialist in ear, nose, and throat
conditions. This referral will be on a two-week pathway, which means you should be
seen within two weeks."
• Procedures in ENT:
1. Nasal endoscopy: "The specialist will likely perform a procedure called a
nasal endoscopy, where they look inside your nose with a small camera."
2. Biopsy: "They may need to take a small sample of tissue for testing."
3. Possible further treatment: "Depending on the results, further treatment
might include surgery, chemotherapy, or radiotherapy, but let's not get ahead
of ourselves. The specialist will discuss all of this with you after their
examination."

Important Notes for Clinicians

1. Allergic Rhinitis:
o Focus on family history of related conditions
o Emphasize non-drowsy antihistamines and trigger avoidance
o Complete the MAFTOSA (Medical history, Allergies, Past medical history,
Drug history, Occupation, Social history, Effect on life) during history taking
2. Unilateral Nasal Polyp:
o This is an important scenario, likely to appear in exams soon
o Always ask about blood, even if not volunteered
o Unilateral polyp is treated as suspected cancer, regardless of blood presence
o Be prepared for the patient to initially present it as "hay fever"
o Remember the two-week referral pathway for suspected cancer
o Weight loss may or may not be included in the scenario
3. General:
o Pay attention to patient behavior (e.g., wiping nose with tissue)
o Be prepared to explain conditions and treatments in patient-friendly
language
o Don't miss critical questions like asking about blood in nasal discharge
o Be aware that some symptoms (like weight loss in unilateral nasal polyp) may
not always be included, but if present, they add to the suspicion of cancer

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Menstrual Migraine

Patient Profile

• 17-year-old female
• Presenting complaint: Headache

Key History Points

1. Duration: Headache for the last one year

2. Pattern: Comes with period, goes with period
3. Important questions to ask:
o "Can you tell me about your periods?"
o "Do you experience painful periods?"
o "Are there any other symptoms you notice around your period time?"
o "Are you sexually active?" (important for contraception considerations)
o "Are you using any form of contraception?"

Diagnosis

• Menstrual Migraine
• Explanation to patient: "Based on your symptoms, this could be a condition called
menstrual migraine. Doctors believe it's due to hormonal changes throughout your
menstrual cycle."

Treatment

1. Acute treatment:
o Nasal sumatriptan
o Explain: "I'm going to prescribe a nasal spray called sumatriptan. You should
use it 2 days before your period is due to start and continue for 3 days after
bleeding starts."
o Note: Oral sumatriptan tablets are not allowed for under 18s. This is why the
scenario specifies a 17-year-old patient.
2. Monitoring:
o Provide a headache diary
o Instruct: "I'd like you to keep a diary of your headaches. This will help us
understand the pattern better."
o Follow up: "We'll schedule a follow-up appointment after 2-3 menstrual
cycles to review your diary and see how the treatment is working."
3. Long-term treatment options:
o Combined contraceptive pills without breaks

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o Estrogen patches
o Explain: "For long-term management, we might consider hormonal
treatments like contraceptive pills taken continuously or estrogen patches.
These work by 'topping up' your hormones to reduce fluctuations."

Notes for Clinicians

• This is one of three scenarios in PLAB 2 where a diary is mentioned (others are IBS
and medication overdose headache)
• Age is crucial here (17) as it affects treatment options
• Be prepared for the patient to ask about long-term treatment

Premenstrual Syndrome (PMS)

Patient Profile

• Typically around 32 years old

• Presenting complaint: Emotional disturbances

Key History Points

1. Emotional symptoms:
o Ask: "Can you describe how you feel emotionally before your period?"
o Patient might say: "I get emotional. I shout at my husband and snap at my
children."
2. Previous contraception:
o Ask: "Have you used any contraception in the past?"
o Patient might say: "I was on Depo Provera, but I stopped about 8 months
ago."
3. Menstrual history:
o Ask: "When did your periods restart after stopping Depo Provera?"
o Patient might say: "My periods started again about 4 months ago."

Approach to History Taking

1. Start with psychological symptoms

o Ask: "Do you notice any changes in your mood or emotions before your
period?"
2. Ask about physical symptoms
o Ask: "Do you experience any physical symptoms like palpitations, sweating,
or hot flashes?"
3. Inquire about behavioral symptoms

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o Ask: "Do you notice any changes in your behavior or daily activities?"
4. Ask about period-related symptoms
o Ask: "Do you have any specific symptoms related to your period itself?"
5. Look for risk factors:
o Ask about mood disorders, weight gain, stress, family history, smoking,
alcohol, relationship issues
6. Assess effect on work and relationships (MAP-DOSA)
o Ask: "How are these symptoms affecting your work and relationships?"

Diagnosis

• Premenstrual Syndrome (PMS)

• Explanation to patient: "Based on what you've told me, you could be experiencing a
condition called premenstrual syndrome or PMS. It's thought to be caused by
hormonal changes throughout your menstrual cycle."

Treatment

1. Lifestyle changes:
o Advise: "Try eating small, frequent meals rich in complex carbohydrates. This
can help stabilize your mood."
o "Regular exercise and maintaining a good sleep routine can also help manage
symptoms."
o "Try to reduce stress, alcohol consumption, and smoking if applicable."
2. Symptom management:
o Advise: "For menstrual pain, you can take over-the-counter painkillers."
3. Monitoring:
o Instruct: "Keep a symptom diary to track how you feel throughout your
cycle."
o "We'll follow up after 2-3 cycles to review your diary and see how you're
doing."
4. Further options:
o Explain: "If these initial steps don't help, we might consider options like
Cognitive Behavioral Therapy (CBT)."
o "We could also discuss contraceptive pills taken continuously to regulate
your hormones."
o "In severe cases, we might consider antidepressants, but that's not our first
approach."

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Perimenopause and Menopause

Patient Profile

• Typically, around 49 years old

• Presenting complaint: Irritability

Key Differences

• Explain: "Perimenopause is the transition phase before menopause. You're

considered to be in perimenopause if your last period was within the past year."
• "Menopause is diagnosed when you've gone 12 months without a period."

Key History Points

• Emotional changes:
o Ask: "Have you noticed any changes in your mood?"
o Patient might say: "I have become irritable. I find myself fighting with my
husband more often."
• Physical symptoms:
o Ask about the same physical symptoms as in PMS (palpitations, sweating, hot
flashes)

Diagnosis

• For perimenopause, explain: "Based on your symptoms and the timing of your last
period, you are likely approaching menopause. This phase is called perimenopause."
• For menopause, explain: "Since it's been over a year since your last period, you have
reached menopause."

Management

• Similar to PMS management (lifestyle changes, symptom tracking, possible

hormone therapy)

Notes for Clinicians

• There is no "premenopausal syndrome" - it's called perimenopause

• Approach to history and management is similar to PMS
• Be prepared to explain the difference between perimenopause and menopause

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Important Notes

1. Menstrual Migraine:
o Focus on the age (17) as it affects treatment options
o Remember to recommend nasal sumatriptan, not tablets
o Discuss long-term hormonal treatments
o This scenario is likely to appear in exams
2. PMS:
o Distinct from menstrual migraine in presentation and age group
o Focus on emotional symptoms in history
o Remember the importance of lifestyle changes in management
o Be prepared to discuss the link between stopping Depo Provera and onset of
symptoms
3. Perimenopause/Menopause:
o Similar presentation to PMS but in older age group
o Key is timing of last menstrual period
o Use correct terminology (perimenopause, not premenopausal syndrome)
o Be prepared to explain the transition from perimenopause to menopause
4. General:
o Always consider the effect of symptoms on daily life
o Remember the importance of diaries in certain conditions
o Be prepared to explain hormonal influences on symptoms
o Know when to escalate treatment (e.g., to CBT or SSRIs in severe PMS)
o For all conditions, be ready to discuss contraceptive options, especially
combined pills without breaks
o In GP settings, you can offer six-month prescriptions for contraceptives with
a review after six months

Subarachnoid Hemorrhage in A&E

Patient Profile
Age: Around 38-40 years old
Presenting complaint: Sudden onset of headache this morning

Key History Points

Onset: Sudden, started this morning
Ask: "When did the headache start?"
Patient response: "It started suddenly this morning."
Activity at onset: Doing decorations at home
Ask: "What were you doing when the headache started?"
Patient response: "I was doing some decorations at home."
Previous history: Patient has migraine (important for differentiation)

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Ask: "Do you have a history of migraines?"

Patient response: "Yes, I do have migraines, but this is different."
Severity: Severe headache, 9 out of 10
Ask: "On a scale of 1 to 10, where 10 is the worst pain you've ever experienced,
how would you rate this headache?"
Patient response: "It's about a 9 out of 10. It's really severe."
Aggravating factors: Sneezing and coughing make it worse
Ask: "Does anything make the headache worse?"
Patient response: "Yes, when I sneeze or cough, it gets worse."
Other factors: Patient drinks alcohol
Ask: "Do you drink alcohol?"
Patient response: "Yes, I do."

Patient Presentation
Patient may be holding hands at the back of the head or holding head
Patient is visibly in pain
Consider offering painkillers based on patient's body language
If patient appears in severe pain, say: "I can see you're in a lot of pain. Would you like
some pain relief?"

Important Questions to Ask

Ask about fever: "Do you have a fever or feel hot?"
Ask about trauma: "Did you hit your head or have any injury recently?"
Ask about meningeal signs and photophobia: "Are you sensitive to light? Does moving
your neck cause pain?"
Note: Key difference from meningitis is absence of fever and rash

Examination
State: "I'd like to examine you now."
Check for meningeal signs (may be positive)
Note: Similar to meningitis, but without rash or fever

Diagnosis
State: "Based on your symptoms, this condition is called subarachnoid hemorrhage. It's
a bleed in the brain."

Initial Treatment
Give morphine for pain relief
Say: "I'm going to give you some strong pain relief called morphine."
Note high blood pressure (e.g., 169/89 or 180/x)
Say: "Your blood pressure is quite high, which can happen with this condition."

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Administer nimodipine
Explain: "I'm also going to give you a medication called nimodipine, which can
help protect your brain."

Further Management
Arrange CT scan
Explain: "We need to do a CT scan of your brain to confirm the diagnosis."
Explain to patient:
"If the CT scan shows bleeding, we'll refer you to neurosurgeons (brain
surgeons)."
"Most often, treatment is conservative, but sometimes surgery may be needed."
"If the CT scan is normal, we'll wait 12 hours from the onset of your headache
and then do a procedure called a lumbar puncture."
Note: Don't elaborate on lumbar puncture details unless asked.

Subarachnoid Hemorrhage in GP
Patient Profile
Similar age to A&E scenario (around 38-40)
Presenting with headache

Key History Points

Onset: At work
Ask: "Where were you when the headache started?"
Patient response: "I was at work."
Brought in by: Work colleague
Ask: "How did you get here today?"
Patient response: "My work colleague brought me."
Previous history: No migraine (different from A&E scenario)
Ask: "Do you have a history of migraines?"
Patient response: "No, I don't."
Aggravating factors: Coughing and sneezing may make it worse (only in one scenario,
either GP or A&E)
Ask: "Does anything make the headache worse?"
Patient response: "Yes, when I cough or sneeze, it gets worse."
Other factors: Alcohol consumption (as in A&E scenario)
Ask: "Do you drink alcohol?"
Patient response: "Yes, I do."

Patient Presentation
Patient may be sitting with a tissue and continuously wiping the nose

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Patient may be holding the head or visibly in pain

Diagnosis
Same as A&E: "Based on your symptoms, this condition is called subarachnoid
hemorrhage. It's a bleed in the brain."

Management in GP
Call an ambulance immediately
Say: "I'm going to call an ambulance to take you to the hospital immediately."
Explain to patient why ambulance is necessary:
"It's not safe for you to travel by private transport."
"You could collapse on the way."
"The ambulance can monitor you and start treatment."
"They can arrange for prompt treatment when you reach the hospital."
"The ambulance can guarantee your passage to the hospital without delays."
If patient asks to go with friend:
Patient might ask: "Can I go with my friend? They drove me here."
Response: "I understand you want to go with your friend, but it's not safe. The
ambulance is the best option for your safety and quick treatment."

Important Notes
Differentiation:
A&E scenario: Patient has history of migraine
GP scenario: Patient does not have history of migraine
Presentation can vary:
Patient may describe it as "headache" or "pain at the back of my head"
Be prepared for patient to say: "I have a pain at the back of my head" instead of
mentioning headache
Always arrange ambulance transfer from GP, even if patient suggests private transport
Be prepared for high blood pressure readings
Remember key differentiating factors from meningitis (absence of fever and rash)
Don't provide unnecessary information about lumbar puncture procedure unless
specifically asked
In the A&E scenario, when explaining CT scan results:
If normal CT: "If the CT scan is normal, we'll wait 12 hours from the onset of
your headache to do another procedure called lumbar puncture."
Don't elaborate on what you're looking for in the lumbar puncture unless asked
Be aware that management details (like discussing lumbar puncture) may have changed
since the pandemic
In both scenarios, be prepared to offer pain relief based on patient's visible discomfort

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Remember that subarachnoid hemorrhage is a bleed in the brain, regardless of whether

it's subarachnoid, subdural, or epidural

Giant Cell Arteritis (GCA)

GCA presents in two different ways: simple headache and sudden loss of vision.

Scenario 1: Simple Headache

Patient Profile
Female, 50+ years old (elderly)
Setting: GP
Presenting complaint: Headache

Key History Points

Duration: Headache for weeks
Location: Side of the head
Associated symptoms:
Jaw claudication (jaw pain)
Tenderness over the temples
Weight loss
Ask about:
Eye problems (note: in this scenario, there are no visual symptoms)
Polymyalgia rheumatica

Taking the History

Ask: "How long have you had this headache?"
"Can you show me where the pain is?"
"Do you have any pain or discomfort in your jaw when you chew?"
"Is there any tenderness around your temples?"
"Have you noticed any changes in your weight recently?"
"Have you experienced any problems with your vision?"
"Do you have any muscle pain or stiffness, particularly in your shoulders or hips?"

Diagnosis
Giant Cell Arteritis (GCA), also known as Temporal Arteritis

Explanation to Patient
"Based on your symptoms, you may have a condition called Giant Cell Arteritis or
Temporal Arteritis. This is an inflammation of the blood vessels around the side of your
head."

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Management
Medical emergency: Same day referral
"This condition requires urgent treatment, so we need to refer you to a specialist
today if possible."
Refer to rheumatology (same day if possible, within 3 days if not)
Same day referral to ophthalmology (eye clinic)
Start high-dose steroid medication (prednisone) without delay
"I'm going to start you on a high dose of steroid medication called prednisone
right away."
Investigations:
Blood tests: ESR, CRP
Ultrasound of blood vessels
Biopsy (done by head and neck surgeons)
Treatment duration: 1-2 years
Regular follow-up with specialists
Discuss steroid side effects (one of five scenarios where this is necessary)

Scenario 2: Sudden Loss of Vision

Patient Profile
Male, 50+ years old
Setting: GP
Presenting complaint: "I have some problem in my eye"

Key History Points

Vision problem:
Ask: "What sort of problem are you having with your eye?"
Patient response: "I see a curtain falling down"
Ask about:
Headache: "Have you been experiencing any headaches?"
Jaw claudication: "Do you have any pain in your jaw when you chew?"
Tenderness over temples: "Is there any tenderness around your temples?"
Differential diagnosis:
Ask about symptoms related to: Stroke, TIA, Retinal detachment, Hypertension,
Diabetes, Central retinal artery occlusion

Examination Findings (given on paper)

Scalp tenderness
No vision on affected side (usually right side)
Visual acuity is zero on affected side

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Note: This is not a mannequin scenario. Before the pandemic, there used to be an eye
mannequin, but now findings are given on paper.

Management
Not an ambulance case, but urgent
Advise immediate visit to eye hospital
"I need you to go to the eye hospital immediately."
Ask patient not to drive, arrange transport
"It's not safe for you to drive. Can someone take you to the hospital?"
Start high-dose steroids immediately
"I'm going to start you on a high dose of steroids right away."
Arrange same-day rheumatology appointment

Patient Concerns
Patient may ask: "Will I get my vision back?" Response: "Unfortunately, the changes are not
reversible. It's like a stroke in the eye. We're treating to protect your other eye."

Pituitary Adenoma
Patient Profile
Male, age not specified
Setting: GP
Presenting complaint: "My wife thinks I'm going blind"

Key History Points

Recent incidents:
Ask: "Why does your wife think you're going blind?"
Patient response: "I broke my side mirror"
Follow-up: "Is this the only accident you've had?"
Patient may add: "There are some scratches on the side of my car, but I don't
know how that happened"
Vision questions:
"How is your vision generally?"
"Do you have any patches or dark areas in your vision?"
"Do you have any problems with reading, writing, or recognizing faces?"
"Can you read number plates or identify objects clearly?"
"Do you have any problems with night vision?"
"How is your vision when the light is low or dim?"
Other symptoms:
"Have you had any headaches?"
"Any balance problems?"

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"Any numbness or weakness in your body?"

"Have you noticed any changes in your weight?"
"Any changes in your facial appearance?"
"I'm sorry to ask this, but have you noticed any unusual discharge from your
breast?" (Ask sensitively, explain why you're asking)
Driving history

Examination Findings (given on paper)

Bitemporal hemianopia

Explanation to Patient
"The examination shows you have something called bitemporal hemianopia. This means
you can't see on the sides, but you can see everything in front without problems. This may
be due to a condition called pituitary adenoma."
"At the base of our brain, there's a small gland called the pituitary gland. It produces
hormones that control other hormones, growth, and various body functions. When there's
a growth or tumor in this gland, it can compress the nerve responsible for vision, affecting
your vision in this way."

Management
Two-week pathway referral to endocrinology
"I'm going to refer you to an endocrinologist. You should be seen within two
weeks."
Endocrinology will arrange MRI
If confirmed, referral to neurosurgeons
Treatment:
Usually surgery (through the nose)
Sometimes medical treatment by endocrinologists if possible

Important Notes
GCA:
Remember the two presentations: simple headache and sudden vision loss
Always consider GCA in older patients with new headaches or visual symptoms
Immediate steroid treatment is crucial
Discuss steroid side effects (one of five scenarios where this is necessary)
Pituitary Adenoma:
Be aware of subtle presenting complaints like "My wife thinks I'm going blind"
Thorough vision history is crucial
Remember to ask about endocrine symptoms (e.g., milky discharge)
Bitemporal hemianopia is a key finding, not a diagnosis
Explain bitemporal hemianopia in simple terms

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General:
Be prepared for patients to describe symptoms in unexpected ways (e.g., "curtain
falling" for GCA vision loss)
Always complete a thorough history (MAFTOSA)
Be prepared to explain conditions and treatments in patient-friendly language
Remember the urgency of these conditions and the need for prompt referral and
treatment
Note the changes in examination procedures since the pandemic (e.g., no
mannequins, findings given on paper)
Differential Diagnosis:
For sudden vision loss, consider: Stroke, TIA, Retinal detachment, GCA,
Hypertension, Diabetes, Central retinal artery occlusion
For visual field defects, consider: ARMD, Cataract, GCA, Pituitary adenoma
Exam Tips:
GCA is considered an easy diagnosis in PLAB 2
Pituitary adenoma may present with unexpected symptoms (e.g., car accidents
due to visual field loss)
Be prepared for scenarios where symptoms are described in ways that seem to fit
other conditions (e.g., "curtain falling" in GCA, which sounds like retinal
detachment)

Carbon Monoxide Poisoning

Patient Profile
18-year-old adult
Setting: GP (Note: Sometimes can be a telephone consultation, but not currently)
Presenting complaint: Headache

Key History Points

Duration: Headache for one month
Ask: "How long have you had this headache?"
Expected response: "For about a month"
Character: Bursting headache
Ask: "What sort of headache is it?"
Expected response: "It's a bursting headache"
Alleviating factors: Better when going out of the house
This will be revealed during SOCRATES questioning
Social history: Lives with boyfriend
This will be revealed during COMAH questioning
Other information: Landlord recently did maintenance work
This will be revealed during COMAH questioning

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History Taking (SOCRATES + COMAH)

SOCRATES
Site: Could be everywhere
Ask: "Where exactly do you feel the headache?"
Note: Patient might indicate various areas
Onset: One month ago
Already established in initial questioning
Character: Bursting
Already established in initial questioning
Radiation: Ask about any radiation
Ask: "Does the pain spread to any other areas?"
Alleviating/Aggravating factors:
Ask: "Is there anything that makes it better?"
Follow up: "What about moving away from your building?"
Expected response: "Yes, it gets better when I go out of the house"

COMAH (Insert between Alleviating and Aggravating in SOCRATES)

C for Cohabitants:
Ask: "Is there anybody living with you?"
Expected response: "Yes, I live with my boyfriend"
Follow up: "Has your boyfriend complained of similar symptoms?"
Ask: "Is there any pregnant woman in the household?"
Ask: "Are there any children staying in the house?"
Ask: "Does anyone else who visits or stays overnight complain of similar
symptoms?"
O for Outdoor activity:
Ask: "Does the headache improve when you go outdoors?"
Expected response: "Yes, it gets better when I go out"
M for Maintenance work:
Ask: "Has there been any recent maintenance work in your home?"
Expected response: "Yes, the landlord recently did some maintenance work"
Follow up: "Was any work done on the boiler or cooker?"
Ask: "Have you had any recent installment of a boiler or cooker?"
Ask: "Have you had any indoor barbecues recently?"
A for Alarm:
Ask: "Do you have a carbon monoxide alarm in your home?"
Note: Emphasize this is different from a smoke alarm
H for Housing
Ask about ventilation: "How is the ventilation in your home? Are there windows in
all rooms, including the bathroom?"

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Additional Symptoms to Ask About

Ask the patient if they've experienced any of the following:
Muscle pain
Chest pain
Any symptoms that might suggest a heart attack
Dizziness
Confusion
Blushing
Personality changes

Examination
State: "I would like to perform a neurological examination"
Note: Observation is normal (Don't assume low oxygen saturation)

Diagnosis
State to the patient: "Based on your symptoms and history, this could be carbon monoxide
poisoning."

Explanation to Patient
"Carbon monoxide poisoning occurs when you breathe in carbon monoxide, which is a
toxic gas. It can come from faulty equipment like boilers. Carbon monoxide is produced
when gas doesn't burn completely. It's important to understand that it's colorless and
odorless, so you can't see or smell it. When it reaches a certain level in your body, it starts
showing toxic symptoms."

Management (6 steps)
Emergency:
Tell the patient: "This is an emergency situation. You need to go to the hospital
immediately."
Hospital investigations:
Explain: "At the hospital, they will do a blood test to check your
carboxyhemoglobin level. This will confirm if you have carbon monoxide
poisoning."
Treatment:
Explain: "If the test confirms carbon monoxide poisoning, the treatment is high
flow, 100% oxygen."
Notification:
Inform the patient: "Carbon monoxide poisoning is a notifiable condition,
which means we have to report it to health authorities."

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Inform landlord:
Advise: "You need to inform your landlord about this. They are required to
inform a place called gas line."
Follow-up:
Instruct: "Your boyfriend should also get tested for carbon monoxide poisoning."
"I'd like you to come back for a follow-up appointment in one month."

Important Notes
Differential diagnosis:
For one-month headache, consider: sinusitis, migraine, and carbon monoxide
poisoning
Always consider serious conditions like meningitis, even for long-standing
headaches
Don't do differential diagnosis based on headache location. Always consider all
types of headaches.
Carbon monoxide facts:
Produced when gas burns incompletely (Carbon + Oxide → Carbon dioxide,
but incomplete burning leads to carbon monoxide)
Not related to electrical heaters or smoke
Can cause heart attacks (mechanism not specified in transcript)
Examination and symptoms:
Don't assume low oxygen saturation. Carbon monoxide poisoning works
through a different mechanism.
If oxygen saturation were low, the patient would have shortness of breath, which
is not a typical symptom of carbon monoxide poisoning.
Alarms and ventilation:
Be careful not to confuse carbon monoxide alarms with smoke alarms
Remember to ask about ventilation in the house, especially in flats in London
which often have poor ventilation
Treatment:
Don't base treatment on oxygen saturation levels. There's no treatment based on
high or low saturation.
History taking:
Always complete PMAFTOSA (Medical history, Allergies, Past medical history,
Treatment, Occupation, Social history, Effect on life)
Use the SOCRATES + COMAH approach for detailed history taking
Things to avoid:
Don't ask about electrical heaters or anything related to electricity
Avoid mentioning smoke or smoke alarms when discussing carbon monoxide
Don't assume or mention low oxygen saturation

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Sinusitis
Definition
Sinusitis is inflammation of the sinuses.

What are sinuses?

Sinuses are empty pockets or spaces in our facial bones.

Important Notes
Only acute bacterial sinusitis is considered in PLAB 2
Presents with greenish discharge
Treated with phenoxy methyl penicillin
No viral sinusitis scenarios in PLAB 2
No testing required

Key Points to Remember

Don't mention viral sinusitis
Don't suggest any testing
Don't overcomplicate the scenario

Explanation to Patient
"Sinusitis is an inflammation of the empty spaces in your facial bones. In your case, it
appears to be a bacterial infection, which we can treat with an antibiotic called phenoxy
methyl penicillin."

Tension Headache
Scenario Details
Setting: GP
Patient: Usually a man, but sometimes a woman
Includes eye mannequin examination

Key History Points

Timing:
Ask: "When do you usually get these headaches?"
Expected response: "Especially in the evening, after work, or in the last hour of
work"
Follow-up: "Do you notice the headache starting when you get home from
work?"

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Occupation:
Ask: "What do you do for work?"
Expected response: "I'm a teacher"
Note: Teaching is considered very stressful in the UK
Location:
Ask: "Where exactly do you feel the headache?"
Expected response: "On both sides of my head, like a band"
Character:
Ask: "How would you describe the pain?"
Expected response: "It feels like pressure or tightness"
Frequency:
Ask: "How often do you get these headaches?"

Examination
State: "I'd like to examine your eyes now"
Use the eye mannequin, but no abnormal findings will be visible
Even if the examiner offers to give you the findings verbally, insist on examining the
mannequin yourself

Diagnosis
"Based on your symptoms and the examination, this seems like a tension-type headache,
which is a headache due to stress."

Treatment
Over-the-counter painkillers:
Advise: "You can take paracetamol or aspirin for the pain"
Warning: "Be careful not to overuse these medications, as that can lead to
medication overuse headaches"
Alternative treatments:
Suggest: "Some people find acupuncture helpful for tension headaches"
Advise: "Regular exercise can also help reduce stress and prevent these
headaches"
Optional: "For some people, physiotherapy can be beneficial"

Important Notes
Discuss medication overuse: "It's important not to take painkillers too frequently, as
this can actually cause more headaches"
Remember it's a mannequin scenario, usually male but not always
Pay attention to the occupation and timing of headache onset
Don't diagnose as "just a headache" - always provide a specific diagnosis

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Intracranial Hypertension
Scenario Details
Setting: GP
Patient: Female, visibly obese (dressed to appear large or with a pillow inside clothing)
Includes eye mannequin examination

Key History Points

Duration:
Ask: "How long have you been having these headaches?"
Expected response: "For several weeks"
Associated symptoms:
Ask: "Have you noticed any changes in your vision?"
Expected response: "Yes, my vision has been blurry"
Aggravating factors:
Ask: "Does anything make the headache worse?"
Expected responses:
"Coughing and sneezing make it worse"
"Bending down or leaning forward makes it worse"
Risk factor:
Note the patient's visible obesity (don't comment on it directly)
Medication history:
Ask: "Are you taking any medications, including contraceptives?"
Expected response: "Yes, I'm on the pill"
Note: OCP use is protective, mentioned to confuse you

Examination
State: "I'd like to examine your eyes now"
Use the eye mannequin
Findings: Papilledema (swollen disc)
Appearance: Yellowish, light-colored discs on both sides
If you haven't seen papilledema before, google some images before the exam

Explanation to Patient
"When I examined your eyes, I noticed that the back of your eyes, called the optic discs,
appear swollen. This swelling is due to increased pressure inside your head. You could be
having a condition called intracranial hypertension, which means the pressure inside your
skull is increased. Being overweight can contribute to this condition."

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Management
Immediate referral:
Advise: "I need to refer you to the hospital's Accident & Emergency department
immediately"
Investigations:
Explain: "At the hospital, they will likely perform a CT scan to further
investigate the pressure in your head"
Treatment:
Explain: "Treatment usually starts with medication given through an IV, called
acetazolamide"
Further information: "In some cases, if medication doesn't work, surgery to place
a shunt might be considered, but that's usually a last option"

Important Notes
Remember to note the visible obesity without commenting on it directly to the patient
Don't be confused by the OCP use - it's protective, not causative
Be prepared to explain papilledema to the patient in simple terms
Know the management steps from IV medication to potential surgery

General Notes
There's no such thing as "just a headache" in PLAB 2 scenarios
Always provide a specific diagnosis
Be aware of changes in scenarios pre- and post-pandemic (e.g., tension headache
becoming a mannequin scenario)
When a mannequin is present, always examine it even if the examiner offers to give you
the findings verbally
For sinusitis, remember it's always acute bacterial sinusitis in PLAB 2, treated with
phenoxy methyl penicillin
For tension headache, remember the key features: teacher occupation, end of day onset,
bilateral band-like pain
For intracranial hypertension, remember the key features: obese female, blurry vision,
worsening with coughing/sneezing/bending, papilledema on examination

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Chest Pain
Scenarios
Myocardial Infarction (MI)
Unstable Angina
Stable Angina
Musculoskeletal Pain
Pericarditis
Shingles
Pulmonary Embolism (PE)
Post-therapeutic Neuralgia
Note: There is no distinction between acute coronary syndrome and non-ST elevation MI
in this context.

Diagnostic Approach

Initial Patient Interaction

When a patient presents with chest pain, begin your assessment as follows:
Ask: "What sort of chest pain are you experiencing?"
This open-ended question allows the patient to describe their symptoms in their
own words.
Ask: "Where do you feel the pain in your chest?"
Key point: Cardiac origin pain is typically retrosternal (behind the sternum), not
on the left side.
Ask: "Does the pain move to your arm?"
This question helps identify classic cardiac pain radiation.

Critical Diagnostic Questions

Ask: "Do you have chest pain at the moment, right now as we talk?"
If the patient says yes: This strongly suggests MI. Treat as MI until proven
otherwise.
If the patient says no: Move to the next set of questions.
If the pain occurred earlier, ask: "When did you have this chest pain?"
Patient might respond: "Earlier today."
Follow up with: "What were you doing when the pain started?"
Patient might respond: "I was walking my dog."
Crucial question: "Have you ever had any chest pain while at rest?"
Clarify: "By rest, I mean sitting down and reading a newspaper or book,
watching TV, sitting and talking to someone, or at night while in bed."
If the patient says yes: This indicates unstable angina.
If the patient says no: Proceed to the next question.

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Ask: "Do you only get chest pain when you do exercise or work uphill?"
If yes, follow up with: "Does the pain go away when you rest?"
If the patient answers yes to both: This suggests stable angina.

Detailed Differential Diagnosis

Myocardial Infarction (MI)

Key identifier: Patient is experiencing chest pain at the time of consultation.
Action: Treat as MI until proven otherwise.

Unstable Angina
Key identifier: History of chest pain occurring at rest.
This includes pain while:
Sitting and reading
Watching TV
Talking to someone
Lying in bed at night

Stable Angina
Key identifiers:
Pain only occurs with physical exertion (e.g., exercise, walking uphill)
Pain relieves with rest
No history of pain at rest

Other Conditions
While focused on cardiac causes, be aware of other potential causes like
musculoskeletal pain, pericarditis, shingles, pulmonary embolism, and post-
therapeutic neuralgia.

Important Considerations
Location of pain:
Cardiac pain is typically retrosternal, not left-sided.
Ask specifically: "Where do you feel in the chest?"
Radiation of pain:
Typical cardiac pain may radiate to the arm.
Ask: "Does it go to your arm?"
Timing of pain:
Current pain vs. past pain is crucial for differentiation.
Activity relation:
Understand if pain is related to exertion or occurs at rest.

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Diagnostic Pearls
Current chest pain of cardiac origin strongly suggests MI.
Rest pain is a key indicator of unstable angina.
Pain only with exertion, relieved by rest, suggests stable angina.
The pattern of pain occurrence is crucial for differentiation.

Sample Conversation Flow

Doctor: "Hello, I understand you're here because of chest pain. Can you tell me more
about it?"
Patient: "Yes, I've been having this pain in my chest."
Doctor: "Where exactly do you feel the pain in your chest?"
Patient: "It's right here in the middle of my chest."
Doctor: "Does the pain move anywhere else, like to your arm?"
Patient: "Yes, sometimes it goes down my left arm."
Doctor: "I see. Are you having this pain right now as we speak?"
Patient: "No, not right now."
Doctor: "When did you last experience this pain?"
Patient: "Earlier today when I was walking my dog."
Doctor: "Have you ever had this pain while you were resting? For example, while sitting
and reading, watching TV, or at night in bed?"
Patient: "No, I only get it when I'm active."
Doctor: "So you only get this pain when you're doing something physical, like exercise or
walking uphill?"
Patient: "Yes, that's right."
Doctor: "And does the pain go away when you rest?"
Patient: "Yes, it does."
Doctor: "Thank you for this information. Based on what you've told me, it sounds like you
might be experiencing what we call stable angina. However, we'll need to do some further
tests to confirm this."

Things to Avoid During Consultation

Don't jump to conclusions based on incomplete information.
Avoid dismissing atypical presentations.
Don't forget to ask about pain at rest - it's a crucial differentiator.
Avoid medical jargon that patients may not understand.

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Myocardial Infarction (MI)

I. Clinical Scenario

A. Setting
Primary setting: A&E (Accident & Emergency) department
Historical note: Previously included scenarios over the phone
Pandemic impact: Increased telephone scenarios during the pandemic
Current focus: A&E setting (original scenario)

B. Patient Demographics
Age range: 50 to 60 years old
Note: MI can occur in relatively young patients
Typical age: Around 55-60 years old
Can be as young as 50

II. Patient Presentation

A. Chief Complaint
Chest pain

B. History of Present Illness

Onset:
Started 2-3 hours ago
Specific example: While having breakfast
Pain Characteristics:
Initial intensity: 9/10
Current intensity: 6/10 or 7/10
Location: Central, crushing chest pain
Radiation: Pain goes to the arm
Important Note:
Pain intensity decreased without intervention
Initial pain: 9/10
Current pain: 6/10 or 7/10
Caution: This decrease can be confusing
Key point: MI can present with decreasing pain intensity
Current Status:
Patient is experiencing chest pain during the consultation
Emphasized point: Pain is present "right now, as we talk"

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C. Risk Factors
Smoking history: Patient smokes
Family history:
Father had a heart attack
Brother had a heart attack or stroke
Other possibilities: "Somebody had a stroke, somebody had a heart attack"

III. Diagnostic Approach

A. History Taking
Use the SOCRATES method for comprehensive pain assessment

B. Physical Examination
Perform a focused cardiovascular examination

C. ECG
Order an ECG
Important note: ECG is going to be normal
This applies to:
Early MI
Unstable angina
Stable angina
Instruction: "Have a look, tell it is normal"

IV. Communication with Patient

A. Delivering the Diagnosis

Use a warning shot:
Exact phrase: "I'm afraid this chest pain may be coming from your heart."
State the possible diagnosis:
Exact phrase: "You could be having a heart attack. We call this myocardial
infarction."

B. Explanation of MI
Provide a simple explanation:
"In the heart, the heart has its own blood vessels."
"When there's a blockage in any of these blood vessels, that compromises the blood
supply to the heart cells."
"That causes the pain due to that blockage, obstruction, or clog formation."
"That compromises, reduces, interrupts the blood supply."
"That causes the pain."

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"That is heart attack."

V. Initial Management: MONA Protocol

A. Preparation
First step: Put a cannula

B. MONA Protocol
M - Morphine
Specific drug: Diamorphine
Administration: Through IV (intravenous)
Important note: Give metoclopramide with morphine
O - Oxygen
Administer if oxygen levels are low
N - Nitrates
Options: Nitrate spray or "keep it on my tongue"
A - Aspirin
Dosage: 300 milligram aspirin (higher dose)

VI. Further Investigations

Blood tests:
Troponin
Other blood markers
Repeat the ECG

VII. Referral and Further Management

A. Confirmation and Referral

Wait until MI is confirmed
Refer to cardiology when confirmed

B. Cardiology Management
Angiography
First step in cardiology management
Angioplasty
Performed if there is a blockage
Includes inserting a stent
Bypass Surgery
Indicated for multiple blockages

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VIII. Important Considerations

Do not discuss lifestyle changes during acute MI
Example given: "When somebody having a heart attack, you talk about lifestyle
changes. It's like you go to a wedding dinner and you are sitting and eating
bread."
Focus on immediate management and stabilization
Be prepared to explain the diagnosis and treatment plan clearly to the patient
Reassure the patient while maintaining the urgency of the situation

IX. Sample Conversation Flow

Doctor: "Hello, I understand you're having chest pain. Can you tell me when it started?"
Patient: "It started about two hours ago while I was having breakfast."
Doctor: "I see. On a scale of 0 to 10, how severe was the pain when it started?"
Patient: "It was really bad, probably a 9 out of 10."
Doctor: "And how would you rate the pain now?"
Patient: "It's better now, maybe a 6 or 7."
Doctor: "Where exactly do you feel the pain?"
Patient: "It's right in the center of my chest, and it sometimes goes down my arm."
Doctor: "Do you have any history of heart problems in your family?"
Patient: "Yes, my father had a heart attack, and I think my brother had a stroke."
Doctor: "Do you smoke?"
Patient: "Yes, I do."
Doctor: "Thank you for this information. I'm going to order an ECG for you."
[After ECG]
Doctor: "I've looked at your ECG, and it appears normal. However, I'm afraid this chest
pain may be coming from your heart. You could be having a heart attack, which we call
myocardial infarction. Let me explain what that means..."

X. Things to Avoid During Consultation

Don't dismiss the possibility of MI if pain has decreased without intervention
Avoid delaying treatment to discuss long-term lifestyle changes
Don't hesitate to communicate the seriousness of the situation
Avoid using complex medical terminology without explanation
Don't rush through the explanation of what's happening and what to expect

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Unstable Angina
I. Clinical Scenario

A. Setting
Most common chest pain scenario in General Practice (GP)
Reasons for GP setting:
Patient often says, "I don't want to go to hospital"
Can occur over the phone, especially during pandemic situations
Nowadays, usually inside the consultation room

B. Patient Demographics
Typical age: Around 65, 69 years old

II. Patient Presentation and History Taking

A. Current Status
Question: "Are you having chest pain at the moment?"
Typical response: "No"

B. Recent History
Question: "When did you develop chest pain?"
Patient might talk about yesterday
Important note: Patient may have had chest pain today (this morning) but won't
tell you initially
Key point: In unstable angina, patients often try to hide recent information
They don't like you knowing this
They don't like you being clever
You have to be clever to uncover the truth
Possible patient response: "I had chest pain this morning"
Follow-up question: "What were you doing this morning when you had chest pain?"
Typical evasive response: "I don't remember"
Critical question: "Have you had any chest pain while at rest?"
Need to provide examples of rest:
Reading a book
Watching TV
Speaking to somebody
Lying down on your bed
Possible patient responses:
"I was reading a magazine or newspaper this morning"

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"Yesterday, I was walking with a dog, then I got chest pain, then when I took a
rest, it went away"
Pattern of chest pain:
May report chest pain today, yesterday, last week, and last month
Or might skip today's episode and only mention yesterday, last week, and last
month
Important note: Patient might have had stable angina before, now progressing to
unstable angina

C. Differential Diagnosis
Don't forget anemia symptoms
Anemia can mimic unstable angina or stable angina
Ask about trauma
Go through all differentials for chest pain

III. Diagnostic Approach

A. ECG
Mention need for ECG
In GP setup, nurses might have already done it this morning
ECG result: It's going to be normal
Inform the patient: "ECG is normal"

IV. Communication with Patient

A. Delivering the Diagnosis

Statement: "This could be a condition called unstable angina"
Explanation of angina:
"Angina means chest pain"
"Angina means chest pain caused by reduced or compromised blood supply to
the heart cells, to the heart"
"Reduced blood supply to the heart muscles causes chest pain. That is angina"
Explanation of unstable angina:
"If somebody develops this chest pain spontaneously, without having any stress,
any exercise, that is called unstable"
"Spontaneous chest pain"

B. Emphasizing Seriousness
State: "It is a medical emergency"
Important note: Unstable angina is not an ambulance case
If the patient has chest pain at the moment, that is ambulance, that is MI

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Clinically, whenever you talk to somebody, if they have chest pain at the
moment, that is MI
Ask: "Can you go to the hospital?"
Typical patient response: "No, I don't want to go to the hospital"
Follow-up question: "Can I ask you why?"
Possible patient response: "Because I had bad memories. My father died of heart attack"
Acknowledge patient's concerns: "I understand sometimes it can be difficult"
Advise: "I will advise you to go"
Explanation:
"It is quite serious"
"If there is any delay in your assessment or in your treatment, this can put your
life in danger"
"We will advise you to go to the hospital"
"You do have risk for some heart attack"
"You mentioned to me your father had a heart attack. That increases the chances
of you developing heart attack"
"This can put your life in danger"

V. Management

A. Hospital Management (if time allows to discuss)

ECG
Cardiac marker tests
Possible angiography
Can be done on the same day or within very few days
Preventive medication

VI. Important Considerations

Differentiation between MI and Unstable Angina:
MI: In A&E or requires immediate ambulance if in GP with current chest pain
Unstable Angina: In GP, recent chest pain but not current
Patient Behavior:
May try to hide information about recent chest pain
Might be evasive or claim not to remember details
Don't like appearing less knowledgeable than the doctor
Progression:
Patient may have had stable angina before, now progressing to unstable angina
Family History:
Often includes history of heart problems (e.g., father died of heart attack)

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VII. Sample Detailed Conversation Flow

Doctor: "Hello, I understand you've been having chest pain. Are you having any pain right
now?"
Patient: "No, not at the moment."
Doctor: "When did you last have chest pain?"
Patient: "Well, I had some yesterday."
Doctor: "I see. What about this morning? Did you have any pain today?"
Patient: "Um... I don't really remember."
Doctor: "It's important to know if you've had any recent pain, even if you were resting. For
example, have you had any chest pain while reading a book, watching TV, or just lying in
bed?"
Patient: "Well... now that you mention it, I did have some discomfort this morning while
reading the newspaper."
Doctor: "Thank you for sharing that. It's crucial information. Have you had similar
episodes in the past week or month?"
Patient: "Yes, a few times. Last week and I think last month too."
Doctor: "I see. I'd like to do an ECG. [After ECG] The ECG looks normal, but based on
what you've told me, this could be a condition called unstable angina. Let me explain what
that means. Angina is chest pain caused by reduced blood supply to your heart. When this
happens spontaneously, without stress or exercise, we call it unstable angina. It's a serious
condition that needs prompt attention."
Patient: "But I don't want to go to the hospital. My father died there of a heart attack."
Doctor: "I understand that must be difficult for you. Sometimes these situations can be
challenging. However, this is a medical emergency. If there's any delay in assessment or
treatment, it could put your life in danger. The fact that your father had a heart attack
actually increases your own risk. I strongly advise you to go to the hospital for further tests
and possible treatment."
Patient: "I'm still not sure..."
Doctor: "I know it's a lot to take in, but your health and life are at stake here. The hospital
can provide necessary tests like cardiac markers and possibly an angiography. They can also
start you on preventive medication. This is the best way to protect yourself and prevent a
more serious heart attack."

VIII. Things to Avoid

Don't dismiss or overlook recent episodes that the patient might try to hide
Avoid assuming the patient will freely offer all relevant information
Don't forget to consider other differentials, especially anemia
Avoid using medical jargon without explanation
Don't neglect to emphasize the emergency nature of the condition, even if the patient is
reluctant to seek hospital care
Avoid rushing the conversation; give time for the patient to remember and share details

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Stable Angina
I. Clinical Scenario
A. Setting
General Practice (GP)

B. Patient Demographics
Age range: Around 60, 50, 69, 65
Note: Specific ages mentioned, showing variability

II. Patient Presentation and History Taking

A. Duration of Symptoms
Key identifier: Chest pain for the last six months
Critical point: "If you hear, I had a chest pain for the last six months. You should know
that it's going to be stable angina."

B. Pattern of Chest Pain

Triggered by exertion
Specific example: Gets chest pain whenever he walks uphill to the shop
Relief with rest
Specific example: Sits on a bench, chest pain goes away
Consistency
Has been occurring for the last six months
Critical point: Never had any rest chest pain

C. Detailed Scenario Example

Patient's living situation: "His cottage is here in the town"
Geographical description: "Okay, it is, you know, it's a hill, grass. There is a path."
Comparison: "Okay, imagine like a Switzerland."
Specific detail: "There is a bench."
Patient's routine:
"This man smokes and walk to the shop."
"He gets chest pain on the way."
"Okay, he sits on there, on the bench."
"Okay, then chest pain goes away."
"Then he walks up."
"He buys bread there."

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D. Additional Patient Information

"He's a smoker, okay."
Dietary habits: "His wife cooks, okay. His wife cooks and he eats, okay."
Note: This detail is repeated, suggesting importance

E. Differential Diagnosis
"Anemia symptoms, you must ask, okay."
"Anemia symptoms, you need to ask, right."
Note: Repeated emphasis on asking about anemia

III. Diagnostic Approach

A. History Taking
Focus on pattern of chest pain (exertion-induced, relieved by rest)
Duration of symptoms (six months)
Absence of rest pain

B. ECG
"You can mention ECG on your testing, so fine."

IV. Explanation to Patient

A. Defining Angina
"Angina means chest pain caused by, okay. Chest pain caused by, okay. Chest pain
caused by reduced blood supply to the heart muscles."

B. Explaining Stable Angina

"We call this as stable angina because this chest pain caused by doing exercise or with
the, okay. With the exercise or with the physical activity, okay."
"When there's a demand is high, okay. When there's a high demand of blood supply in
the, in the body and relieved with the rest, okay."
"So, this kind of chest pain can be relieved, okay. Stabilizes with the rest because that's
why we call this a stable angina."

V. Management

A. Immediate Management
Medications to take home:
"That is nitrates to take home, nitrates medication"
"Lower doses of blood, blood thinner medication. Okay, that is aspirin, seventy-
five milligrams."

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Tests to run:
"Then you run all the test, like anemia, cholesterol, you know, all the test, sugar
levels, all the test."

B. Referral
Refer to chest pain clinic
Specific name: "Rapid access chest pain clinic"
Acronym: "RACPC"
Type of referral: "Okay, urgent referral to the chest pain clinic."

C. What to Expect at the Chest Pain Clinic

"Okay, you'll be seen, you'll be assessed by the cardiology."
Tests they might do:
"They'll do blood test, okay, cholesterol, sugar"
"Okay, some stress test to the heart"
"They might do angiography, angiography."

D. Main Treatment
Preventive medication:
"That is blood thinner medication, cholesterol medication, blood pressure
medication."
Lifestyle changes
"In addition to that, making some lifestyle changes, you can improve. You could
improve."
"Okay. Yeah. You can reduce the chances. Okay. Chances."

VI. Important Considerations

Differentiation from other types of anginas:
Stable angina: Consistent pattern, exertion-induced, relieved by rest
No rest pain in stable angina
Risk Factors:
Smoking
Possibly poor diet
Chronic Nature:
Symptoms present for six months

VII. Sample Detailed Conversation Flow

Doctor: "Can you tell me about your chest pain?"
Patient: "Well, I've been having this pain for about six months now."
Doctor: "I see. Can you describe when you typically experience this pain?"

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Patient: "It happens when I walk up to the shop on the hill. There's a grassy path, kind of
like in Switzerland, you know?"
Doctor: "That's a helpful description. What do you do when the pain starts?"
Patient: "There's a bench on the way. I sit there for a bit, have a smoke, and the pain goes
away. Then I can continue up to the shop to buy bread."
Doctor: "Does the pain ever occur when you're resting or not exerting yourself?"
Patient: "No, never. It's only when I'm walking uphill."
Doctor: "I understand. Let me explain what I think is happening. This sounds like a
condition we call stable angina. Angina means chest pain caused by reduced blood supply
to your heart muscles. We call it stable angina when it occurs predictably with exercise or
physical activity and is relieved by rest, which is exactly what you're describing."
Patient: "I see. Is it serious?"
Doctor: "It's a condition we need to manage. I'm going to prescribe you some medications -
a nitrate to help with the pain and a low dose of aspirin. We'll also run some tests,
including checking for anemia, cholesterol levels, and blood sugar. Then, I'll refer you to
what we call a Rapid Access Chest Pain Clinic. There, you'll see a cardiologist who might
do some additional tests like a stress test or possibly an angiography."
Patient: "What about my smoking? And my wife's cooking?"
Doctor: "Those are important points. The main treatment will involve preventive
medications, but making some lifestyle changes can really improve your condition and
reduce your chances of it getting worse. We can discuss specific changes that might help
you."

VIII. Things to Avoid

Don't overlook the duration of symptoms - six months is a key identifier for stable
angina
Avoid dismissing the importance of the pain relief with rest
Don't forget to ask about anemia symptoms
Avoid using medical jargon without explanation
Don't neglect to mention the importance of lifestyle changes in management
Avoid rushing through the explanation of what stable angina is and why it's called
"stable"

Musculoskeletal Chest Pain and Pericarditis

I. General Considerations
Setting: Both conditions typically present in A&E (Accident & Emergency)
Patient Demographics:
Young patients
Specific ages mentioned: 20 to 30
Critical Point for All Chest Pain Cases:

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"Any, any person, regardless of the age, if they come to A&E with a chest pain,
you must do ECG and troponin."
Musculoskeletal Chest Pain
A. Clinical Scenarios
Scenario 1: Bicycle Fall

Scenario 2: Football Injury

"Patient was playing football and he was trying to give a head kick and he fell
down on the chest."

B. Past Medical History

Patient will have Von Willebrand disease

D. Patient Presentation
Musculoskeletal pain, when you ask the patient musculoskeletal pain, point out with
one finger, is going to point out the left side.
Note: Center is for the heart.
E. Physical Examination
Preparation:
If there is a couch, you need to know this is going to be an examination.
Sometimes patient can take out the t-shirt.
Steps:
"Have a look. Okay. For bruises and any skin changes and redness."
"Inspection, palpate. Just palpate for tenderness. Okay. Throughout the chest."
"Third one, pick up the stethoscope and listen to the heart and the lungs."
Possible Findings:
"Otherwise, the examiner will tell you there is some tenderness on the lower rib
or lower left rib, there is some tenderness."
F. History Taking
"When you take a history of the patient, ask - do you have any pain when you're
breathing?"
"Especially when you take a deep breath in or when you exhale."
"When you release your breath."

G. Diagnostic Approach
ECG:
X-ray:
"You need to do x-ray."
"If it is a trauma history, in order to see the injuries, we would like to do an x-
ray"

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Troponin:
"And a marker called troponin."

H. Management
Pain Management:
"I'll give you some painkiller like paracetamol type painkiller."
"If that doesn't help, you can take co-codamol."
Important Note:
"Mention specifically, we will advise you to not to take any aspirin or ibuprofen."
"Because you have a possibility of bleeding."
"because of this condition."

I. Communication with Patient

"It could be a condition called musculoskeletal pain that due to a trauma."

Pericarditis
A. Clinical Scenario
"Pericarditis is also young fellow in the, in the A&E around 25."
"He had come with the chest pain, central crossing chest pain."
"It is in the center. It's not crushing, but central chest pain"

B. Patient Presentation
Pain Characteristics:
"Leaning forward makes it better."
"Taking a deep breath in makes it worse."
Recent History:
Patient had a viral infection last week

C. Diagnostic Approach
ECG:
When you mentioned ECG in this scenario, they will give you an ECG here.
In Pericarditis, all the leads have the ST elevation."
Other Tests:
You need to do markers, ESR, CRP, troponin.

D. Management
First-line Treatment:
"Our treatment is ibuprofen."
"it is for about one to two weeks."

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If ineffective:
"Okay, if that doesn't work, you need to speak to your GP and get a medication
called colchicine."
If still ineffective:
"If that doesn't work, steroids."

E. Communication with Patient

Explaining ECG:
Never try to explain ECG to the patient.
We got the ECG. ECG is the tracing of your heart. The tracing of your heart
has got some changes. These changes are in line with, a condition called
pericarditis.
Explaining Pericarditis:
"Inflammation of the covering of the heart, usually caused by viral infections."
"If you had any viral infection, this causes pericarditis."
"Viral infection is the common reason. But meantime, it can be reactive."
"That means, reactive inflammation. That means, if you had a viral infection in
the past, as a reaction to the infection, the body can have inflammation in
some other parts of the body."

IV. Important Considerations

Always check for MI in any chest pain case:
ECG patterns across different conditions:
ECG in MI, normal.
ECG in unstable angina, normal.
No ECG in stable angina.
No ECG in musculoskeletal.
You have an ECG in pericarditis.
Resource for ECG learning:
Life on the Fast Lane.

Shingles
I. General Considerations
Prevalence: Shingles is the second most common cause of chest pain.
Patient Demographics: Shingles patients are typically around 70 years old. This age is
specifically chosen because there is a vaccination program in the NHS for
individuals between 65 and 80 years old.

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II. Patient Presentation

Chief Complaint: The patient typically presents with chest pain.
Pain Characteristics: When asked to point to the location of the pain, the patient will
indicate multiple areas across the chest. This scattered pattern of pain is unusual
and should be noted as a potential indicator of shingles.

III. Diagnostic Approach

A. History Taking
Begin with the SOCRATES method for pain assessment.
Key Questions: After completing the SOCRATES assessment, ask the patient if they
have noticed any rash. If a rash is present, it's crucial to determine when the rash
first appeared. This information is necessary to decide whether acyclovir treatment
can be administered effectively.
Additional Questions: For elderly patients, inquire about any immunocompromised
conditions. Ask about recent weight loss or fever, as these could indicate underlying
cancer. Confirm if the patient has had chickenpox in the past.
Important Note: Remember to consider the timing for treatment in cases of herpetic
vitiligo as well. Familiarize yourself with the treatment window for acyclovir in
various conditions.

B. Physical Examination
After taking the history, inform the patient that you need to perform a physical
examination.
Visual Inspection: When examining the patient, you will be provided with a picture of
the rash. Carefully observe the rash characteristics to confirm the diagnosis of
shingles.

IV. Diagnosis
Identifying Shingles: Based on the patient's history and the characteristic rash, you can
diagnose the condition as shingles.
Explaining Shingles to the Patient: Explain to the patient that shingles is a viral
infection causing a painful rash. It's caused by the same virus responsible for
chickenpox. After a person has chickenpox, the virus remains dormant in the
nerves. When the immune system is weakened, the virus can reactivate, causing
shingles.

V. Management
A. Treatment
Antiviral Medication: The primary treatment for shingles is acyclovir, an antiviral
medication. It should be administered for three to five days. Stress the importance
of starting treatment within 72 hours of rash onset for it to be effective.

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Pain Management: Recommend paracetamol and codeine for pain relief.

B. Prevention of Spread
Advise the patient that they can be infectious to individuals who have never had
chickenpox. The period of infectivity lasts until all vesicles have crusted over,
typically taking five to seven days.
Instruct the patient to avoid contact with babies less than one month old and pregnant
women.
Advise the patient to cover the rash while it's weeping to prevent spread.
Instruct the patient to avoid using adhesive dressings. The rash should be kept clean
and dry.

C. Vaccination
Inform the patient about the NHS vaccination program for individuals between 65 and
80 years old.
Advise the patient to make an appointment with the nurses for vaccination once they
have recovered from the current episode of shingles.

VI. Important Considerations for Healthcare Providers

Always ask about the exact timing of rash onset to determine if antiviral treatment is
appropriate.
Don't forget to inquire about the patient's history of chickenpox.
Be vigilant for signs of immunocompromise or underlying cancer in elderly patients.
Emphasize the importance of preventing spread to vulnerable individuals.
Remember to recommend vaccination for eligible patients after recovery.
Provide clear instructions on rash care and pain management.
Always give an information leaflet to reinforce your verbal instructions.

VII. Sample Conversation

Doctor: "Hello, can you tell me about the chest pain you're experiencing?"
Patient: "It's strange, doctor. The pain is all over my chest, in different places."
Doctor: "I see. That's an unusual pattern for chest pain. Have you noticed any rash
associated with this pain?"
Patient: "Yes, I noticed a rash recently."
Doctor: "Can you tell me exactly when you first noticed the rash? The timing is very
important for treatment."
Patient: "I think it was two days ago."
Doctor: "Thank you for that information. Have you ever had chickenpox?"
Patient: "Yes, when I was a child."
Doctor: "I see. Have you experienced any recent weight loss or fever?"
Patient: "No, nothing like that."

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Doctor: "Alright. I'd like to examine the rash now. [After examination] Based on what I see,
this condition is called shingles. It's caused by the same virus that causes chickenpox. The
virus has been dormant in your nerves since you had chickenpox and has now reactivated.
We'll start you on an antiviral medication called acyclovir for five days. It's important we
caught this within 72 hours of the rash appearing.
We'll also give you paracetamol and codeine for the pain. It's crucial to keep the rash clean
and dry, and avoid contact with pregnant women or babies under one month old until the
rash has fully crusted over, which usually takes about five to seven days. Don't use any
adhesive dressings on the rash.
Once you've fully recovered, we should discuss getting you vaccinated to prevent future
occurrences. There's a vaccination program for people between 65 and 80 years old.
Do you have any questions about what I've explained?"
Patient: "No, I think I understand. Thank you, doctor."
Doctor: "You're welcome. I'll provide you with an information leaflet with all these details.
Remember to make an appointment with the nurses for the vaccine once you've
recovered."

Pulmonary Embolism (PE)

I. General Considerations
Prevalence and Demographics:
PE in medical exams typically involves female patients.
Hangover headache is man, boy. Meningitis, boy. Migraine, there is a man and
lady. Tension headache, boy, but there is a lady as well now.
Importance of Early Recognition: Recognizing the possibility of PE early in the
consultation can boost confidence, improving communication and explanation
skills.

II. Patient Presentation

A. GP Setting
Chief Complaints:
Chest pain
Shortness of breath
No fever
Risk Factors (at least two will be given):
Use of oral contraceptive pills (OCP)
Recent long-distance travel, e.g., "Patient had a flight from Turkey. The flight
took about four hours. She was coming from holiday."
Recent surgery with bed rest, e.g., "Patient had appendicectomy and was
bedridden with contraceptive pills."

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B. A&E Setting
Patient Demographics:
Very young person, around 23 or 25.
Presentation:
Shortness of breath for the last three days, worsening with walking
Chest pain
No fever
Low oxygen saturation
Tachycardia
No elevated temperature
Patient is "stable" - clinically stable
Important History:
Recent A&E visit for leg pain and swelling last week
Left against medical advice due to pet care concerns
Social History:
Homelessness
Recreational drug use, including IV drug use
Shares needles but not sexually active

III. Diagnostic Approach

A. History Taking
DVT Symptoms: Ask about the four key symptoms of Deep Vein Thrombosis:
Swelling of the leg
Pain in the leg
Redness of the leg
Feeling warm
PE Symptoms:
Chest pain
Shortness of breath
Tachycardia
Feeling dizzy
Collapse
Some may have a dry cough
Risk Factors: Explore all potential risk factors mentioned earlier.
Social History: Ask about occupation, drug use, and sexual activity.

B. Physical Examination
Perform a thorough physical examination.

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C. Diagnostic Tests
ECG:
Look for sinus tachycardia
There will be a P wave with the QRS complex. And the PR interval will be
shorter.

IV. Diagnosis
Explain PE to the patient: "Pulmonary embolism means basically clot in your lungs. If you
take contraceptive pills or if you stay still in one place for a long time, you can develop this
when you have poor circulation."
For IV drug users: "IV drug use causes thrombophlebitis. Thrombophlebitis causes
thromboembolism. Thromboembolism can cause PE and DVT."

V. Management
A. Immediate Management
In GP Setting:
Call an ambulance
If patient resists: "It is not safe. People with this condition can develop cardiac
arrest. Sudden cardiac arrest. Suddenly your heart stops beating. It can
collapse. It can put your life in danger."
Explain benefits of ambulance: "It is better to be under supervision of an
ambulance crew. They can monitor. They can start your treatment. Inform
the hospital. Arrange some treatment over there."
In A&E Setting:
Admit the patient

B. Addressing Patient Concerns

For patients worried about pet care: "There may be local charities that can help. A charity
can help if you don't have anybody to look after your pet."

VI. Important Considerations

Always consider PE in female patients with chest pain and relevant risk factors.
Be thorough in asking about DVT and PE symptoms and risk factors.
For IV drug users, be aware of the thrombophlebitis-thromboembolism connection.
Consider social circumstances that may complicate care.
Benefits of ambulance transport: "Guarantee the travel. Safe passage. Initiation of the
treatment. Continuous monitoring. Inform the hospital. Make necessary
arrangements in the hospital. You get priority."

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Post-Herpetic Neuralgia
I. General Considerations
Scenario Frequency: This scenario appears occasionally, approximately twice a year in
exams. Despite its infrequency, it's important to be prepared for it.
Setting: This is a follow-up scenario typically set in a General Practice (GP) setting with
an F2 doctor.
Patient Demographics: The patient is usually around 55 years old and male.
Context:
The patient was diagnosed with post-herpetic neuralgia by a colleague last week.
Initial treatment with co-codamol was started.

II. Six-Step Approach to Follow-up

1. Paraphrase
Begin the consultation by paraphrasing the situation. Use the following dialogue:
Doctor: "I understand you're here for a follow-up today. Also, I understand that recently
you have been diagnosed with a condition. What have you been told? What is your
understanding? Can you tell me what happened last week?"
Patient: "Yeah, I had a chest pain."
Doctor: "Did anyone explain to you exactly what sort of condition you have?"

2. Check Understanding and Explain

After the patient responds, provide an explanation:
Doctor: "Let me explain what post-herpetic neuralgia means. Neuralgia means nerve pain.
Post-herpetic neuralgia means pain after having shingles. You had shingles last week, which
is a viral infection. This viral infection affects the nerves. So, even after your recovery from
the rash, you can still have pain because that viral infection affected the nerve. That's what
we call post-herpetic neuralgia - pain in the nerves after shingles."
Note: The explanation doesn't need to be a robotic definition. Focus on helping the
patient understand. After explaining, ask:
Doctor: "Do you understand?"

3. Discuss Treatment
Ask about the treatment:
Doctor: "What sort of treatment have you been given?" Patient: "I was given co-codamol."
Doctor: "Do you take it regularly?" Patient: [Allow for patient response]
Doctor: "Is it helpful?" Patient: [Allow for patient response]

4. Assess Symptoms
Inquire about symptoms:
Doctor: "What sort of symptom did you have initially?" Patient: "I had pain."

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Doctor: "Can you grade the pain before the treatment on a scale of 1 to 10, where 10 is the
worst pain you can imagine?" Patient: [Allow for patient response]
Doctor: "And how would you grade the pain now after the treatment?" Patient: "Earlier it
was like a 10 or 9, now it's a 6."
Ask about side effects of co-codamol:
Doctor: "Have you experienced any side effects from the co-codamol? These might include
nausea, vomiting, constipation, or breathing issues." Patient: [Allow for patient response]

5. Discuss Complications
Explain potential complications:
Doctor: "Post-herpetic neuralgia can sometimes lead to complications like depression or
affect your mood. How is this condition affecting your life?" Patient: [Allow for patient
response]

6. Address Ongoing Management

Assess the effectiveness of the current treatment:
Doctor: "Based on what you've told me about your pain levels, it seems the co-codamol is
helping somewhat. However, if the pain doesn't improve further with co-codamol, we
might consider stepping up to a medication called gabapentin."
If the patient asks about topical treatments:
Patient: "Do you have any cream I can apply, doctor?"
Doctor: "Yes, there is a cream called capsaicin that you can apply for this pain. It's made
from capsicum, which is chili. You can apply this to the affected area."

III. Important Considerations

This follow-up approach can be used for various conditions, not just post-herpetic
neuralgia.
Always assess the effectiveness of the current treatment by comparing pre- and post-
treatment pain levels.
Be prepared to adjust treatment if necessary, such as switching from co-codamol to
gabapentin if pain relief is inadequate.
Address any patient concerns or questions about their condition or treatment.
Remember that explanation is part of the management. Helping the patient understand
their condition is crucial.
When explaining the condition or treatments, avoid using overly technical language.
Aim for clear, simple explanations that the patient can easily understand.

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Ectopic Pregnancy
Patient Information
21-year-old female
Presenting with abdominal pain
Setting: General Practitioner's (GP) office

History Taking
Chief complaint: Abdominal pain
Started yesterday
No other symptoms mentioned initially
Menstrual history:
Last menstrual period (LMP): 6 weeks ago
Period is late by 2 weeks
Sexual history:
In a relationship (has a boyfriend)
Contraception: Uses condoms inconsistently ("on and off")
Risk factors:
No mentioned risk factors for previous infections

Diagnostic Process
Consider causes of acute abdominal pain
After completing history, mention pregnancy test
Pregnancy test result: Positive

Diagnosis
Suspect ectopic pregnancy (pregnancy outside the womb)

Explaining to the Patient

Inform about the nature of the condition: "I'm afraid this type of pregnancy is outside
the womb, which we call an ectopic pregnancy."
Explain the prognosis: "Unfortunately, this sort of pregnancy will not continue to
grow."
Emphasize the need for immediate action: "This needs to be confirmed immediately,
and you need treatment. You need to be assessed right away."
Recommend hospital transport: "I'm going to call an ambulance to take you to the
hospital for immediate assessment and treatment."

Patient's Likely Response

Patient: "Doctor, I don't want an ambulance. It's too much drama. I came with my
boyfriend. Can I go with him instead?"

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Addressing Patient's Concerns

Explain the risks: "I understand your concern, but it's not really safe to go by private
transport. An ectopic pregnancy can burst and bleed anytime. You can have profuse
bleeding within a very short period of time."
Emphasize the dangers: "You could collapse on the way to the hospital. We can't
guarantee how you'll reach the hospital safely."
Highlight the benefits of ambulance transport: "If you go by ambulance, they can
monitor you, start treatment, give fluids, and keep an eye on you throughout the
journey. They'll also be in communication with the hospital, arranging priority
treatment for when you arrive."
Explain hospital procedures: "When you get to the hospital, they'll do a blood test to
check your hormone levels and perform an ultrasound to confirm the diagnosis."
Discuss potential treatments: "You might need a keyhole surgery to remove the
pregnancy. In some cases, they might offer medical treatment, but surgery is more
common for this condition."

Things to Avoid
Don't dismiss the patient's concerns about using an ambulance
Avoid using excessive medical jargon
Don't rush through the explanation of risks
Never understate the seriousness of the condition

Legionella Pneumonia
Patient Information
Presenting in Accident & Emergency (A&E) with cough and fever
History Taking
Chief complaints:
Cough
Fever
Ask: "Are you coughing up any phlegm or mucus?" Patient response: "Yes, I'm
coughing up some yellow stuff."
Previous treatment:
Ask: "Have you seen any doctor for this before coming here?" Patient response:
"Yes, I saw my GP."
Ask: "Did they give you any medication?" Patient response: "Yes, they gave me an
antibiotic, but it didn't work." (Note: The antibiotic was likely amoxicillin)
Travel history:
Ask: "Have you traveled anywhere recently?" Patient response: "Yes, I just got
back from Spain."

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Accommodation details:
Ask: "What kind of place did you stay in while in Spain?"
Ask: "Did you use air conditioning in your accommodation?" (Note: Answers to
these questions are not provided in the transcript, but are important to ask)

Suspecting Legionella
Key factors:
Travel to Spain (a hot country)
Previous antibiotic treatment failure
Potential exposure to stagnant water (e.g., in air conditioning systems)
Differential diagnosis: Consider atypical pneumonia, specifically Legionella pneumonia

Explaining to the Patient

"Based on your symptoms and travel history, I suspect you might have a type of chest
infection called pneumonia. Particularly, this could be a type of pneumonia called
Legionella pneumonia. It's named after the bacteria that causes it, which often grows in
stagnant water in warm climates, like in air conditioning systems in hot countries."

Diagnostic Process
Explain the need for tests: "To confirm this, we need to run some tests now."
Describe the tests:
"We'll do a chest X-ray to look at your lungs."
"We'll need a urine sample to check for a specific marker of Legionella
infection."
"We'll also take a throat swab to check for another type of atypical pneumonia
called Mycoplasma."
Explain the importance of these tests: "These tests will help us determine exactly what's
causing your symptoms and guide our treatment."

Treatment
"If we confirm it's Legionella, we'll treat you with an antibiotic called clarithromycin, which
is effective against this type of pneumonia."

Additional Notes
Pneumocystis Pneumonia
Mentioned as another type of pneumonia, but no specific details provided in the
transcript

NEWS Chart Scenario

Similar scenario exists for hospital setting using NEWS chart

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Important Points to Remember

Always consider ectopic pregnancy in women of reproductive age with abdominal pain
and late period
Emphasize the urgency and potential dangers of ectopic pregnancy to patients
For suspected atypical pneumonia, especially with travel history, consider Legionella
Remember the diagnostic tests:
Legionella (L) - urine sample
Mycoplasma (M) - mouth/throat swab

Things to Avoid During Consultation

Don't dismiss patient's preferences for transport, but explain risks thoroughly
Avoid medical jargon when explaining conditions to patients
Don't forget to ask about travel history in respiratory infections
Never assume typical antibiotics will work for atypical pneumonia without proper
testing
Don't rush through explanations or ignore patient concerns

Key Associations to Remember

Ectopic pregnancy: Abdominal pain + late period
Legionella: Travel to hot countries + pneumonia symptoms + failure of typical
antibiotics
PID (Pelvic Inflammatory Disease): Mentioned in relation to ectopic pregnancy, but no
details provided in the transcript

Dizziness Scenarios
Overview of Dizziness Scenarios
There are only three main scenarios in the entire curriculum where a patient presents
primarily with dizziness:
Benign Paroxysmal Positional Vertigo (BPPV)
Meniere's Disease
Vestibular Neuritis
Important notes:
There are no scenarios where acoustic neuroma presents primarily as dizziness.
Some people mistakenly ask about meningitis in dizziness cases, but this is not
appropriate.

Setting of Scenarios
BPPV and Meniere's Disease: General Practitioner (GP) setting
Vestibular Neuritis: Accident & Emergency (A&E) setting

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Approach to a Patient Presenting with Dizziness

1. Establish the Nature of Dizziness

First question to ask: "What do you mean by feeling dizzy?"
Don't assume; always clarify with the patient
Provide options immediately to help the patient describe their experience:
"Does it mean the room is spinning?"
"Do you feel faintish and weak and black out?"
"Do you feel like you are spinning?"

2. Duration and Pattern

Ask: "Since when have you been experiencing this?"
Clarify: "Is it continuous or does it come and goes?"
If episodic: "How long does each episode last?"
"How many episodes have you had so far?"

3. DOOPARA Approach (preferred over ODIPARA)

D: Duration (already covered)
O: Onset (started suddenly or gradually)
O: Other associated symptoms
P: Progression (getting better or worse)
A: Aggravating factors
Ask: "Is there anything that makes it worse?"
Examples:
"Does moving your head make it worse?" (relevant for BPPV)
"Does sitting up or standing up from a chair make it worse?"
R: Relieving factors
Ask: "Is there anything that makes it better?"
Examples: Taking rest, sleeping, lying down
A: Associated symptoms

4. DVTF Questions
D: Deafness (hearing problems)
V: Vertigo
T: Tinnitus
F: Fullness (in the ear)

5. Differential Diagnosis Questions

For Vestibular Neuritis: "Have you had any recent flu or fever?"

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6. Other Important Considerations

For elderly or middle-aged patients in A&E, consider:
TIA/Stroke
Heart problems
Blood pressure-related issues
Metabolic issues (e.g., blood sugar)
Complete MAFTOSA
Blue section:
Occupation (very important)
Example: If the patient is a scaffolder, this is crucial information
Driving
Eyes (effect of symptoms on vision)

Examination
ENT examination
Cranial nerve examination
Balance examination

Key Points to Remember

Duration is crucial for differentiating between conditions:
BPPV: Few seconds to maximum 1 minute
Meniere's Disease: Used to be 15-20 minutes, now up to 24 hours
Vestibular Neuritis: Lasts for days, patient will have symptoms at the time of
consultation
Always clarify what the patient means by "feeling dizzy"
Don't assume; always ask specific questions
Use the DOOPARA approach for a thorough history
Don't forget to ask about hearing problems (deafness)
Consider occupation and its implications (e.g., scaffolder)
Advise patients about driving and work implications

Things to Avoid
Don't assume you know what the patient means by "dizzy"
Don't forget to ask about occupation and driving
Don't omit questions about hearing problems
Avoid asking too many irrelevant questions in exams
Don't forget to consider central causes (TIA/stroke) in appropriate patients

Examination Notes
All scenarios mentioned are history-based
No specific examination findings are mentioned

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Benign Paroxysmal Positional Vertigo (BPPV)

Patient Profile
Setting: GP
Patient: Middle-aged man, around 50 years old
Occupation: Scaffolder (works at height on frames)
Chief Complaint: Dizziness for the last one week
Duration of episodes: Used to say only for few seconds, now he says one minute
Note: Manager asked him to see the doctor

History Taking
Follow the DOOPARA approach as outlined earlier
Pay special attention to occupation and impact on work

Examination
Perform Dix-Hallpike maneuver
Remember: "Dix for diagnosis" (D for D)
In this scenario, Dix-Hallpike is positive
Note: The transcript mistakenly refers to this as "Dix-Holbein", but Dix-Hallpike
is the correct term

Diagnosis
Benign Paroxysmal Positional Vertigo (BPPV)

Explanation to Patient
Provide a clear definition of BPPV: "It is a condition of the inner ear that causes repeated
episodes of sensation of spinning for a very short period of time, especially when you move
your head in a certain position."
Break down the term:
Benign: It's not harmful
Positional: It happens when you change position
Paroxysmal: It comes and goes
Vertigo: Spinning sensation
Remember:
Explaining the definition shows your understanding of the condition's
pathophysiology.
It demonstrates your ability to explain something to a patient.
Definition is key in management, to improve after two and three, after two it is the
definition.

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Management
Reassurance:
Explain that it's self-limiting and can settle on its own
Discuss watchful waiting as an option: "We can wait and see."
Treatment options:
Epley maneuver
Note on GP capabilities:
Not all GPs can perform this. It requires extra training and a competency
sign-off.
Follow-up:
If Epley maneuver not done immediately, wait for four weeks
Follow up after four weeks
If dizziness persists, refer to ENT
Work-related advice:
Explain why working at heights is not safe with this condition
Advise: "We'll advise you to avoid working on the heights."
Suggest: "Either you change the role, alternative role within the same
organization. If that doesn't work, you change the work, change the
company."
Always explain why it's not suitable, why it's dangerous
Lifestyle advice:
Get out of bed slowly
Recovery takes several weeks
It can happen again
Driving advice:
Advise to avoid driving when feeling dizzy

Key Points to Remember

Focus on clear explanations and definitions
Prioritize important information (work safety, treatment options) over minor points
Be prepared to explain why certain activities (like working at heights) are dangerous
Don't panic about performing procedures in the exam setting - "They will never ask you
to do a real procedure on a real human being."

Things to Avoid
Don't confuse Dix-Hallpike (diagnostic) with Epley maneuver (treatment)
Avoid starting with minor points (like getting out of bed slowly) before addressing
major concerns (work safety, treatment options)
Don't assume all GPs can perform the Epley maneuver

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Meniere's Disease
Patient Profile
Setting: GP
Patient: Lady, 50 plus (around 55)
Chief Complaint: Dizziness for the last two weeks
Duration of episodes: Used to be 15 to 20 minutes, now 24 hours
Frequency: Two episodes in the last two weeks
Occupation: Works in a supermarket
Note: Patient drives

History Taking
Chief complaint: "I feel dizzy"
Duration and frequency:
Ask: "How long have you been experiencing this?"
Patient response: "For the last two weeks"
Ask: "How long do the episodes last?"
Patient response: "24 hours now, used to be 15 to 20 minutes"
Ask: "How many episodes have you had?"
Patient response: "Two episodes in the last two weeks"
DVTF Questions:
Deafness: Ask: "How's your hearing?" Patient response: "Sometimes I don't hear
very well" Note: Patient doesn't say "I have hearing loss" directly
Vertigo: Already established
Tinnitus: Ask: "Do you experience any ringing sensation in your ears?" Patient
response: "Yeah, there is some ringing sensation"
Fullness: Ask: "Do you have any feeling of fullness in your ears?" Patient
response: "My ears are blocked" or "I feel like my ears are blocked"
Occupation:
Ask: "What's your occupation?"
Patient response: "I work in a supermarket"
Follow-up: Ask about working with machinery
Driving:
Ask: "Do you drive?"
Patient response: Patient drives

Examination
Mention that you would perform an examination
Note: Everything is normal in the examination
Important: Hearing test is normal

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Explanation: It's not a permanent hearing loss. The patient experiences hearing
problems only during episodes.

Diagnosis
Meniere's Disease

Explanation to Patient
"This could be a condition called Meniere's disease. It's a condition of the inner ear that
causes dizziness. In the inner ear, there are small tubes filled with fluids. They balance the
body, they control the balance. When there is a problem with the drainage of these fluids,
fluids can build up, increase the pressure, that causes dizziness. This can happen if you
have certain allergies, if you have a problem with the immune system, or in the family."

Management
Referral:
Urgent referral to ENT (Ear, Nose, and Throat specialist)
Explain: "We need to refer you urgently to an ENT specialist."
Tests:
MRI: "The specialist will arrange an MRI. This is the main test. It will tell you
nothing else is wrong."
Audiometry: "They will do a more sensitive hearing test."
Immediate treatment:
Medication: Prochlorperazine
Explain: "We'll give you a medication called Prochlorperazine now. We're going
to refer, the specialist has to see and do the test."
Long-term treatment (to be decided by specialist):
Preventive medication (e.g., betahistine)
Symptomatic treatment
Explain: "Usually it's going to be preventive medication and symptomatic
treatment. They can also offer a preventive medication called betahistine."
Lifestyle advice:
Driving: "Advise the patient to avoid driving."
Work: "Avoid working with the machineries. We'll give you a leaflet."
Medication: "Keep the medication readily available."
Follow-up:
GP follow-up in 5-7 days if no improvement
Explain: "If there is no improvement within five to seven days with this
medication Prochlorperazine, come back."
DVLA:
Mention: "If the condition is confirmed, we'll need to inform DVLA."

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Key Points to Remember

Hearing test is normal in this scenario, despite the patient reporting occasional hearing
difficulties
Be positive in your approach; don't start with negative information
Always mention the medication name (Prochlorperazine) as it's important
MRI is to rule out other conditions, not to confirm Meniere's disease
The condition can be related to allergies, immune system problems, or can run in
families

Things to Avoid
Don't be negative or start with "unfortunately, there's no treatment" or "we cannot cure"
Don't forget to mention the medication name
Don't assume the hearing test will be abnormal
Don't bring negativity into the scenario
Don't rush to discuss incurability or lack of treatment options unless specifically asked

Additional Notes
The management is primarily referral to ENT
The GP initiates treatment while waiting for the specialist appointment
Be prepared to explain the condition in simple terms, focusing on the inner ear fluid
imbalance
Remember to advise about work and driving restrictions
Always provide a follow-up plan

Vestibular Neuritis - Fully Expanded

Patient Profile
Setting: Accident & Emergency (A&E)
Patient: Usually a lady, but can also be a man
Arrival: Brought by ambulance
Chief Complaint: Severe dizziness with nausea and vomiting

Initial Observation
Patient is sitting in A&E
Holding a vomiting bowl, indicating severe nausea
Visibly dizzy

Patient History
Onset and Severity
Ask: "Can you tell me what happened?"

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Patient response: "I was shopping in the mall. Suddenly, I turned to look at my friend
and started feeling dizzy."
Patient thought it was a stroke and called an ambulance

Current Symptoms
Ask: "How are you feeling right now?"
Patient response: Likely to indicate ongoing severe dizziness and nausea
Note: Symptoms are present at the moment of consultation

Recent Medical History

Ask: "Have you had any recent illnesses?"
Patient response: "I had flu one week ago."

Other Symptoms
Ask about other symptoms
Patient response: No other symptoms reported, just dizziness with nausea and vomiting

Diagnosis
Vestibular Neuritis

Explanation to Patient
"Based on your symptoms, this could be a condition called vestibular neuritis. It's an
inflammation of a nerve called the vestibular cochlear nerve, which is responsible for
hearing and balance."

Management
Assessment for Admission
Explain: "We need to decide whether you need to stay in the hospital or can go home. This
depends on two main things:"
Ability to take oral medication:
Ask: "Are you able to take medication by mouth?"
Explain: "You'll need to take medication regularly for three days."
Ability to eat and drink:
Ask: "Are you able to eat and drink anything right now?"
Explain: "If you can't eat or drink, you might become dehydrated, which can
affect your kidneys."

Treatment Options
If severe vomiting and unable to take oral medication:
Explain: "We may need to admit you and refer you to an ear, nose, and throat
specialist."

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Offer medication options: a) Buccal medication (kept in the mouth) b)

Intramuscular injection of Prochlorperazine or Cyclizine
Explain: "We can give you medication either to keep in your mouth or as an
injection."
Once able to take oral medication:
Prescribe regular medication for three days
Explain: "You'll need to take this medication regularly for three days, even if you
start feeling better."
Discharge criteria:
Explain: "When you're able to eat, drink, and take medication by mouth, you
should be able to go home."
Note: Admission might be for a few hours or a few days, depending on recovery
Follow-up:
Explain: "If your symptoms last longer, we may refer you to a Vestibular
Rehabilitation Center for exercise programs."

Lifestyle Advice
Work: Discuss implications for workplace
Driving: Advise, "Do not drive when you feel dizzy."

Key Points to Remember

Vestibular neuritis often follows a recent flu-like illness
The main concerns are dehydration and inability to take oral medication
Treatment duration is typically three days of regular medication
Symptoms are severe and present at the time of consultation
Patient's fear of stroke led to ambulance call

Things to Avoid
Don't assume all patients need admission; assess based on ability to eat, drink, and take
medication
Don't forget to ask about recent illnesses, especially flu-like symptoms
Don't overlook the severity of symptoms and their impact on daily activities

Additional Information: Vestibular Neuritis vs. Labyrinthitis

Vestibular neuritis: Inflammation of the vestibular nerve causing dizziness
Labyrinthitis: Vestibular neuritis plus hearing loss
Note: There is no separate labyrinthitis scenario in the curriculum
If a patient with vestibular neuritis symptoms also reports hearing loss, it would be
classified as labyrinthitis

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Pre-operative Scenarios
Laparoscopic cholecystectomy (less common now, but could suddenly appear in exam)
Dermoid cyst removal (important to study, can come suddenly in exam)
Hernia repair
Ankle pin removal
Knee surgery (post-operative, most frequent and important)
Note: Hip surgery is no longer included in the scenarios.

General Pre-operative Assessment Structure

Initial Paraphrase
"I understand you are going for surgery."
"I understand you have planned to have a surgery."
"Today you have come for an assessment."

Explanation of Assessment Purpose

"This assessment is to check whether everything is okay before you go for surgery."
"We are going to check if you're fit for the surgery."
"Basically, we are going to check your fit for the surgery."

Outline of Assessment Process

Ask questions about medical background
Perform examination
Run some tests
Explain what will happen on surgery day
Always tell the plan to the patient.

Inquiry About Surgery

"Do you know what sort of surgery you're going to have?"
"Did anyone explain it to you?"
"What made you decide to have this surgery?"
"Was it a planned surgery?"
Explore a little bit about the patient's understanding and reasons for surgery.

Systemic Review
Start with: "Have you been recently unwell? Any fever, flu, or maybe COVID?" Then
proceed systematically from head to toe:
Head: Headache, feeling dizzy, any balance problems
Eyes
Chest

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Lungs
Gastrointestinal tract (GIT)
Genitourinary system
Skin: Any rashes
Joints: Any problems

Past Medical History

Probe any mentioned conditions (e.g., high blood pressure, diabetes)
Ask about duration, medication, and control of conditions
For any condition found, ask:
"How long have you been diagnosed with it?"
"Do you take any medication?"
"Is it well controlled?"
Don't probe too much, just to the extent necessary for important information.

Anesthesia-related Questions
"Any problem with your neck? Any neck injuries or neck practices?"
"Any problem with mouth opening?"
"Any problem in your jaw? Any jaw pain?"
"Any loose teeth?"
"Any fillings?"
"Any recent dental treatments?"

Occupation
Important because patient may ask later, "When can I go to work?"

Social History
"Who do you live with?"
"Do you have anybody to look after you after surgery?"
"Who is at home?"
"Do you have anybody to help you after the surgery?"

Lifestyle Factors
Alcohol consumption
Smoking habits
Recreational drug use

Examination
Mention that you would perform an examination after taking the history.

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Surgery Discussion
General Points
Don't discuss day surgery unless specified in the scenario
If patient asks about day surgery, say: "It can be done as day surgery, but the operating
surgeon has to decide. You don't take that decision."
Explain: "Usually you get admitted on the day of the surgery."

Fasting Instructions
Fast for 6 hours before surgery
Clear fluids (water, black tea) allowed up to 2 hours before surgery
Remember "two to six" rule
Don't recommend green tea or Coca-Cola
For diabetic patients, mention Lucozade as a sugary drink option

Specific Scenario Details

Laparoscopic Cholecystectomy
Patient takes Sumatriptan for migraines (advise to stop 24 hours before surgery)
Past admission for cholecystitis (patient was treated and is fine now)
Keyhole surgery procedure

Potential Patient Questions and Answers

Complications:
During surgery: Damage to surrounding tissue, bleeding
After surgery: Bleeding, pain, infection, failure of surgery
Explain: "If there's bleeding, we might give you blood. If there's infection, we'll
give antibiotics. If you have pain, we'll give painkillers."
Blood transfusion (for Jehovah's Witness patients)
Return to work timing:
Desk job (e.g., bank work): 2-3 weeks
Manual work: 4-6 weeks
Sexual activity resumption: 4-6 weeks
Driving: 4-6 weeks
Surgery duration: 20-30 minutes
Explain: "The time is shorter compared to open surgery and recovery is also
quicker."

Dermoid cyst Removal

Patient may ask questions about having children
No other specific issues mentioned

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Ankle Pin Removal

Patient is diabetic (either on insulin or metformin)

Hernia Repair
Patient may have high blood pressure on the day of assessment

Special Considerations for Jehovah's Witnesses

If patient refuses blood transfusion:
Ask: "Can I ask why you don't accept blood?"
When they explain they're a Jehovah's Witness:
Say: "Thank you for letting us know."
Ask: "Do you have any signed document? It's called an advanced directive. We need to
keep it in our records."
Explain: "The surgeon who is going to operate may discuss this with you."
Inform: "In the hospital, there's a committee called Hospital Liaison Committee for
Jehovah's Witnesses. Basically, people from your church."
Suggest: "You can speak to them and get advice."
If patient says no one can change their mind, explain: "It's not to change your mind. It's
better to know about the community. Doctors also approach them for advice on
how to treat patients."

Key Points to Remember

Always probe mentioned medical conditions
Be prepared for specific questions related to each surgery type
Handle sensitive topics (like religious beliefs) respectfully and professionally
Focus on patient safety and informed decision-making
Don't assume about day surgery options
Be positive in your approach and explanations
Prioritize important information over minor details

Things to Avoid
Don't discuss day surgery unless specified in the scenario
Don't probe too deeply into medical history; focus on necessary information
Don't recommend green tea or Coca-Cola as clear fluids before surgery
Don't forget to ask about occupation, as it's important for recovery planning
Don't be negative or start with complications; focus on positive aspects first
Don't try to change a patient's religious beliefs, but provide information about available
resources

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Dermal Cyst Removal

Scenario Overview
Patient: 30-year-old lady
Procedure: Dermoid cyst removal (Note: Not dermatoid - correct terminology is crucial)
Cyst size: 18 x 8 centimeters
Surgical approach: Laparotomy
Incision: At the bikini line
Hospital stay: Planned
Sutures: Absorbable
Consent: Already obtained from the patient

Assessment Structure
This scenario requires discussion of pre-operative, intra-operative, and post-operative
aspects.

Pre-operative Assessment
Follow the general pre-operative assessment structure as outlined in previous notes. This
includes:
Initial paraphrase
Explanation of assessment purpose
Outline of assessment process
Inquiry about surgery
Systemic review
Past medical history
Anesthesia-related questions
Occupation
Social history
Lifestyle factors

Intra-operative Explanation
Explain the surgery verbally, using hand gestures if needed. In the past, drawings were
used, but now it's a verbal explanation only.
"Let me explain how the surgery will be performed:
This is a laparotomy, which means surgery on your tummy.
You have a cyst, which is a collection of fluid in a sac.
This cyst is in your ovary, one of your reproductive glands.
The surgery is to remove this sac.
They will make a cut about 10 centimeters long.
The cut will be just under your bikini line, about 1-2 centimeters below it.
It will be a horizontal cut.

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They will open the tissue to reach the cyst.

Your cyst is about 18 by 8 centimeters, which is why we need a 10-centimeter cut.
When they reach the cyst, they will tie both ends of it with a knot.
This knot prevents the fluid from spilling out.
They will then cut both ends and remove the cyst.
After removal, they will stitch the opening.
We call stitching 'suturing' in medical terms.
They'll use absorbable material for the stitches.
This means the material will be absorbed by your tissue over time.
It will become incorporated into your tissue.
You won't need to come back for stitch removal."

Post-operative Care
Explain the post-operative process:
Recovery Room:
"After surgery, you'll go to a recovery room for about 3-4 hours."
"As soon as you wake up, you'll be able to drink."
"After about two hours, you'll be able to eat."
Ward Transfer:
"You'll then be moved to a normal room in the gynecology ward."
Physiotherapy:
"A physiotherapist will visit within 24 hours."
"They'll help you with walking and mobility."
Hospital Stay:
"You're planned to stay in the hospital for two days."
Home Recovery:
"After discharge, you'll continue your recovery at home."

Potential Patient Questions and Answers

Is it cancer? Answer: "No, this cyst is not cancer. We call it a benign or non-cancerous
tumor. It's basically a collection of fluid in a sac, not a cancerous growth."
Will I be able to have children? Answer: "As long as your other ovary is working, you
should be able to have children. The chances may be slightly lower, but you should
still be able to conceive."
What are the complications of surgery? Answer:
During surgery: Two main risks are damage to surrounding tissues and bleeding.
After surgery: There are four main risks - bleeding, pain, infection, and failure of
the surgery.

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Key Points to Remember

Use correct terminology: It's a dermoid cyst, not a dermatoid cyst
Explain the procedure clearly, using simple language
Be prepared to address concerns about cancer and fertility
Provide clear post-operative care instructions
Explain the use of absorbable sutures
This scenario is common and important to know well

Things to Avoid
Don't use the term "dermatoid" - it's incorrect
Don't use medical jargon without explanation
Avoid minimizing the surgery or its potential impact
Don't forget to mention the post-operative care and recovery process
Avoid giving guarantees about fertility, but be reassuring
Don't omit any part of the explanation (pre-op, intra-op, post-op)

Hernia Surgery
Scenario Overview
Setting: Pre-operative assessment unit
Assessor: F2 doctor
Patient: Planned for hernia surgery (herniorrhaphy)
Current issue: High blood pressure (160/90) measured by nurse today
Family history: Father had similar surgery
Occupation: Warehouse worker

Pre-operative Assessment
Follow the general pre-operative assessment structure, paying special attention to:
Blood pressure issue
Family history of hernia
Occupation (relevant for recovery)

Explaining the Surgery (with Drawing)

Use pen and paper to draw and explain. Keep talking throughout the explanation,
avoiding silence.
Draw a tummy line.
Explain: "People develop hernia through weakness in the tummy wall."
Draw a pouch-like structure: "This is the hernia."
Explain: "What we have inside the hernia is the bowel content. The bowel goes down
due to the tummy pressure."
Describe the surgery:

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"The surgeon is going to put a cut in your tummy. It's going to be an open
surgery, not keyhole."
"They'll pull everything out and put the bowel back inside the tummy."
"Then they'll close the opening with artificial mesh material."
"This material will get incorporated into your tissue, giving extra strength and
preventing hernia from happening again."
"Finally, they'll stitch the cut closed."
Invite questions after the explanation.

Post-operative Care
Provide general advice about fasting and other standard pre-operative instructions.

Potential Patient Questions and Answers

About high blood pressure: Q: "They told me about my blood pressure. My blood
pressure is high. Are you going to cancel my surgery?" A: "Your blood pressure is
160/90, which is quite high, but not high enough that we need to cancel the
surgery right now. If it were more than 180, they might cancel. It's not that high. It
could be that sometimes when patients visit doctors, their blood pressure goes up.
We call this 'white coat' effect. It may just be happening today, or you may have
longstanding high blood pressure. I suggest you speak to your GP about this. They
will do some testing and might give you some medications if you need them. In the
meantime, I'll make a note about your blood pressure for the surgical team."
About TRUSS: Q: "My father had a similar surgery for hernia. They gave him
something called TRUSS. Are you going to give this to me?" A: "TRUSS is not
recommended for young people because it weakens the tummy wall and can impair
healing. It can be given to elderly people or some people who may not be able to
have surgeries. TRUSS is like a belt or suspenders that reduces the hernia and holds
it in place. But for you, we recommend surgery instead of TRUSS."
Recovery questions: Q: "When can I have sex?" A: "Generally, you should wait 4-6
weeks." Q: "When can I go to work?" A: "You should be able to return to work in 4-6
weeks." Q: "When can I drive?" A: "You can usually start driving again after 4-6
weeks." Q: "When can I go home after the surgery?" A: "If everything goes well, you
should be able to go home on the same day. For uncomplicated hernia surgery,
same-day discharge is often possible."

Key Points to Remember

Always address the high blood pressure issue
Explain the surgery using drawings
Be prepared for questions about alternative treatments like TRUSS
Provide clear post-operative recovery timelines
Mention the possibility of same-day discharge

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The time frame for most recovery activities is 4-6 weeks

Things to Avoid
Don't forget to draw and explain the surgery
Avoid silence during the explanation
Don't dismiss the blood pressure concern, but also don't overly alarm the patient
Don't recommend TRUSS for young patients
Avoid giving specific recovery times; stick to the 4–6-week guideline for most activities
Don't forget to mention the patient's occupation (warehouse worker) when discussing
return to work

Additional Notes
This scenario involves drawing and explaining, which is different from some other
scenarios
The blood pressure issue is a key part of this scenario and must be addressed
The family history of hernia surgery is relevant and leads to the question about TRUSS
The patient's occupation as a warehouse worker is important for discussing return to
work

Ankle Pin Removal

Scenario Overview
Setting: Orthopedics department
Assessor: F2 doctor
Procedure: Ankle pin removal
Patient History:
Diabetes (either on metformin or insulin)
Previous surgery 6-8 weeks ago for fracture
Experienced nausea and vomiting during previous surgery
Has a dog that needs care

Pre-operative Assessment Structure

Initial greeting and purpose explanation
Review of past medical history
Specific focus on diabetes management
Discussion of previous surgical experience
Addressing concerns (e.g., pet care)
Brief explanation of the procedure
Preparation instructions

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Detailed Assessment Points

1. Past Medical History
Ask about diabetes: "Can you tell me about your diabetes management?"
Inquire about the previous fracture: "You had surgery for a fracture about 6-8 weeks
ago, is that correct?"
Probe about other medical conditions

2. Diabetes Management
Advise admission the day before surgery
Explain medication handling:
"When you come to the hospital, you don't need to bring any of your
medications. We will provide all necessary medications here."
If on insulin: "We will give you insulin and use what we call a sliding scale. This
means we'll administer insulin through the vein according to your sugar
levels."
If on metformin: "We'll switch you to insulin for the surgery period."
Inform about surgery timing: "Because of your diabetes, we'll likely schedule you as the
first surgery in the morning."

3. Previous Surgical Experience

Address nausea and vomiting concerns:
"I understand you had nausea and vomiting after your previous surgery. This is a
concern for you, correct?"
"Unfortunately, this can happen again. I will write this concern in your notes."
"The anesthesia team will give you medications to help prevent or manage this,
but please be aware it might still occur."

4. Pet Care
Ask: "You mentioned you have a dog. Is there anyone who can look after it while you're
in the hospital?"
If no support available:
Suggest: "There may be local animal charities that can help. Also, there are
agencies that look after pets when people are away. If you can afford it, this
might be an option."

5. Procedure Explanation
Keep it simple: "The procedure involves removing the pin from your ankle. It's a
straightforward process and doesn't require extensive explanation."

6. Preparation Instructions
Fasting instructions (standard pre-operative fasting guidelines)

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Admission timing: "We'll admit you the day before surgery due to your diabetes."

7. Post-Surgery Considerations
If asked about pick-up times:
Response: "It's difficult for me to tell exactly when they can come and pick you up. It's
better to speak to the doctors and nurses in the ward when you get admitted. They
can give you more accurate information about when it will be possible for someone
to pick you up."

Key Points to Remember

This scenario is straightforward; maintain a simple and clear discussion
Focus on addressing the patient's specific concerns (diabetes, previous nausea/vomiting,
pet care)
Be prepared for random questions and redirect to appropriate staff when necessary

Things to Avoid
Don't give specific timelines for discharge or pickup
Avoid dismissing the patient's concerns about previous surgical experiences
Don't forget to address the diabetes management plan, including admission timing and
medication handling
Don't provide detailed explanations or drawings of the procedure as it's not necessary
for this simple pin removal
Avoid making decisions about post-operative care that should be made by the ward staff

Potential Patient Questions and Appropriate Responses

Q: "When should I ask my friend Tony to come and pick me up?" A: "It's difficult for
me to give an exact time. It's best to discuss this with the doctors and nurses in the
ward after your surgery. They'll have a better idea of when you'll be ready for
discharge."
Q: "Will I experience nausea and vomiting again?" A: "While we can't guarantee it won't
happen, we'll take precautions based on your previous experience. The anesthesia
team will be informed and will use medications to help prevent or minimize these
side effects."
Q: "Do I need to bring my diabetes medications?" A: "No, you don't need to bring any
medications. We'll provide all necessary medications here in the hospital, including
managing your diabetes with insulin during your stay."
Q: "How long will the surgery take?" A: "The pin removal is a relatively quick procedure,
but I can't give you an exact time. The surgical team will be able to provide more
specific information on the day of your surgery."
Q: "Can I eat before coming to the hospital?" A: "Since we're admitting you the day
before surgery due to your diabetes, you'll receive specific instructions about eating

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and drinking from the ward staff. Generally, you'll need to fast before the surgery,
but they'll manage this carefully considering your diabetes."

Post-operative Care for Knee Arthroplasty

Scenario Overview
Setting: Orthopedics department
Patient: Around 60 years old lady
Procedure: Knee arthroplasty
Status: Admitted, surgery scheduled (possibly for tomorrow)
Task: Discuss recovery process and post-operative management only

Initial Approach
Greet the patient
Paraphrase: "I understand you are going for a surgery. I've been told that you have been
explained everything about the surgery."
Explain your purpose: "I am here today to explain to you in terms of how we are going
to look after you and in terms of your recovery after the surgery. I'm here to discuss
what you would like to discuss about how we are going to take care of you after the
surgery. It is about the post-operative care."
Invite initial questions: "Do you have any questions at all from your side?"

Addressing Clot Concerns

If patient expresses worry about clots:
Ask: "Can I ask you why you're worried about clots?"
Listen to patient's response about friend's experience
Show empathy: "I'm sorry to hear about your friend. How is she doing at the moment?"
Explain: "Let me explain how we prevent clots. But first, I need to ask you three
questions."
Ask three risk factor questions:
"Have you had any clots in your lungs or in your leg in the past?"
"Are you on any hormonal treatment?"
"Has anyone in your family had any clots?"
Explain clot prevention measures:
"When we admit somebody for this sort of surgery, we give blood thinner
medication. It's given as an injection or as a tablet to prevent clots."
"We give compression stockings. This is to prevent clots."
"We practice early mobilization. As soon as we finish the surgery, we try to move
our patients immediately to improve circulation. This will prevent clots."

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Brief Medical History

Ask: "Do you have any ongoing medical problems?"
Inquire: "Do you take any regular medication?"
Note: Allergy information is not emphasized in this scenario

Social History (crucial for elderly patients)

Living Conditions:
"I would like to know about your living condition. Where do you live?"
"Do you live in your own house? What sort of housing is it?"
"Is it a bungalow or a two-story building?"
"How are the rooms set? Where is the main bedroom? Is the toilet on the same
floor?"
"Do you need to climb staircases? Where is the kitchen?"
Social Support:
"Who do you live with?"
"Is there anybody at home? Is there anybody to help you after the surgery?"
Mobility and Independence:
"Before this, how independent were you in terms of your day-to-day activities?"
"What sort of activities can you do yourself?"
"What sort of activities do you need help with?"
"Do you have any care? Do you get any support?"

Post-operative Recovery Explanation

"Let me explain to you what is going to happen after the surgery, your recovery."
Immediate Post-op (Recovery Room):
"Immediately after the surgery, they will bring you to a room called the recovery
room."
"When you wake up from the sleep in the recovery room, you will be on your
back."
"There will be some tubes running in your body for medications, for saline, for
urine."
"When you wake up, you may have some little confusion, headache, but in very
few minutes, you'll be fine."
"Anticipate that you may feel a little sick."
Timeline:
"Within half an hour, 30 minutes, you will be able to take a sip of water."
"After a couple of hours, a doctor will come and check whether they can hear
your bowel sound. When they hear the bowel sound, then you can resume
eating."
"In three to four hours, you will be moved to a surgical ward like here. Until you
get discharged, you'll be in this ward."

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"A physiotherapist will come in 12 to 24 hours. They will help you and
encourage you to work with support like crutches or a frame."
"Physiotherapy will happen until you get discharged."
"You'll be discharged home in two to three days. It's very quick."

Home Recovery
Social Services Assessment:
"Before you get discharged, social services will assess in terms of checking your
support."
Physiotherapist and Occupational Therapist Roles:
"Physiotherapists work with your body. They will try to strengthen what you
have."
"Until you completely recover, they will do exercises from time to time to
strengthen what you have."
"They might give you some walking aids to improve your mobility."
"Occupational therapists work outside your body. Their main job is visiting your
home."
"They will look at the place of recovery, check if it is safe, and see if any changes
need to be done."
"For example, they look at the floor, check if it's safe, see if any rails need to be
fixed for walking."
"They check staircases, toilets, and adjust things according to your needs."

Recovery Milestones and Patient Questions

Feeling Normal:
"You should be able to stop using the crutches or walking frame and resume
normal leisure activities in about six weeks."
Return to Work:
For manual work: 6-12 weeks
Driving:
"You should be able to drive when you can bend your knee enough to get in and
out of a car and control the car properly. That takes about six to eight
weeks."
Running:
Ask: "Did you use to run before?"
Explain: "Running can be sometime difficult. When you run, you put a lot of
force on a single leg. It can cause failure of the surgery or it can dislodge the
joint."
Advise: "You can ask the surgeon who is operating on you. They will better
advise you according to your situation."

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"People who used to run before knee arthroplasty tend to run after, but if
someone was not running before, it can be difficult for them."
Pain and Swelling:
"The pain can last for three months, and the swelling can last up to one year."
"Full recovery takes about two years."
Climbing Stairs:
"After six weeks, you should be able to climb stairs at home."

Key Points to Remember

Focus solely on post-operative care and recovery
Be prepared for questions about clots, home care, and return to activities
Emphasize the roles of physiotherapist and occupational therapist
Provide clear timelines for recovery milestones

Things to Avoid
Do not discuss pre-operative assessment or intra-operative details
Do not talk about pain management (as specified in the scenario)
Avoid giving specific medical advice about running or activities beyond general
guidelines
Don't forget to address the patient's living situation and support system
Don't assume about the patient's living arrangements or support system; always ask

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Learning Disability Scenarios

There are only four learning disability scenarios in the entire PLAP-II:
Insulin management
Rivaroxaban management
First-time DVT diagnosis
Morning after pill consultation
Note: All Warfarin scenarios have been replaced with Rivaroxaban, except in cases of
mechanical heart valves (mentioned in lower GI bleed scenarios).

Identifying Learning Disability Scenarios

The scenario description will explicitly state that the patient has a learning disability.
It will be written outside the scenario, similar to how gender dysphoria scenarios are
labeled.

General Approach to Learning Disability Patients

Adjust Communication Style:
Slow down your speech
Avoid complicated medical terms
Simplify explanations without oversimplifying
Imagine communicating with a 42-year-old who has the intelligence of a 3-4 year
old child
Increase Frequency of Comprehension Checks:
Double the usual number of comprehension checks (4-6 times instead of 2-3)
Use phrases like:
"Is it clear so far?"
"Do you want me to repeat anything?"
"Do you understand?"
Avoid asking after every single sentence to prevent irritation
Be Aware of Non-verbal Cues:
Patients may make faces when they don't understand complicated words

Consultation Structure for Learning Disability Follow-ups

Standard Follow-up Structure:
Paraphrase the reason for follow-up
Discuss admission or medical condition
Ask about current treatment
Check symptoms (initial and current)
Address complications and side effects
Perform NEOM (big S)
Fix any issues identified

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Additional Steps for Learning Disability Patients (Add at the beginning):

After introduction, say: "I also learn from my notes. I understand from my notes
that you also have some learning difficulties."
Ask: "Can you tell me what sort of difficulties you have, please? This will help
me to understand you better and help you better."
Inquire about specific challenges:
"Are you able to read and write?"
"How do you handle your medical information?"
"Is there anybody who helps you on a daily basis?"
"Are you able to manage and understand medical information?"
Adapt to Patient's Specific Challenges:
Listen carefully to the patient's response about their difficulties
Tailor your approach based on their specific challenges

Scenario-Specific Notes
Insulin Management:
Patient may say: "Sometimes I forget, doctor. I forget things."
Adapt your approach to address forgetfulness
Rivaroxaban Management:
Patient may say: "Doctors talk too fast. Doctors keep on talking too fast, I'm not
able to follow them. They also use big, big words."
Response: "I will slow it down. I will try and make sure you understand."
First-time DVT Diagnosis:
Patient may mention both difficulty understanding and forgetfulness
Be prepared to address both issues in your communication
Morning After Pill:
Patient may say: "You need to ask my mother."
This indicates a severe learning disability
Patient may not understand much, leading to a challenging consultation
Remember: Morning after pill is a treatment, not health promotion, so it must
still be provided

Key Points to Remember

Always adjust your communication style for learning disability patients
Pay attention to the specific challenges mentioned by the patient
Increase frequency of comprehension checks
Be patient and willing to repeat or rephrase information
In severe cases, recognize the limitations in patient understanding but proceed with
necessary treatment

Things to Avoid

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Don't use complicated medical terms (e.g., avoid "hypertensive")

Don't speak too quickly
Don't assume the patient's level of understanding
Don't forget to check comprehension regularly, but not after every sentence
Don't oversimplify to the point of being condescending

Additional Notes
The style of communication is crucial in learning disability scenarios
The assessment focuses on how well you adapt your communication
Each scenario may present different challenges in patient understanding
Be prepared for potentially chaotic consultations, especially in severe cases like the
morning after pill scenario

Rivaroxaban Scenario for Patients with Learning Disabilities

Scenario Overview
Setting: Anticoagulant clinic
Patient: Paul Johnson, 40-year-old man with learning disability
Diagnosis: Deep Vein Thrombosis (DVT) 6 weeks ago
Treatment: Rivaroxaban
Current issue: Not taking medication regularly

Important Note on Anticoagulants

INR is only checked for Warfarin
NOACs (Novel Oral Anticoagulants) like Rivaroxaban don't require INR monitoring

Medication Details
Loading dose: 15 mg BD for 2 weeks
Maintenance dose: 20 mg OD

Consultation Structure
Initial Approach
Greet the patient
Paraphrase: "I understand you have come for a follow-up at the anticoagulant
clinic."
Address learning disability: "I also learned from my notes that you have some
learning difficulties. Can you please tell me what sort of difficulties you have?
This will help me to understand you better and help you in a better way."
Assess Patient's Understanding
Ask: "Are you able to read and write?"
Inquire: "How do you handle your medical information?"

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Ask: "Is there anybody who helps you on a daily basis?"

Ask: "What is your understanding about what is happening with you, your
ongoing medical problem, and your treatment?"
Explain DVT in Simple Terms
"In our body, the blood runs like water everywhere. It keeps on running."
"Due to some reason, the blood can become thick like jelly or yogurt in one
place."
"It can stay there, prevent circulation, and cause swelling and pain."
"That's what you have. That's why you developed pain and swelling."
Check understanding: "Do you understand?"
Discuss Medication
Ask: "Do you know what medication you've been given?"
Explain: "It's called Rivaroxaban."
Ask patient to repeat the name: "Is it possible to repeat after me? Rivaroxaban."
Ask: "Do you take it regularly? Do you take it every day without missing it?"
If patient asks what "regularly" means, explain: "Regularly means do you take it
every day without missing it?"
Address Misunderstandings
If patient says they only take it when in pain:
Ask: "Do you take it only when you have pain?"
Ask: "Why do you take it like that?"
Apologize: "I'm so sorry, we should have explained this to you earlier."
Ask: "Has anyone explained to you before?"
Show empathy and be extremely nice
Assess Symptoms
Ask: "What sort of symptoms did you have before?"
Inquire: "After the treatment, how are you feeling?"
Ask: "Are you still having any swelling, any pain, any redness?"
Ask: "Does it feel warm?"
Check for Complications
Ask about bleeding: "Did you get any bleeding? From your poo or wee? Any
bruises? Any bleeding from gums or ears?"
For DVT, ask about PE symptoms: "Do you have any breathing problems, chest
pain, or rapid heartbeat?"
Social History
Ask: "Who do you live with?"
Inquire about daily support: "Is there anybody who comes to support you on a
daily basis?"
Ask: "Do you have any carer? Does anybody come and visit? Any social services?"
Assess independence: "Are you independent? What sort of activities can you do
yourself?"

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Ask: "Do you work as well?"

Fixing the Issue (Management)
Explain medication regimen clearly:
"Let me explain about the medication first. It's a regular medication."
"Regular medication means you need to take this medication every day
without missing."
"You need to take it regardless of whether you have pain or not."
"It's better to take it at the same time every day. Let's say 6 p.m., 6 o'clock
in the evening."
Establish a routine:
Ask: "Do you do anything specific at 6 p.m.?"
If they mention watching TV: "Is there any specific program you watch?"
Suggest: "Whenever the program starts, you can take your medication."
Or suggest: "You can simply put an alarm at six o'clock. Is that okay for
you?"
Explain Consequences of Non-adherence
"If you don't take it regularly, you can have a similar problem again."
"You can have a clot in the leg."
"This clot can travel to your lungs and cause breathing problems."
Check understanding: "Do you understand?"
Safety Netting
"When you take this medication regularly, if you see any bleeding from your
gum, mouth, nose, with poo or urine, or have excessive bruises, you need to
speak to your doctor."
"If you have a fall or head injury, you need to go to the hospital. You may need a
CT scan."
"Avoid taking some other painkillers like aspirin or ibuprofen from over-the-
counter."
"If you visit other doctors like a dentist or doctors abroad, you need to tell them
that you take this medication."
Closing
Ask: "Do you have any questions?"
Show empathy and be nice throughout the consultation

Key Points to Remember

Speak slowly and use simple language
Check understanding frequently: "Do you understand?"
Be patient and willing to repeat or rephrase information
Show empathy and be extremely nice
Don't fix issues immediately; address them in the management section
Ensure the patient understands the importance of regular medication intake

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Remember that people with learning disabilities may have been trained to disclose their
difficulties to healthcare professionals

Things to Avoid
Don't use complicated medical terms
Avoid asking about occupation in terms of "What do you do for a living?"
Don't assume the patient's level of understanding
Avoid rushing through explanations
Don't be reluctant to ask about their learning difficulties; it's in the patient's best
interest
Don't forget to check if the patient can read or write before offering written
information

Insulin Management for Patients with Learning Disabilities

Scenario Overview
Setting: Outpatient medical clinic
Patient: 24-year-old man with learning disability
Reason for visit: Annual review
Recent history: Diagnosed with DKA (Diabetic Ketoacidosis) two weeks ago
Current treatment: Two types of insulin (rapid-acting 3 times a day, long-acting once in
the evening)
Support: District nurse usually helps with insulin administration
Current blood sugar: 11

Consultation Structure
Initial Approach
Greet the patient
Paraphrase: "I understand you have come for a review."
Address learning disability: "I also understand that you have some learning
difficulties. What sort of difficulties do you have? Would you like to tell us?"
Explain: "I would like to know more about you because this will help me to
understand you better and help you better."
Possible patient response: "Sometimes I forget things, Dr. Srinivasan."
Assess Patient's Understanding
Ask: "Are you able to read and write?"
Inquire: "How do you handle your medical information generally?"
Ask: "Do you understand what diabetes is? What is your understanding about
that?"

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Inquire about recent hospital admission: "You also had a recent hospital
admission. Do you know what happened? What was the reason for your
admission? Would you like to tell us exactly what happened?"
Possible patient response: "I was sick, so I was admitted."
Explain Diabetes and DKA in Simple Terms
"You have a condition called diabetes. Diabetes means having high blood sugar."
"You also developed a complication called diabetic ketoacidosis or ketoacidosis."
"This happened due to lack of treatment with insulin."
"When sugar levels go high, the body can produce a toxic substance called
ketones."
"That causes the symptoms and is the reason for your admission."
Check understanding: "Do you understand?"
Discuss Current Treatment
Ask: "You have been given a treatment with medication called insulin. Do you
take it regularly?"
Follow-up question: "How often do you take it?"
Possible patient response: "I take it whenever I eat something sugary or if I eat a
large meal."
If patient says they take it only with sugary foods or large meals, ask: "Why do
you take it in that way? Did anyone explain to you?"
Possible patient response: "They gave me so much information, but I didn't
understand."
Respond: "I'm sorry. We should have explained this to you better."
Assess Symptoms
Ask about current DKA symptoms
Inquire about diabetic symptoms
Check for diabetic complication symptoms
Ask about insulin side effects
Specifically ask about hypoglycemia symptoms: "Do you ever experience feeling
dizzy, headache, blurry vision, rapid heartbeat, sweating, shaking hands,
feeling hungry, or collapse?"
Social History
Confirm district nurse support: "I understand district nurses usually help you
with insulin. How often do they come? What sort of help do they offer?"
Ask: "Who do you live with? Is there anybody to help you after the treatment?"
Inquire: "What sort of activities can you do yourself? What sort of activities do
you need help with?"
Ask: "Do you work as well?"
Examination
Perform basic examination if necessary
Management Plan

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Discuss blood sugar results: "Today we did a blood test. Unfortunately, your
sugar levels are quite high at 11. For Type 1 diabetes, we aim to be under 9."
Explain consequences of irregular insulin use: "If you don't take insulin
regularly, you can have the same problem like ketoacidosis or complications
affecting your nerves, eyes, and heart."
Insulin Education
Explain two types of insulin: a) Short-acting insulin:
"You have been given two types of insulin. The first is called short-acting
insulin."
"This needs to be taken three times a day with your three meals."
"It's better to have three meals a day."
"You take this insulin with your meals - with breakfast, lunch, and
dinner."
"You prepare a meal, take your insulin, and within 15 minutes, you
should eat."
"This insulin you take in the daytime."
"Daytime insulin usually comes with either orange or yellow labels,
because you take it in the daytime when we have the sun." b) Long-
acting insulin:
"You have another insulin to take at night before you go to bed."
"This is called long-acting insulin."
"It usually comes with a blue label, because you take it at night when we
have the moon."
Explain hypoglycemia: "When you take insulin, your sugar levels can drop. You
might develop some symptoms like shaking of your hands, raising of heart
rate, sweating, or feeling dizzy. If you ever develop that, you have to stop
whatever you're doing and eat something with sugar."
Advise keeping sugar sources available: "It's better to always have some stock of
food readily available, like chocolate bars, glucose tablets, Lucozade drink,
something with sugar."
Practical Management Strategies
Offer to write down insulin timing instructions: "I will write down everything for
you in terms of the insulin timing."
Suggest: "You can put this on the table or on the fridge."
Recommend: "You can have a clock visible."
Advise: "Whenever you enter the kitchen or open the fridge, you will know
about the insulin time. You can keep reminded."
Involve Other Healthcare Professionals
"We will write this to your GP and your district nurses."
"We will also ask diabetic nurses to follow you up."

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Recap and Clarification

Be prepared to repeat information about short-acting and long-acting insulin if
the patient asks
Ask: "Is it clear? Do you understand? Do you want me to repeat anything?"

Key Points to Remember

Speak slowly and use simple language
Check understanding frequently
Be patient and willing to repeat or rephrase information
Focus on practical, easy-to-follow instructions for insulin management
Emphasize the importance of regular insulin use
Be prepared to explain concepts multiple times
Show empathy and be extremely nice throughout the consultation

Things to Avoid
Don't use complicated medical terms
Avoid assuming the patient's level of understanding
Don't rush through explanations
In this scenario, don't suggest linking insulin time to TV programs
Don't assume the frequency or extent of district nurse support without asking
Don't forget to address the patient's specific learning difficulties (e.g., forgetfulness)
Avoid using terms like "toxic substance" without explanation
Don't overwhelm the patient with too much information at once

DVT Consultation for Patient with Learning Disability

Patient Profile
Setting: F2 in A&E
Patient: 25-28 year old man
Presenting complaint: Leg pain
Key information: Patient has a learning disability
Prior investigation: Doppler already performed, showing DVT

Initial Approach
Greet the patient warmly and introduce yourself
Inquire about the learning disability:
"I understand you have some learning difficulties. Would you please tell me
what sort of difficulties you have?"
"I'd like to know about you better. It will help me understand and help you
better."
Ask specifically: "Are you able to read and write?"

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Inquire: "How do you understand and manage your medical information?"

Determine the best way to communicate with the patient based on their
responses

Assessing Leg Pain and DVT Symptoms

Ask about the leg pain:
"Would you like to tell us about your leg pain?"
Inquire about duration, severity, and any factors that make it better or worse
Explore DVT symptoms in detail:
Ask about swelling: "Have you noticed any swelling in your leg?"
Inquire about pain: "Can you describe the pain? Is it constant or does it come
and go?"
Check for redness: "Have you noticed any redness on your leg?"
Ask about warmth: "Does your leg feel warmer than usual?"
Note: Be prepared to rephrase questions if the patient doesn't understand

Assessing PE (Pulmonary Embolism) Symptoms

Explain that sometimes the problem in the leg can affect breathing, then ask:
"Have you felt short of breath recently?"
"Have you had any pain in your chest?"
"Have you been coughing? If yes, have you noticed any blood when you cough?"

Investigating Causes and Risk Factors for DVT

Past medical history:
"Have you ever had any clots in your lungs or legs before?"
Family history:
"Has anyone in your family ever had blood clots in their legs or lungs?"
Hormonal treatments:
"Are you taking any special medicines that might affect your hormones?"
Immobility:
"Have you been on any long journeys recently, like a long flight?"
"Have you had to stay in bed for a long time recently?"
"Have you had any operations or surgeries lately?"
Cancer screening (approach sensitively):
"Have you noticed any changes in your weight recently, especially losing weight
without trying?"
"Have you had any fevers or temperatures lately?"
"Have you noticed any new lumps or bumps on your body?"
Note: Explain that these questions are routine and help understand why the clot might
have formed.

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Examination and Investigations

Complete the MAFOSA:
Mention observations clearly
Explain each step of the physical examination to the patient
Explain the scanning procedure:
Use the term "ultrasound scan"
Describe it as: "A scan that uses sound waves to look inside your leg. We put
some gel on your skin and move a small device over it to see the blood
vessels."
Avoid using terms like "jelly scan" or "oven scan"

Explaining DVT to the Patient

Use simple language and possibly visual aids:
"In our body, blood usually flows smoothly, like water in a river."
"Sometimes, for different reasons, the blood can become thick and sticky, a bit like
jelly."
"When this happens, the thick blood can't move properly and gets stuck in one place in
your leg."
"This stuck blood causes the pain and swelling you're feeling."
Explain the complication: "Sometimes, a piece of this thick blood can break off and
travel to your lungs. This can make it hard to breathe, which is why we asked about
breathing problems."

Management Plan
Explain the need for admission:
"We need you to stay in the hospital for a little while so we can look after you
properly."
Additional tests to be done:
Chest X-ray: "A picture of your chest to check your lungs"
ECG: "A test that looks at how your heart is working"
Possible CTPA: "A special scan that looks closely at your lungs"
D-dimer test: "A blood test that helps us understand more about the clot"
Other blood tests: "We'll need to take some blood samples to check your overall
health"

Treatment
Explain anticoagulation therapy:
"We're going to give you medicine that helps thin your blood. This will stop the
clot from getting bigger and help your body break it down."
Mention specific medications: "The medicine might be called Rivaroxaban or
Apixaban. We'll decide which is best for you."

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Duration of treatment:
If cause is unknown: "You'll need to take the medicine for at least 6 months."
If cause is identified: "You'll need to take the medicine for at least 3 months to
start with."
Admission duration:
"You'll stay in the hospital until we're sure you're getting better. Then you can go
home and continue taking the medicine."

Addressing Patient Concerns

If patient asks why they got DVT:
"Sometimes we don't know exactly why clots form. It could be because of your
genes - the instructions in your body that you get from your parents."
"Or it might be because someone else in your family has had clots before."
"Sometimes it happens and we can't find a clear reason. But the important thing
is that we've found it and we're treating it."

Things to Avoid During Consultation

Don't use complex medical terminology without explanation
Avoid using informal terms like "jelly scan" or "oven scan"
Don't rush through explanations; take time to ensure patient understanding
Avoid making assumptions about the patient's level of comprehension
Don't dismiss or minimize the patient's concerns or questions
Avoid speaking to accompanying persons instead of the patient directly

Additional Considerations
Speak clearly and at a pace comfortable for the patient
Use visual aids if available to help explain concepts
Offer to repeat information or explain in different ways if needed
Encourage the patient to ask questions throughout the consultation
Be patient and empathetic, recognizing the challenges associated with learning
disabilities
Ensure all information is provided in a format accessible to the patient (e.g., written
summaries, easy-read formats)
Consider involving a family member or caregiver if appropriate and with patient
consent
Remember to check the patient's understanding periodically throughout the
consultation

Follow-up Plan
Explain that regular check-ups will be needed

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Discuss signs that should prompt the patient to seek immediate medical attention (e.g.,
increased swelling, severe pain, difficulty breathing)
Provide clear instructions on how and when to take the prescribed medication
Offer resources for further information suitable for patients with learning disabilities

Hypertension Follow-up
Scenario Overview
Setting: Annual follow-up for hypertension
Patient: 65-year-old man
Current medication: Amlodipine for hypertension
New problem identified through recent tests

Initial Test Results

AST and ALT: Elevated
MCV: High
Haemoglobin: Low
Blood pressure: Normal (well-controlled)

Consultation Approach
This is a telephone consultation
Patient may talk excessively - allow them to speak without interruption
Collect necessary information while listening
Note: This is the third scenario where patients talk too much (others include
oxybutynin scenario and breast cancer patient refusing treatment)

Initial Assessment
Start with hypertension follow-up
Acknowledge long-term medical problem (hypertension)
Assess patient's understanding of hypertension:
"I understand you're here for a follow-up. You've been diagnosed with a long-
term medical problem. What did you understand about it?"
Expected response: "I have high blood pressure."
Follow-up: "What is your understanding about blood pressure?"
Explain if necessary: "High blood pressure means the pressure inside your blood
vessels has increased. If not controlled, it can lead to serious conditions like
stroke and heart attack."
Confirm current medication (Amlodipine) and its effectiveness

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Symptom Check (The Big S)

Inquire about symptoms related to:
Anaemia:
Fatigue
Weakness
Shortness of breath
Vitamin B12 deficiency:
Numbness
Weakness
Abnormal sensations
Brain fog
Tiredness
Liver issues:
Abdominal pain
Jaundice (yellowing of skin or eyes)
Changes in urine colour
Changes in stool colour or consistency

History Taking
During the conversation, pay attention to:
Recent life events (e.g., "Since my wife died...")
Dietary habits (e.g., "I go to pub. I sit with my friends and eat, I eat a lot of burger.",
"Sometimes I eat at McDonald's")
Alcohol consumption (e.g., "I drink two pints of beer every day.")
Follow up on alcohol: "Is it every day?"
Possible response: "It used to be four pints of beer. But sometimes it can be even two
pints of beer."

Key Information to Extract

Alcohol consumption:
Two pints of beer daily = approximately 5-6 units
Calculate weekly intake: 35-42 units per week
Diet:
Assess if patient is consuming animal products (important for ruling out folate
deficiency)
Note: Burgers (beef) indicate adequate folate intake

Interpreting the Information

Suspect alcohol abuse based on:
Elevated AST and ALT
High MCV

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Low haemoglobin
Regular alcohol consumption
Suspect B12 deficiency due to:
High MCV
Low haemoglobin
Adequate dietary intake but possible absorption issues
Note: Problem is with absorption, not dietary intake

Understanding Alcohol-Related Liver Function Tests

Normal liver function tests don't typically include GGT
Look for:
Isolated GGT elevation
AST higher than ALT (AST:ALT ratio > 1)
Remember: AST > ALT suggests alcohol-related liver damage (Mnemonic: AST =
Alcohol, Scotch, whiskey)

Explaining Results to Patient

Liver function:
"The blood tests show two markers called AST and ALT are increased. This
suggests there might be some damage to your liver."
Blood cell abnormalities:
"Your blood levels are low, and the size of your red blood cells has increased.
This can happen if you have a deficiency in a vitamin called B12."
Potential cause:
"If you drink alcohol regularly, it can damage the lining of your stomach. This
can impair the absorption of a vitamin called B12, which is common in
people who drink alcohol regularly."

Further Investigations
Explain the need for additional tests:
Repeat AST and ALT
Check GGT (gamma-glutamyl transferase)
Check vitamin B12 and folate levels

Treatment Plan
If B12 deficiency is confirmed:
B12 replacement therapy via injections:
Loading dose: Injections every other day for the first two weeks
Maintenance: Injections every three months
Explain why injections are preferred over tablets:

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"If there's damage to the lining of your stomach, there may be problems
absorbing this vitamin from tablets. Injections bypass this issue."
If patient asks about tablets:
"If you have damage to the lining of the stomach, there may be a problem with
absorption of this vitamin in your bowels."

Alcohol Counselling
Discuss the need to reduce alcohol consumption
Offer support and resources for cutting down on alcohol

Follow-up Plan
Arrange for the additional blood tests
Schedule a review appointment for the following week
Plan to start B12 treatment if deficiency is confirmed

Female Version of the Scenario

Setting: F2 in GP, well-woman clinic follow-up
Patient: Approximately 60-year-old woman
Presenting complaint: Routine blood test results (not hypertension follow-up)
Key findings: Same as male version (elevated AST/ALT, high MCV, low haemoglobin)
Additional history:
Reports abdominal pain, takes Omeprazole
Drinks one bottle of wine daily (approximately 9 units)
Management:
Same as male version (GGT test, vitamin B12 and folate check, B12 replacement
if confirmed)
Counsel on reducing alcohol intake
Offer support for alcohol reduction

Key Points to Remember

Allow patients to speak without interruption, but guide the conversation to collect
necessary information
Look for patterns suggestive of alcohol abuse: elevated liver enzymes, high MCV, low
haemoglobin
Consider B12 deficiency in patients with alcohol use disorder
Explain test results and treatment plans in simple terms
Always address alcohol consumption and offer support for reduction
Use injection therapy for B12 replacement in cases of malabsorption
Schedule follow-up to review additional test results and initiate treatment
Be aware of different presentations (male vs. female scenarios)
Remember AST > ALT suggests alcohol-related liver damage

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Don't forget to discuss reducing alcohol consumption in both scenarios

Things to Avoid
Don't interrupt the patient, even if they talk excessively
Avoid using complex medical terminology without explanation
Don't forget to ask about alcohol consumption
Avoid making assumptions about the cause of abnormal results without proper
investigation
Don't neglect to offer support for alcohol reduction
Avoid rushing through the explanation of test results and treatment plan

Postural Hypotension and Fall Scenario in GP Practice

Scenario Overview
Setting: F2 in GP practice
Patient: 50-year-old man
Incident: Collapsed outside the practice, brought inside
Key information: Patient not registered with this GP practice

Understanding GP Registration in the UK

Every individual is registered with only one GP
If someone registers in a different town, the old registration is automatically cancelled
You cannot ignore unregistered patients in emergency situations, but you cannot treat
them fully

Patient Background
Has high blood pressure
Takes two medications: Amlodipine and Enalapril
GP increased dose last week
Came with a friend who had an appointment
Was sitting outside, stood up to go with friend, then fell down
Occupation: Teacher (important for risk assessment)

Initial Assessment

Fall Analysis
Ask about the fall:
"How did you sustain the fall? Would you like to tell us?"
"Did you trip on something?"
"Do you have any blackouts?"

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"Do you feel dizzy?"

Before the fall:
"Did you have any warning signs?"
"Did you have any headache or feel dizzy?"
"Were you feeling unwell, nauseous, or vomiting?"
After the fall:
Ask about loss of consciousness
Inquire about vomiting
Check for development of fits
Assess for confusion
Note: Fall is an incident - consider before, during, and after

Possible Causes of Falls

Brain-related:
TIA
Stroke
Balance problems (cerebellar)
Eye-related issues
Heart-related:
MI (Myocardial Infarction)
PE (Pulmonary Embolism)
Arrhythmias
Blood pressure issues:
Postural hypotension
Changes in blood pressure treatment (new medication, dose change, type
change)
Dehydration:
Diarrhoea
Vomiting
Electrolyte imbalances:
Hyponatremia
Chronic conditions:
Heart failure
Liver failure
Kidney failure
Musculoskeletal issues:
Joint swelling and pain
Unsteadiness
Hip fractures

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Physical Examination
Complete the MAFTOSA
Check blood pressure lying down and standing up
Note: There will be a significant difference in BP measurements

Diagnosis and Explanation

Explain to the patient:
"Your blood pressure drops when you change your position from lying down to
standing up. We call this postural hypotension."
"There is a drop in your blood pressure when you change your position from lying
down to standing up."
"This is the reason for your fall."
"If you take blood pressure medication, this can happen. Changes in blood pressure
medication can cause this."

Management Plan
Inform the patient:
"As you are not registered in this practice, I don't have access to your records."
"I will not be able to give you proper treatment."
Advise the patient:
Speak to their GP today
If patient asks, "Can I go tomorrow?", respond: "You can go tomorrow, but it's
better as early as possible."
Explain that their occupation as a teacher is risky:
"Your occupation as a teacher is risky. Teachers can sit and suddenly
stand up. Teachers can stand and teach. It is risky."
Explain what the GP needs to do:
Reduce medication
Trial different dosages to reach an optimum dose
Balance controlling blood pressure and preventing falls
May involve:
Removing one medication
Reducing the dose of one medication
Reducing the dose of both medications
This process may take several weeks with regular check-ups:
"They have to trial by reducing slowly. Maybe they might take out one
medication, or maybe reduce the dose of one medication, or maybe
reducing the dose of both medications."
"They have to trial different things slowly in order to reach the optimum
dose."
"The GP has to do this on a weekly basis until they reach the right dose."

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Preventive measures while waiting for GP appointment:

Advise the patient to take care during position changes
Mention that there are five things they can do to prevent falls (refer to
WhatsApp message for details)
If patient asks, "What can I do to prevent?", refer them to the five prevention
methods

Key Points to Remember

Always assess for emergency situations, even if the patient is not registered with your
practice
Thoroughly investigate the circumstances of the fall (before, during, and after)
Consider multiple possible causes for falls
Explain postural hypotension in simple terms
Emphasize the importance of speaking to their regular GP
Advise on preventive measures while waiting for proper treatment adjustment
Recognize the risk associated with the patient's occupation

Things to Avoid
Don't ignore the patient because they're not registered with your practice
Avoid changing medications without access to the patient's full medical records
Don't underestimate the risk associated with the patient's occupation
Avoid dismissing the seriousness of postural hypotension and its potential
consequences
Don't forget to advise the patient about preventive measures while waiting for their GP
appointment

Follow-up
Advise the patient to contact their GP for immediate follow-up
Stress the importance of medication adjustment and regular monitoring
Emphasize the need for the GP to trial different medication doses to find the optimum
balance

Elderly Fall and Hip Fracture Scenario in Hospital Ward

Scenario Overview
Setting: F2 in elderly ward
Patient: Elderly lady
Admission reason: Chest infection (pneumonia)
Current situation: Treated for pneumonia, was due to be discharged
New incident: Patient had a fall 30 minutes ago

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Initial Assessment
Fall Analysis
Start with empathy:
"I understand you had a fall. I'm sorry to hear that. Unfortunately, you had a fall."
Ask about the fall:
"Where did you have a fall?"
Expected response: Patient went to the toilet and fell down
Investigate thoroughly:
Ask about before, during, and after the fall
"Can you tell me what happened before, during, and after the fall?"
Before the fall:
Ask about any warning signs
Inquire about dizziness, weakness, or other symptoms
During the fall:
Ask for details of how the fall occurred
After the fall:
"Are you having any symptoms after the fall?"
Expected response: She's having some pain in her hip

Possible Causes of Falls

Consider and inquire about:
Brain-related issues
Eye-related problems
Heart-related issues
Neurological problems affecting legs

Physical Examination
Check blood pressure
Perform other relevant examinations based on the fall causes
Hip examination:
"I would like to examine your hip."

Hip Examination Findings (Given on Paper)

Affected side (right) is shorter than the left side
Right leg is externally rotated
Tenderness at the hip

Diagnosis and Explanation

Explain to the patient:
"Unfortunately, I'm sorry to tell you, you may have sustained a hip fracture."

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"There is a long bone called femur in your leg. The first part of the leg is with a bone
called femur."
"The neck of the femur, the neck of that bone might have fractured."
"This forms part of your hip joint, which is why you're experiencing pain in that area."

Management Plan
Cancel discharge:
"Unfortunately, we need to postpone or cancel your discharge today."
Further investigations:
"We need to arrange an X-ray to confirm the fracture."
"We may also need to do a CT scan for more detailed images."
Specialist referral:
"We'll need to make an orthopaedic referral."
Treatment:
"The orthopaedic team will need to fix the fracture."
"This usually involves either fixation of the bone or potentially a hip
replacement, depending on the exact nature of the fracture."

Key Points to Remember

This scenario might appear in exams as "hip pain" or "hip tenderness" or "right iliac
fossa pain"
Always take falls in elderly patients seriously, even if they seem minor
Conduct a thorough examination, paying special attention to the area of pain
Look for signs of hip fracture: shortened and externally rotated leg
Explain the situation and next steps clearly to the patient
Ensure proper pain management while waiting for further tests and treatment

Things to Avoid
Don't dismiss the fall as a minor incident
Avoid moving the patient unnecessarily before proper examination
Don't forget to cancel the planned discharge
Avoid using complex medical terminology without explanation

Follow-up
Ensure the X-ray and CT scan are performed promptly
Follow up on the orthopaedic referral
Keep the patient informed about the process and expected timeline for treatment

Additional Notes on Postural Hypotension

While this scenario focuses on a hip fracture, it's important to remember key points about
postural hypotension:

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Explanation of postural hypotension:

It's a drop in blood pressure when changing positions
Treatment approach:
Involves careful calibration of blood pressure medications
Preventive measures:
Important to educate patients on preventive measures

Other Scenarios
Celiac Disease
Involves antigen antibody
Diagnostic procedure: Endoscopy
Explain how endoscopy is done
Treatment: Gluten-free diet
Important note: Patient should continue eating gluten until diagnostic tests are
completed

Barrett's Oesophagus
Definition: Metaplasia (one type of epithelium changing into a different epithelium)
Location: Lower one-third of the oesophagus
Management plan: Endoscopy in two years
Patient education:
If patient asks, "Why don't you cut it off now?": a. Explain it may be too early for
that sort of treatment b. Possibility of reversal to original state c. The
disadvantages outweigh the advantages d. Surgery on the food pipe has severe
complications
Explain: "The lining, the structure of the lining of your food pipe has changed."

Analgesic Nephropathy
Scenario: Patient taking painkillers for rheumatoid arthritis for a long time
Diagnostic indicator: Low eGFR in routine blood test
Management:
Stop NSAID medication (e.g., ibuprofen)
Switch to paracetamol
Recommend physiotherapy
Mandatory referral to specialist

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ACE Inhibitor-Induced Nephropathy

Scenario 1: Recent start of ACE inhibitors
Timeline: ACE inhibitors started 2-3 weeks ago, blood test 1 week ago shows affected
kidney function
Management:
Stop ACE inhibitor treatment
Change to calcium channel blockers (e.g., amlodipine)
Review with blood test after two weeks
If kidney function stays the same, refer (RIFA)

Scenario 2: Long-term use of ACE inhibitors

Patient on treatment for two years (e.g., amlodipine and enalapril)
Management:
Stop enalapril immediately
Add beta blockers
Urgent referral to nephrology
Note: Look at creatinine and urea levels; if very high, follow this management plan

Renal Colic
A&E Scenario:
Symptoms: Loin pain going to groin
Initial management: Diclofenac given by nurses
Key diagnostic test: Urine dipstick
If blood in urine: CT scan within 24 hours
Further management depends on stone size (discuss millimetres)
GP Scenario:
Patient seen by out-of-hours GP the previous day
Note: Out-of-hours GP can't access records or make referrals
Current visit: Perform urine dipstick
If blood present: Arrange CT scan within 24 hours

Obesity Counselling
BMI threshold: 40 or above
Alternatively: BMI above 30 with other medical problems
Approach:

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Explain "You are falling under category of obesity" (avoid saying "you're obese")
Discuss lifestyle changes
Consider referral for surgical assessment
Medication: Orlistat
Be prepared to discuss side effects if patient asks:
Digestive problems (e.g., oily stools)
Bulky stools
Fat-soluble vitamin deficiencies (e.g., Vitamin D)
Tummy pain
Issues with toilet flushing
Important: Know differentials for weight gain beyond hypothyroidism and PCOS

Q-risk Assessment
Definition: "Q-risk is basically a forecast. It is a prediction about your chances of
developing stroke or heart attack in the next coming 10 years."
Risk categories:
Less than 5%: Really low risk
5-10%: Moderate risk
More than 10%: High risk, chances are higher
Scenarios:
Starting high blood pressure medication
Starting cholesterol medication
Focus on providing detailed lifestyle advice
Avoid vague statements like "You need to eat healthy"
Provide specific, actionable advice

Constipation (Elderly Patient)

Physical examination is crucial:
Must examine back passage and abdomen
Potential findings: Faecal impaction (presence or absence doesn't change management)
Diagnostic test: Abdominal X-ray (mandatory to rule out serious conditions like
perforation)
Treatment:
Laxatives
If laxatives ineffective, consider enema

Key Points to Remember

Always provide thorough explanations to patients
Be aware of sensitive topics (e.g., obesity) and use appropriate language

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Know the differentials for conditions (e.g., causes of weight gain)

Understand when to refer to specialists
Be prepared to discuss medication side effects
Always consider the possibility of serious underlying conditions
Don't believe everything you hear about exam scenarios; focus on understanding and
doing the right thing

Things to Avoid
Don't use offensive terms when discussing weight with patients
Avoid dismissing symptoms without proper investigation
Don't forget to perform necessary physical examinations
Avoid giving vague lifestyle advice; be specific and detailed
Don't ignore potential serious conditions (e.g., perforation in constipation cases)

Tacrolimus for Kidney Transplant

Scenario: Patient taking tacrolimus for kidney transplant
Action: Urgent referral to transplant specialist
Important: Advise patient not to stop medication
Note: Use wig for the sake (context unclear)

Cat Bite
Scenario: Cat bite occurred in Turkey (not UK)
Note: In UK, pets are usually vaccinated (except snakes)
Context: Stray cat in a park during holiday
Patient didn't seek treatment in Turkey, came to UK
Treatment:
Dressing
Four medications: a. Antibiotics (Augmentin) b. Tetanus vaccine c. Rabies
antibody d. Rabies vaccination

Dog Bite
Scenario: Dog bite occurred 4 days ago
Treatment: Started on Augmentin
Complication: Diarrhoea started on second day, now 8 times a day
Current: Third day of treatment, one more day of antibiotics left
Management:
Ask about diarrhoea details
Explain it's a side effect of the medication, not C. diff

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Advise to complete the course (one more day left)

Encourage hydration
Offer to take a stool sample to rule out other infections
Ask patient: "Would you like to continue for one more day or restart with
another antibiotic for 4-5 days?"
Recommend completing current course if possible
Inquire how diarrhoea is affecting the patient

Raynaud's Phenomenon
Note: Study this condition

Osteoporosis
Note: Simple osteoporosis scenario

Eye Scenarios
a. Blepharitis
Note: No actinic keratosis in PLAB 2
Actinic keratosis is a fungal infection
Actinic keratosis is a risk factor for blepharitis
b. Retinal Detachment
Key symptom: Patient can't see things on the sides
May present similar to bitemporal hemianopia
Risk factors: Hypertension, previous cataract surgery
Action: Same day referral
Treatment: Surgery
c. Toxoplasmosis
Presentation: Blurred vision
Context: Patient on steroids for Polymyalgia Rheumatica
Caution: May be misdiagnosed as cataract due to steroid use
Examination: Use eye mannequin (comes with mannequin)
Management:
Immediate referral to ophthalmology
Urgent referral to infectious disease department
Medication: Pyrimethamine and sulfadiazine
Confirm with blood test

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d. Ocular Herpes
Risk factor: History of cold sores (patient had a few times)
Action: Refer to eye clinic (RIFA)
e. Scleritis
Risk factor: Patient taking methotrexate
f. Age-Related Macular Degeneration (ARMD)
Note: Only one ARMD scenario now, old one is gone
Referral: From optometrist due to degenerative changes
Symptoms to ask about:
Scotomas (black patches in vision)
Night vision problems or issues in low light
Wavy appearance of straight lines (e.g., window lines, blinds, curtains)
Metamorphopsia (distorted vision, e.g., lion looking like a horse)
Difficulty recognizing faces, reading, watching TV
Risk factors: Previous eye conditions, family history
Important focus: Patient's concern about caring for wife with dementia
Management:
Urgent referral to ophthalmology (regardless of wet or dry ARMD)
Explain ophthalmology will do scanning and pictures of the eye
Potential treatments: Laser treatment or eye injections to slow
progression
Address patient's concerns:
Reassure about maintaining some function for daily activities
Discuss good social security system and support for dementia
patients
Explain slow progression of condition
Emphasize time to organize care plans
Suggest possibility of supervising and organizing care even if direct
involvement is limited

Ankylosing Spondylitis
Scenario: 25-year-old man with back pain for 6 months
Occupation: Bus driver
Symptoms:
Back pain
Weight loss
Stiffness (worsening over time, affects work)

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Note: Patient may express concern about prostate cancer due to family history (ignore
this concern for 25-year-old)
Examination:
Mention Schober test to check back flexibility
Finding: Tenderness at sacroiliac joint
Definition: "Ankylosing spondylitis is basically an inflammation of the spine, mainly
the bones and the ligaments. It's an autoimmune condition."
Investigations:
ESR and CRP
HLA-B27 gene test (important to mention "gene test called HLA-B27")
X-ray
Referral: Routine referral to rheumatology if HLA-B27 positive
Further tests by specialist: MRI, spirometry
Additional symptoms to ask about: Tiredness, breathing issues (due to fusion affecting
breathing)
Treatment:
Initial: Painkillers (NSAIDs), exercise therapy (different types: group
therapy, individual therapy, massage, underwater exercise)
If ineffective: Steroids
Advanced: Disease-modifying medications, anti-TNF medications
Some cases may require surgery
Follow-up:
Safety netting for septic arthritis
Provide leaflet
Refer to Ankylosing Spondylitis Society

Key Points to Remember

Always consider the patient's context and concerns (e.g., ARMD patient worried about
caring for wife)
Be aware of potential misdiagnoses (e.g., toxoplasmosis vs. cataract)
Know when to refer urgently vs. routinely
Understand the importance of genetic tests in certain conditions (e.g., HLA-B27 in
ankylosing spondylitis)
Provide comprehensive explanations and management plans
In ARMD, focus on patient-cantered management, addressing personal worries
alongside medical issues

Things to Avoid
Don't jump to conclusions based on age (e.g., prostate cancer in a 25-year-old)
Avoid dismissing side effects as more serious conditions without proper assessment
Don't forget to address patients' personal concerns alongside medical issues

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Avoid using medical jargon without explanation

Don't ignore the impact of conditions on patients' daily lives and work

Urinary Incontinence
a. Stress Incontinence
Symptom: Urine leakage during coughing and sneezing
Management: Kegel exercises

b. Urge Incontinence
Presentation: Patient may say, "I have an embarrassing problem."
Symptom: Need to rush to the toilet; accidents if delayed
Patient may say: "I need to rush to the toilet. If I'm a bit late, accident happens."
Clarify: "Accident" means urine leakage
Note: Part of a syndrome with overactive bladder
Definition: Combination of urge incontinence and overactive bladder
Management:
Bladder training
Refer to urology

Uterine Prolapse
Symptom: Patient reports "there is something coming down below"
Risk factor: Multiple childbirths (not Amazon delivery)
Associated symptom: Urinary incontinence
Note: Study this condition separately

Erectile Dysfunction (ED)

Scenario 1: Gay Couple
Context: Man having relationship with man, has high blood pressure
Current medication: Beta blocker
Patient request: Asking for Viagra
Management:
Change blood pressure medication to calcium channel blocker
Prescribe Viagra
Scenario 2: Elderly Man (Psychogenic ED)
Age: Around 70
Presentation: Patient says, "I feel rubbish"

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Further questioning: "I'm not able to perform down below"

Context: Straight man with wife, no risk factors
Diagnosis: Psychogenic ED
Management: Prescribe Viagra
Scenario 3: Man with Heart Condition
Context:
Previous heart attack
Heart failure
On multiple medications: nitrates (nitro-glycerine), thiazide, simvastatin
Low ejection fraction
Presentation: Patient says, "I feel rubbish" (hidden agenda)
Further questioning reveals inability to perform sexually
Patient request: Asking for Viagra
Management:
Do not prescribe Viagra (contraindicated with nitrates)
Explain: "For somebody taking nitrates type of medication, it is not
recommended to take Viagra."
Recommend temporary solution: Erectile dysfunction pump from pharmacy
Refer to urology for alternatives:
Locally injected medications

OB/GYN Scenarios
Premature ovarian failure (comes as a test discussion)
Rhesus factor scenario in antenatal care
Rhesus positive
Patient not immune to rubella
Additional Scenario to Study
TIA (Transient Ischemic Attack) and driving

Exam Preparation Advice

Paediatric List:
Remove breast milk jaundice from the list
Include intussusception
Revise all 10 paediatric scenarios the day before the exam
Day Before Exam Review:
Revise all psychiatry scenarios
Revise all paediatric scenarios
Revise all skin scenarios (if not already done)
General Advice:

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Help each other study unfamiliar scenarios

Be prepared for sudden appearance of less common scenarios
Don't rely solely on friends' exam experiences

Key Points to Remember

Understand the difference between stress and urge incontinence
Be aware of hidden agendas in patient presentations
Know contraindications for medications like Viagra
Familiarize yourself with alternative treatments for conditions like ED
Stay updated on new scenarios like recusal
Don't confuse uterine prolapse with stress incontinence

Things to Avoid
Don't confuse stress incontinence with uterine prolapse
Avoid prescribing Viagra to patients on nitrates
Don't ignore patients' indirect communication (hidden agendas)
Avoid neglecting to revise key scenarios before the exam
Don't assume all patients will directly state their main concern
Avoid relying on one-page notes without thorough understanding

Additional Notes
There may be one-page notes available for some scenarios (e.g., urge incontinence,
erectile dysfunction)
Always understand the right approach and do the right thing, regardless of what others
claim about their exam experiences
Be sceptical of unusual scenario reports from other students
Intussusception is a trend in paediatric scenarios

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Ear Scenarios
Total scenarios in the ear syllabus:
Five otitis media scenarios
Two earwax scenarios
Two acoustic neuroma scenarios
Cholesteatoma (comes with a picture)
Malignant otitis externa (comes with a picture)
Benign tinnitus
Note: Dizziness scenarios are taught separately to avoid confusion with malignant scenarios
and pictures.

Otitis Media Scenarios

Important Considerations for Otitis Media
Duration of symptoms is crucial
Up to 4 days: Don't give antibiotics
5th day and beyond: Consider antibiotics
Presence of otorrhea (ear discharge): Give antibiotics

Scenario 1: Adult with 1-day ear pain

Presentation: Man (grown-up) with one day of ear pain
Action: Don't give antibiotics

Scenario 2: Adult with 5-day ear pain, penicillin allergy

Presentation: Adult with five days of ear pain, allergic to penicillin
Action: Give clarithromycin

Scenario 3: Child with 2-day ear pain

Presentation: Mother brings child with ear pain
Duration: Two days
Mother's complaints:
Child crying
Child not sleeping
Has tried paracetamol and ibuprofen
Nothing is working
Action:
Don't give antibiotics

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Recommend paracetamol every 4 hours

Not more than 4 doses in 24 hours
Explanation to mother:
"Most ear inflammation is caused by viruses"
"Antibiotics won't work in this case"
"It may get worse before it gets better"
"Continue with paracetamol for pain relief"
Important: Don't give chlorphenamine to children unless there's an allergic rash

Scenario 4: Child with ear discharge

Presentation: Child with otorrhea (ear discharge)
Action: Give antibiotics (usually amoxicillin)
Note: Presence of discharge overrides the duration rule

Scenario 5: Child with ear pain, discharge, and perforation

Presentation:
Child pulling ear
Waking from sleep
Ear discharge present
Tympanic membrane perforation visible on examination
Action:
Explain to parents:
"Most perforations heal on their own"
"We need to refer to an ENT specialist today"
Same-day referral to ENT specialist
ENT specialist may:
Clean the ear (toileting)
Give ear drops
Take a swab
Consider surgery (tympanoplasty) in some cases

Earwax Scenarios
Risk factors for earwax problems:
Water entering the ear
Using earbuds

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Scenario 1: First-time earwax presentation

Presenting complaint: Hearing problem after swimming
Patient background: Works in a bank
History-taking:
Ask about swimming or recent water exposure
Inquire about earbud use
Examination:
Use otoscope
Technique:
Hold otoscope with three fingers
Use two fingers to stabilize on patient's face
Pull ear upwards and backwards
Rest two fingers on cheek while examining
If earwax is found:
Explain to patient:
"I can see some earwax in your ear canal"
"Earwax is a natural substance made of dead cells, salt, and oily
secretions"
"It's actually a natural cleaning and protective mechanism for your ear"
"Sometimes it can build up and cause hearing problems"
Treatment plan:
Prescribe medicated ear drops (almond oil-based or olive oil-based)
Instructions: "Use 3 drops, 2 times a day, for 3 weeks" (3-2-3 rule)
If patient asks about immediate irrigation:
Response: "Irrigation is not recommended as a first-line treatment"
Explanation:
"It can sometimes cause complications like perforation or
irritation of the ear canal"
"It's better to try the ear drops first, which are safer and often
effective"
If patient insists due to work:
"I understand your concern about work, but irrigation is now
done privately and you'd need to pay for it"
"It's best to try the ear drops first, as they're often effective and
much safer"

Scenario 2: Earwax follow-up

Patient background:
Previous visit: Doctor couldn't visualize eardrum
Given sodium bicarbonate ear drops

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History of swimming in Spain, sudden ear block

Current presentation:
Patient speaks loudly, bends down to hear
History-taking (speak loudly and clearly):
"When did you first notice the hearing problem?"
"What symptoms did you have when you first came in last week?"
"What tests did the doctor do last time?"
"What treatment were you given?"
"Have you been using the ear drops as prescribed?"
"Have you noticed any improvement since using the drops?"
Examination:
Use otoscope as described earlier
Two possible outcomes:

Outcome A: Impacted wax still visible

Explain to patient:
"I can still see some impacted wax in your ear canal"
"The ear drops haven't fully cleared the blockage"
Recommend irrigation:
"The next step would be to perform ear irrigation to remove the wax"
"However, this procedure is now done privately and you'll need to pay for it"
"I can refer you to a nearby clinic that offers this service"
"You can choose your preferred clinic and negotiate the price with them"

Outcome B: Clear tympanic membrane

Explain to patient:
"I've examined your ear and I can see your eardrum clearly now"
"There's no visible earwax causing a blockage"
Address ongoing hearing loss:
"Since you're still experiencing hearing loss, we need to investigate further"
"Sudden hearing loss without a clear cause is a serious condition that we need to
address quickly"
Action plan:
"I'm going to refer you for a hearing test (audiometry) and to see an ENT
specialist today"
"This is to rule out any underlying conditions causing your hearing loss"
Possible diagnoses:
Acute idiopathic sensorineural hearing loss
Acoustic neuroma
Further tests:

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"The ENT specialist may recommend an MRI scan to check for any
abnormalities"
Treatment possibilities:
"If it's a condition called acute idiopathic sensorineural hearing loss, it's usually
treated with steroids"
"If they find a growth called an acoustic neuroma, surgery might be necessary"
Prognosis:
"In many cases, more than 50% of people recover their hearing with proper
treatment"
"For those who don't fully recover, hearing aids can be very helpful"

General Ear Examination Guidelines

Otoscope technique:
Hold with three fingers
Use two fingers to stabilize on the patient's face
Pull ear upwards and backwards
Rest two fingers on cheek while examining
Right hand can be used for both ears, but left hand is better for left ear
For left ear examination:
Hold otoscope in left hand
Stabilize two fingers on patient's cheek
This provides better stability and prevents trauma if patient moves
Tuning fork:
Not used in earwax scenarios
For children or uncooperative patients:
Always stabilize fingers on the cheek to prevent trauma if the patient moves
Explanation: "If the patient moves, the whole system will move, preventing
potential injury"

Important Points to Remember

Antibiotics for otitis media:
Don't give if symptoms are present for less than 5 days
Give if otorrhea (ear discharge) is present
Paracetamol dosage for children with otitis media:
Every 4 hours
Not more than 4 doses in 24 hours
Earwax treatment:
Medicated ear drops (almond or olive oil-based)
3 drops, 2 times a day, for 3 weeks (3-2-3 rule)
Sudden hearing loss protocol:
Same-day referral for audiometry and ENT if cause is unknown

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MRI to rule out acoustic neuroma

Tympanic membrane perforation:
Most heal on their own
Refer to ENT specialist for assessment and possible treatment
Ear irrigation:
Not recommended as first-line treatment for earwax
Now done privately, patient needs to pay
Risks include perforation and irritation of the ear canal
Hearing loss is taken very seriously in the UK healthcare system

Acoustic Neuroma Scenarios

Scenario 1: Young Adult with Unilateral Hearing Loss
Patient Profile:
Age: 40-45 years old
Occupation: Works in a telephone call centre
Chief Complaint: Hearing problem on the right side

History Taking:
Presenting Complaint:
Ask: "How may I help you today?"
Expected response: "I'm having trouble hearing on my right side."
Onset and Duration:
Ask: "How did you first notice your hearing loss?"
Ask: "How long have you been experiencing this problem?"
Note: Patient may mention difficulty making calls at work
Characteristics of Hearing Loss:
Ask: "Is it only in your right ear or both?"
Ask: "Is the hearing loss constant or does it come and go?"
Ask: "Is there anything that makes it better or worse, like being in a quiet or
noisy place?"
Associated Symptoms (Cardinal Symptoms of Ear Disease):
Ask: "Have you experienced any ear pain?"
Ask: "Any dizziness or balance problems?"
Ask: "Do you hear any ringing or other noises in your ear?"
Ask: "Have you noticed any numbness or weakness in your face?"
Previous Treatments:
Ask: "Have you tried any treatments for this?"
Note: Patient may mention using over-the-counter eardrops, thinking it was
earwax

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Risk Factors and Differential Diagnosis:

Infections and inflammation:
Ask: "Have you had any discharge or redness in your ear?"
Ask: "Any recent sore throat, fever, or flu-like symptoms?"
Earwax:
Ask: "Have you ever been told you have excessive earwax?"
Ask: "Do you use cotton buds or have you had water enter your ear
recently?"
Trauma:
Ask: "Any recent injuries to your ear or head?"
Ask: "Have you been exposed to very loud noises recently?"
Ask: "Any recent air travel or scuba diving?"
Work-related:
Ask: "Does your work involve exposure to loud noises?"
Past Medical History:
Ask: "Do you have any other medical conditions?"
Ask: "Are you on any regular medications?"
Family History:
Ask: "Does anyone in your family have hearing problems?"
Ask: "Are there any significant medical conditions that run in your family?"
Note: Patient will mention brother with neurofibromatosis

Examination:
Otoscope Examination:
Explain: "I'm going to look in both of your ears with this instrument called an
otoscope. It won't hurt, but please let me know if you feel any discomfort."
Technique:
Hold otoscope with three fingers
Use two fingers to stabilize on patient's face
Pull ear upwards and backwards
Rest two fingers on cheek while examining
Examine both ears
Findings: "The inside of both your ears looks normal."
Tuning Fork Tests:
Explain: "Now I'm going to do some hearing tests with this tuning fork. It will
help us understand what type of hearing loss you might have."
Rinne Test:
Procedure: "I'm going to place this vibrating fork on the bone behind
your ear, then move it in front of your ear. Please tell me when you
stop hearing the sound, and then if you can hear it again when I
move it."

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Perform on both ears

Interpretation: Positive Rinne (normal) if air conduction > bone
conduction
Weber Test:
Procedure: "I'm going to place this vibrating fork on the top of your head.
Please tell me which ear you hear the sound in more, or if it's equal in
both ears."
Findings (given on paper): "Rinne positive left and right, Weber lateralizes to the
left"
Interpretation: "These results suggest a sensorineural hearing loss on your right
side."

Diagnosis and Explanation:

Tell patient: "Based on our examination and tests, you have some hearing loss on your
right side. The type of hearing loss you have seems to be related to the nerves in
your ear, which we call sensorineural hearing loss."
Explain: "There's a condition called acoustic neuroma that can cause this type of
hearing loss. It's a non-cancerous growth on the nerve that connects the ear to the
brain."
Mention genetic link: "You mentioned your brother has a condition called
neurofibromatosis. This condition is associated with a higher risk of developing
acoustic neuroma, so this is something we need to consider."

Management Plan:
Referral:
Explain: "I'm going to refer you to an Ear, Nose, and Throat (ENT) specialist.
This will be a two-week referral, which means you should be seen within two
weeks."
Further Tests:
Explain: "The ENT specialist will likely order an MRI scan to get a detailed
picture of your ear and the surrounding structures. They will also do more
detailed hearing tests."
Treatment:
Explain: "If it is an acoustic neuroma, the main treatment is usually surgery.
However, the ENT specialist will discuss all the options with you based on
the size and location of the growth."
Reassurance:
"While we wait for your appointment, continue your normal activities. If you
notice any new symptoms or worsening of your hearing, please come back to
see me."

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Scenario 2: Elderly Patient with Tinnitus

Patient Profile:
Age: 65-69 years old
Occupation: Journalist
Chief Complaint: Ringing sensation in the ear (tinnitus)
History Taking:
Presenting Complaint:
Ask: "What brings you in today?"
Expected response: "I've been having a ringing sensation in my ear."
Onset and Duration:
Ask: "When did you first notice this ringing?"
Ask: "Has it been constant or does it come and go?"
Note: Symptoms present for weeks
Characteristics of Tinnitus:
Ask: "Can you describe the sound? Is it ringing, buzzing, or something else?"
Ask: "Is it in one ear or both?"
Ask: "Does anything make it better or worse?"
Associated Symptoms:
Ask: "Have you noticed any changes in your hearing?"
Note: Patient may mention some difficulty hearing
Ask about other cardinal ear symptoms (pain, dizziness, balance issues)
Impact on Daily Life:
Ask: "How is this affecting your daily activities or sleep?"
Past Medical History:
Ask about previous ear problems, noise exposure, medications
Occupational History:
Ask: "As a journalist, are you exposed to any loud noises in your work?"
Family History:
Ask about family history of hearing problems or other relevant conditions
Note: Brother had neurofibromatosis

Examination and Diagnosis:

(Similar to Scenario 1)

Management:
(Similar to Scenario 1, with focus on tinnitus management if acoustic neuroma is ruled
out)

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Cholesteatoma Scenario
Patient Profile:
Age: Around 70 years old
Chief Complaint: Ear discharge for two weeks
History Taking:
Presenting Complaint:
Ask: "How may I help you today?"
Expected patient response: "I have some discharge from my ear."
Duration and Onset:
Ask: "How long have you had this discharge?"
Expected response: "About two weeks."
Ask: "Did it start suddenly or gradually?"
Discharge Analysis (MEDS):
Morphology:
Ask: "What does the discharge look like? Is it watery, pus-like, or bloody?"
Ask: "How much discharge is there?"
Evolution:
Ask: "Has the discharge changed since it started?"
Ask: "Is it constant or does it come and go?"
Duration: Already established (two weeks)
Symptoms:
Ask: "Does the discharge have any smell?"
Ask: "Is there any pain associated with the discharge?"
Associated Symptoms:
Hearing loss:
Ask: "Have you noticed any changes in your hearing?"
Patient may mention increasing TV volume
Ask about other cardinal ear symptoms:
"Any dizziness or balance problems?"
"Any ringing or other noises in your ear?"
Past Medical History:
Ask: "Have you had any ear problems in the past?"
Note: Patient had ear problems in his 50s (20 years ago)
Follow-up: "Do you remember what that problem was? Was it something called
'glue ear'?"
Impact on Daily Life:
Ask: "How is this affecting your daily activities?"

Examination:

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Explain: "I would like to examine your ear now. I'll be using an instrument called an
otoscope to look inside your ear canal. It won't hurt, but please let me know if you
feel any discomfort."
Note: A picture will be provided showing damage to the eardrum
Describe findings: "I can see some damage to your eardrum. There appears to be an
abnormal growth."

Diagnosis and Explanation:

Tell patient: "Based on your symptoms and what I can see in your ear, this could be a
condition called cholesteatoma."
Explain: "Cholesteatoma is an abnormal growth of skin cells inside your ear. Normally,
skin cells grow and shed, but in your ear, they've accumulated and formed a
growth."
Potential consequences: "This growth can spread and potentially damage the small
bones in your ear that help with hearing. In some cases, it can even affect the base
of the skull."
Cause of symptoms: "This growth is likely causing the discharge you're experiencing,
and it may be contributing to your hearing difficulties."

Management Plan:
Referral:
Explain: "I'm going to refer you to an Ear, Nose, and Throat (ENT) specialist.
This will be a two-week referral, which means you should be seen within two
weeks."
Further Tests:
Explain: "The ENT specialist will likely order an MRI scan. This will give a
detailed picture of your ear and show the extent of the growth."
Treatment:
Explain: "Treatment for cholesteatoma usually involves surgery to remove the
growth. This is important to prevent further damage to your ear."
Add: "If there's damage to the small bones in your ear that help with hearing,
the surgeon might need to reconstruct these. Sometimes they use artificial
bones for this."
Prognosis:
Reassure: "With proper treatment, many people have good outcomes. The goal
is to remove the growth and prevent it from coming back."
Interim Care:
Advise: "Until you see the specialist, try to keep your ear dry. Avoid swimming or
getting water in your ear when showering. If the discharge increases or you
develop severe pain or dizziness, please seek medical attention immediately."

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General Ear Examination Guidelines

Otoscope technique:
Hold with three fingers
Use two fingers to stabilize on the patient's face
Pull ear upwards and backwards
Rest two fingers on cheek while examining
Right hand can be used for both ears, but left hand is better for left ear
Tuning Fork Tests:
Rinne Test:
Positive (normal) if air conduction > bone conduction
Weber Test:
Lateralization to one side indicates sensorineural hearing loss in the
opposite ear
Tympanic Membrane Description (if required):
Describe pars flaccida (upper portion, looser)
Describe pars tensa (lower portion, tighter)
Note presence or absence of cone of light
Identify handle of malleus

IV. Important Points to Remember

Cardinal Symptoms of Ear Disease:
Hearing loss
Pain
Dizziness
Tinnitus (ringing sensation)
Balance problems
Facial numbness or weakness
Ménière's Disease symptoms (DVTF):
Deafness
Vertigo
Tinnitus
Fullness in the ear
Hearing Loss Referral:
If cause is known: Two-week referral
If cause is unknown: Same-day referral
Occupations at risk for hearing problems:
Airport workers
Sound engineers
DJs
Club security personnel
Music festival organizers

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Ototoxic medications to be aware of:

Some antibiotics
Cyclosporine
Methotrexate
Neurofibromatosis:
Genetic link with acoustic neuroma
Important to note in family history
Approach to Ear Discharge:
Always consider MEDS (Morphology, Evolution, Duration, Symptoms)
Cholesteatoma:
Can present with ear discharge and hearing loss
Requires prompt referral to ENT for further management

Malignant Otitis Externa Scenario

Setting:
Can be in GP or A&E (management slightly differs based on setting)

Patient Profile:
Occupation: Piano teacher
Chief Complaints: Ear pain, swelling, and hearing loss
Relevant Medical History: Diabetes and rheumatoid arthritis (on methotrexate)

History Taking:
Presenting Complaint:
Ask: "How may I help you today?"
Expected response: Patient mentions ear pain, swelling, and hearing loss
Ear Pain Assessment:
Ask: "Which ear is painful? Left or right?"
Ask: "Which part of the ear is painful? Is it the front, outer aspect, or inside?"
Ask: "When did the pain start?"
Ask: "Is it getting better or worse?"
Ask about onset, duration, and progression
Swelling:
Ask: "Can you tell me more about the swelling? Where exactly is it?"
Hearing Loss:
Ask: "How has your hearing been affected?"
Ask: "How is this affecting your work as a piano teacher?"
Associated Symptoms:
Ask about discharge, redness
Risk Factors and Differential Diagnosis:

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Recent flu or sore throat (can lead to otitis media and potentially meningitis or
pneumonia)
Earwax accumulation
Recent trauma to the ear
Past Medical History:
Ask: "Do you have any ongoing medical conditions?"
Note: Patient has diabetes and rheumatoid arthritis
Ask: "What medications are you currently taking?"
Note: Patient is on methotrexate
Complete MAFTOSA

Examination:
Explain the process:
Say: "I would like to examine your ear. First, I'll do a test called Tragus test to
check for pain."
Tragus Test:
Explain: "I'm going to gently press on the front part of your ear. Please let me
know if it causes any pain."
Note: In this scenario, Tragus test will be positive (painful)
Otoscope Examination:
Say: "Now, I'd like to look inside your ear with an instrument called an
otoscope."
Note: In real practice, you wouldn't perform this without a license. For the
scenario, proceed as instructed.
Technique: Hold with three fingers, use two fingers to stabilize on patient's face,
pull ear upwards and backwards
Examination Findings:
You will be presented with two pictures: a. External auditory canal: Swollen with
pus b. Tympanic membrane: Red, swollen

Diagnosis and Explanation:

Tell the patient: "Based on your symptoms and what I can see, you may have a
condition called malignant otitis externa."
Explain: "This is an inflammation of the outer part of your ear. We call it 'malignant'
not because it's cancerous, but because it can be serious due to your underlying
medical conditions."
Further explanation: "Your diabetes and the medication you're taking for rheumatoid
arthritis (methotrexate) can lower your immune system, making it harder for your
body to fight infections."

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Management Plan:
Referral:
If in GP setting: "I'm going to refer you to the hospital immediately."
If in A&E: "I'm going to refer you to the Ear, Nose, and Throat (ENT) specialist
here in the hospital."
Further Tests and Treatment:
Explain: "At the hospital, they will:
Do blood tests to check for any spread of infection
Take a closer look at your ear
Possibly take a swab to identify the specific bacteria causing the infection
Clean and dress your ear (a process called 'toileting')
Likely give you antibiotic ear drops and oral antibiotics (possibly
Ciprofloxacin)
If the infection has spread, you might need to be admitted to the hospital
for intravenous antibiotics."
Follow-up:
Advise: "It's crucial that you follow all the treatment instructions given by the
hospital team. They will also arrange appropriate follow-up appointments."

Benign Tinnitus Scenario

Patient Profile:
Age: Around 45-50 years old (middle-aged)
Occupation: Factory worker (noisy environment)
Chief Complaint: Ringing sensation in one ear for about a month

History Taking:
Presenting Complaint:
Ask: "How may I help you today?"
Expected response: "I have a ringing sensation in my ear."
Characterize the Tinnitus:
Ask: "Which ear is affected? Left or right?"
Note: It's unilateral (one-sided) in this scenario
Ask: "Can you describe the sound you're hearing? Is it like a bell ringing, hissing,
buzzing, sizzling, or humming?"
Ask: "When did you first notice this sound?"
Ask: "Is it constant or does it come and goes?"
Ask: "How long does each episode last?"
Ask: "How many episodes have you had?"
Ask: "Does it happen every day?"
Ask: "Did it start suddenly or gradually?"

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Ask: "Is it getting better, worse, or staying the same?"

Aggravating and Alleviating Factors:
Ask: "Is there anything that makes the sound better?"
Prompt: "For example, does background sound like music or talking to someone
help?"
Ask: "Is there anything that makes it worse?"
Prompt: "For example, is it worse in quiet environments or when watching TV?"
Associated Symptoms (Cardinal Symptoms of Ear Disease):
Ask: "Do you have any pain in your ear?"
Ask: "Any dizziness or balance problems?"
Ask: "Have you noticed any changes in your hearing?"
Ask: "Any numbness or weakness in your face?"
Ask: "Do you feel any fullness in your ear?" (for Ménière's disease)
Differential Diagnosis:
Infections and inflammation:
Ask: "Have you had any ear infections recently?"
Ask: "Any discharge from your ear?"
Earwax:
Ask: "Have you ever been told you have excessive earwax?"
Ask: "Do you use cotton buds to clean your ears?"
Trauma:
Ask: "Have you had any injuries to your ear or head recently?"
Ask: "Have you been exposed to very loud noises lately?"
Medical History:
Ask about conditions that can cause tinnitus:
"Have you ever been diagnosed with thyroid problems?"
"Do you have diabetes?"
"Any history of multiple sclerosis?"
Ask: "Have you had any previous traumas or head injuries?"
Medications:
Ask: "Are you taking any medications regularly?"
Specifically ask about:
Aspirin (important to ask about)
Antibiotics
Cyclosporine
Methotrexate
Ask: "Any other medications you're taking?"
Lifestyle Factors:
Ask: "How's your stress level been lately?"
Ask: "How has your sleep been? Any sleep deprivation?"

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Ask about work: "You mentioned working in a factory. Is it a noisy

environment?"
Follow-up: "How long have you been working there?"
Ask: "Do you use any ear protective equipment at work?"
If yes: "Do you still find it noisy even with the protection?"
If no: "Have you been provided with ear protection?"
Other Factors:
Ask about caffeine, alcohol, and smoking habits

Examination:
Explain: "I'd like to examine your ears now."
Note: In this scenario, examination findings are normal

Diagnosis and Explanation:

Tell the patient: "What you're experiencing is called tinnitus."
Explain: "Tinnitus is the perception of sound, in your case a ringing, without any actual
physical sound from the outer environment. It's not a condition itself, but rather a
symptom that can have various causes."
Potential cause: "In your case, working in a noisy environment could be contributing to
this. It's essentially an abnormal function of your ear, possibly due to the noise
exposure at your workplace."

Management Plan:
Lifestyle Modifications:
Advise: "There are several things you can try to manage your tinnitus:
Take regular breaks from noisy environments
Ensure you're getting enough sleep and relaxation
Exercise regularly and maintain a healthy diet
Stay hydrated by drinking enough fluids
Try to reduce stress through relaxation techniques
Avoid stimulants like caffeine, alcohol, and smoking"
Sound Therapy:
Explain: "Using background sounds, what we call 'white sound', can help mask
the tinnitus. You could try:
Playing soft background music
Using a white noise machine or app with sounds like rainfall
Leaving a radio on at low volume, especially instrumental music"
For sleep: "If it's affecting your sleep, try using these sounds at night. Rain
sounds can be particularly helpful for sleeping."
Work-related Advice:

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Emphasize: "It's crucial to protect your hearing at work. Always wear the ear
protection provided, and if you're still finding it too noisy, speak to your
employer about additional measures."
Follow-up:
Advise: "If there's no improvement in six weeks, please come back to see me. At
that point, we may consider referring you to an ENT specialist."
Note: Remember the 6-week follow-up period
Reassurance:
Say: "Tinnitus, like palpitations, is not a condition in itself, but a symptom.
Many people find that their tinnitus improves with these measures. However,
if you notice any new symptoms or if it significantly affects your daily life,
don't hesitate to come back sooner."

Important Points to Remember

Malignant Otitis Externa:
Serious condition, especially in immunocompromised patients (e.g., diabetes, on
immunosuppressants)
Requires immediate referral to hospital/ENT
Treatment involves systemic antibiotics (e.g., Ciprofloxacin), possibly admission
Tinnitus:
Not a condition itself, but a symptom
Can be unilateral or bilateral
Unilateral tinnitus with other symptoms (e.g., hearing loss) requires further
investigation
Occupational noise exposure is a common cause
Management focuses on lifestyle modifications and sound therapy
Follow-up in 6 weeks if no improvement
Ear Examination:
Tragus test can indicate external ear inflammation
Otoscope examination requires proper licensing (in real practice)
Differential Diagnosis for Ear Symptoms:
Always consider infections (otitis media, externa), earwax, and trauma
Remember systemic conditions (e.g., thyroid disorders, diabetes, multiple
sclerosis) can affect ears
Medications that can cause ear symptoms:
Aspirin (important to ask about)
Some antibiotics
Cyclosporine
Methotrexate

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Approach to History Taking:

Use MEDS approach for symptoms: Morphology, Evolution, Duration,
Symptoms
For tinnitus, ask about the nature of the sound, onset, progression, and
associated symptoms
Always enquire about impact on daily life and occupation
Cardinal Symptoms of Ear Disease:
Hearing loss
Pain
Dizziness
Tinnitus
Balance problems
Facial numbness or weakness

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Testicular Scenarios
Total scenarios: 6
Teaching inguinal scrotal examination
Testicular carcinoma
Epididymal cyst
19-year-old reassurance scenario
Mumps orchitis
Epididymal orchitis with STI
Note: This is a small area in terms of the entire syllabus, but all scenarios are important.

General Approach to Testicular Lumps

History Taking:
Initial Question:
Ask: "How did you find out about the lump?"
Possible responses:
"I saw a TV program and decided to check myself"
"I saw a poster in a public toilet"
"I accidentally found it while showering"
Lump Assessment (MEDS approach):
Morphology:
Ask: "Which testicle is affected? Left or right?"
Ask: "Is the whole testicle swollen or just a part of it?"
If partial, ask: "Which part? Upper, lower, or middle?"
Ask: "How big is it? Can you compare it to something, like a grape, pea,
or peanut?"
Ask: "How does it feel? Is it hard, soft, or filled with fluid?"
Ask: "What's the shape like? Is it regular or irregular?"
Ask: "Can you move it, or is it attached to the underlying tissue?"
Evolution:
Ask: "When did you first notice it?"
Ask: "Has it changed in size since you first noticed it?"
Ask: "Does it change when you lie down?"
Ask: "Does it change when you cough or sneeze?"
Duration: Covered in evolution questions
Symptoms:
Ask: "Is it painful?"
Ask: "Any tingling or numbness sensation?"
Ask: "Any discomfort?"
Ask: "Any redness around the testicle?"

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Ask: "Any swelling around the testicle?"

Ask: "Any skin openings, rashes, or itchiness?"
STI Symptoms:
Ask about all STI symptoms
Sexual History:
Take a detailed sexual history
Fertility Questions:
Ask: "Do you have any children?"
Ask: "Do you want to have children in the future?"
Note: In Western countries, it's important to ask about future family planning
Family History:
Ask about family history of testicular cancer
Testicular Cancer Symptoms:
Ask specifically about:
Testicular pain
Back pain
Loin pain
Gynecomastia (breast enlargement in males)
Risk Factors for Testicular Cancer:
Ask: "When you were born, were there any issues with your testicles?"
Ask: "Have you ever been told that you had an undescended testicle?"
Ask about family history of testicular cancer

Examination:
Inspection:
Inspect penis (anterior and posterior)
Inspect testicles (anterior and posterior)
Palpation:
Bimanual palpation of testicles
Technique: Stabilize testicle with one hand, palpate with the other
Transillumination:
Use a torch directly against the scrotum
If old-school examiner provides rolled paper, use it; otherwise, direct light is fine

Specific Scenarios

Testicular Carcinoma
Patient Profile:
Age: 25-26 years old
Chief Complaint: Found a lump on testicle

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History:
Patient may mention finding lump while showering
Brother diagnosed with testicular cancer 3 months ago
Patient had undescended testicle, operated at 3 months of age

Examination:
Palpation: Will feel a lump
Transillumination: Perform as part of examination

Diagnosis and Explanation:

Tell patient: "Unfortunately, this could be testicular cancer as you suspect. You do have
some risk factors, including a family history and a history of undescended testicle."

Management:
Blood tests:
Tumor markers: Beta-HCG and LDH (not alpha-fetoprotein)
Urgent ultrasound
Refer on cancer pathway (2-week referral to urology)
Further tests by specialist:
MRI
Biopsy (which usually means removal of the testicle)

Patient Concerns:
If patient asks about fertility, explain sperm banking options

Epididymal Cyst
Patient Profile:
Young adult
Chief Complaint: Lump on testicle

Examination:
Will feel a proper, decent-sized lump
Transilluminate the lump

Diagnosis and Explanation:

Tell patient: "This condition is called an epididymal cyst. It's a fluid-filled sac in the
epididymis, which is the tissue next to the testicle that collects sperm."

Management:
Reassure: "It's often self-limiting and can settle on its own in 6-9 months."

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Offer treatment options:

Referral to urologist for: a. Surgery to remove the fluid b. Freezing therapy (if
small)
Arrange routine ultrasound
Do tumour markers (Beta-HCG and LDH) due to young age

Safety Netting:
Warn about testicular torsion: "If you get sudden severe pain, go to the hospital
immediately as the cyst might have twisted."

Reassurance scenario
Patient Profile:
Age: 19 years old
Chief Complaint: Worried about testicular cancer after friends discussed it

History:
No risk factors (no family history, no undescended testicle)
Patient examined himself after friends talked about testicular cancer in young people

Examination:
No lump found (may feel normal epididymal tissue)

Management:
Reassure confidently: "I've examined you thoroughly and there's no lump. You also
don't have any risk factors for testicular cancer."
Educate: "What you're feeling is normal testicular tissue."
Advise: "You can continue self-examining. If you ever find a concerning lump, come
back for a check-up."
No tests needed

Important Note:
Be confident in your reassurance
Avoid unnecessary tests or referrals in clear reassurance scenarios
Don't say things like "I'm not sure" or "Maybe we should do some tests just to be safe"
Don't suggest calling in seniors for a second opinion in clear cases

IV. Important Points to Remember

Always use the MEDS approach for assessing lumps:
Morphology
Evolution

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Duration
Symptoms
Key symptoms of testicular cancer:
Testicular pain
Back pain
Loin pain
Gynecomastia
Risk factors for testicular cancer:
Undescended testicle at birth
Family history of testicular cancer
Proper examination technique is crucial:
Inspection
Bimanual palpation
Transillumination
Tumor markers for testicular cancer:
Beta-HCG
LDH
(Not alpha-fetoprotein in this context)
Management varies by scenario:
Suspected cancer: Urgent referral and tests
Benign conditions: May involve watchful waiting or referral for treatment
Reassurance: Confident reassurance without unnecessary tests
Always consider fertility concerns and discuss when appropriate
Be confident in your assessment and management plan. Avoid unnecessary referrals or
expressing uncertainty in clear cases.
Remember that the healthcare system discourages unnecessary testing:
GPs may face financial implications for unnecessary tests or prescriptions
This system helps control overuse of resources
In reassurance scenarios:
Don't act confused or uncertain
Don't suggest doing tests "just to be on the safe side"
Don't call for senior opinions unnecessarily

Mumps Orchitis
Patient Presentation:
Chief Complaint: "I have testicular pain and a lump" or "I have a swelling in my
testicle"
Whole testicle is swollen

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History Taking:
Ask about swelling:
"Do you have any swelling?"
"Is the whole testicle swollen or just a part of it?"
Expected response: "The whole testicle is swollen"
Ask about recent infections:
"Have you had any swellings anywhere else in your body recently?"
Specifically ask: "Have you had any swelling in your ankles recently?"
Note: Patient may respond, "Yes, I had a swelling in my ankle a couple of days
ago"
Be aware: Experienced actors might sit normally, while inexperienced ones
might hold their ankle to indicate swelling
Ask about past medical history:
"Have you ever been diagnosed with or told you had mumps?"
"Do you know if you've been vaccinated against mumps?"
Expected response: "I'm not sure about vaccines"
Conduct standard MEDS (Morphology, Evolution, Duration, Symptoms) assessment
for the testicular swelling
Take sexual history as usual

Examination:
Whole testicle will be swollen
Note: The mannequin might resemble a hydrocele due to manufacturing limitations. It
may be visible from a distance.

Diagnosis and Explanation:

Tell the patient: "Based on your symptoms and examination, you may have a condition
called mumps orchitis."
Explain: "Mumps is a virus that usually causes infection and inflammation of the
salivary glands, which we call spit glands. As a complication, it can sometimes cause
infection and inflammation of the testicle and surrounding tissue, which we call
orchitis."

Management:
Symptomatic treatment (e.g., pain relief)
Explain that it's a viral condition and will typically resolve on its own
Advise rest and supportive care

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Epididymo-orchitis
Patient Presentation:
Chief Complaint: Testicular pain and swelling

History Taking:
Conduct standard MEDS assessment
Take detailed sexual history

Examination:
Swollen, tender testicle and epididymis

Diagnosis and Explanation:

Tell the patient: "Based on your symptoms and examination, you may have a condition
called epididymo-orchitis."
Explain: "This is inflammation of the testicle and the surrounding tissue called the
epididymis. In your situation, it could be caused by a sexually transmitted infection,
most likely gonorrhoea."
Further explain: "Gonorrhoea is a bacterial infection. We use 'G' for gonorrhoea to
remember it often causes a 'grainy' discharge. Similarly, 'C' for chlamydia often
causes a 'clear' discharge."

Management:
Symptomatic treatment:
Recommend paracetamol for pain relief
Referral:
Advise patient to go to a GUM (Genitourinary Medicine) clinic
Treatment:
Explain that the likely antibiotic treatment will be Ceftriaxone if gonorrhoea is
confirmed
Partner notification:
Explain the importance of informing sexual partners for testing and treatment

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Counselling
Four Box System for Counselling Scenarios
Overview:
Used when patients request information or services
Examples: DNA testing, surgical abortion information, vasectomy referral, worried
about vascular dementia

Structure:
Box 1 & 2: Collect information
Box 3 & 4: Give information

Box 1: Collect General Information

Ask what the patient understands about the topic
Example questions:
"What do you understand about vascular dementia?"
"What do you know about PSA tests?"
"What's your understanding of vasectomy?"
"What do you know about post-mortem examinations?"

Box 2: Collect Specific Patient Information

Ask about patient-specific factors and risk factors
For post-mortem: Ask about concerns regarding the death, any long-term medical
problems of the deceased, recent hospital admissions, family history of sudden
death

Box 3: Provide General Information

Explain the topic based on what was asked in Box 1
Example explanations:
Explain what vascular dementia is
Describe what a PSA test is
Explain the vasectomy procedure
For post-mortem: Explain what it is, how it's done, who does it, where it's done,
indications (e.g., death within 24 hours of hospital admission, unknown
cause of death, criminal activity, police request)

Box 4: Provide Patient-Specific Information

Discuss whether the service/test is appropriate for the patient
Explain next steps
For post-mortem: Explain why it might not be necessary in this case, but inform the
family they can request one if desired

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Scenario: Worried About Vascular Dementia

Important Notes:
This scenario is about future worry, not current symptoms
Focus on discussing risk factors and providing information

Approach:
Box 1: Ask what the patient knows about vascular dementia
Box 2: Inquire about patient's specific concerns and risk factors
Box 3: Explain what vascular dementia is
Box 4: Discuss the patient's personal risk and preventive measures

Other Scenarios Mentioned:

Worried about stroke
Worried about prostate cancer (different from requesting a PSA test)

III. Important Points to Remember

In mumps orchitis, always ask about recent swellings in other parts of the body,
especially ankles.
For STI-related epididymo-orchitis, remember the mnemonic:
G for Gonorrhoea (grainy discharge)
C for Chlamydia (clear discharge)
The Four Box System is crucial for counselling scenarios:
Boxes 1 & 2: Collect information
Boxes 3 & 4: Give information
Tailor your approach to the specific scenario:
"Worried about prostate cancer" is different from "Can I have a PSA test?"
Focus on the patient's actual concern
In counselling scenarios, it's about discussing possibilities and risks, not always about
diagnosis and treatment.
Be confident in your assessment and explanation. Avoid unnecessary tests or referrals
when reassurance is appropriate.
For teaching scenarios (like inguinal scrotal examination), be extremely nice and focus
on quality teaching. Don't pre-plan not to finish or suggest meeting another day.
Remember that some scenarios (like post-mortem discussions) may be less common in
exams now, but it's still good to be familiar with the approach.
When examining testicles, always use bimanual palpation and proper technique.
In reassurance scenarios (like the 19-year-old worried about testicular cancer), be
confident in your assessment. Don't express uncertainty or suggest unnecessary tests
"just to be safe".

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Vascular Dementia
Setting:
F2 doctor in GP practice

Patient Profile:
40-year-old lady
Past medical history: Psoriasis (on steroid cream)
BMI: High (obesity category)

Consultation Structure (Four Box System):

Box 1: Collect General Information

Initial Question:
Ask: "How may I help you today?"
Expected response: "I am worried about vascular dementia"
Explore Reason for Concern:
Ask: "Can I please ask why are you worried about vascular dementia?"
Expected response: "My sister has been diagnosed with vascular dementia"
Follow-up: "I'm sorry to hear about that. How is your sister doing?"
Respond: "Let me see what we can do for you."
Assess Previous Knowledge:
Ask: "What is your understanding about vascular dementia?"
Ask: "Do you know what vascular dementia is?"
Ask: "Have you studied anything or read anything about it?"
Ask: "Have you done any research on your own?"
Ask: "Do you know how vascular dementia affects somebody?"
Ask: "When somebody develops vascular dementia, what sort of symptoms can
they develop?"
Ask: "What is your understanding about the risk factors of vascular dementia?"
Ask: "Do you know what can cause vascular dementia?"
Ask: "Do you know what sort of things can increase the chances of someone
developing vascular dementia?"
Note: Don't ask every single question. 2-4 questions from this list will suffice.
Explore Expectations:
Ask: "Is there anything particularly that you wanted us to help you with
regarding vascular dementia?"
Ask: "Is there anything specifically you wanted to talk about?"

Box 2: Collect Specific Patient Information

Medical History (MAFTOSA):

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Ask about psoriasis: diagnosis, treatment

Ask about other medical conditions like diabetes, high blood pressure
Ask about medications
Note: Psoriasis is a risk factor for vascular dementia
Family History:
Confirm sister's diagnosis
Ask about any other family members with dementia
Lifestyle Factors:
Diet:
Ask: "Do you cook or eat outside?"
Ask: "What sort of food do you usually eat?"
Ask about fast food, food with high fat and sugar
Ask: "Do you eat a lot of fruits and vegetables?"
Ask about red meat consumption
Exercise:
Ask: "How much do you exercise?"
Ask: "Do you exercise at all?"
Smoking and Alcohol:
Ask about smoking habits
Ask about alcohol consumption
Stress levels
Note: Do not do differential diagnoses for this scenario. Focus on risk factors.

Examination:
Measure BMI
Check blood pressure
Note: Examination is relevant here due to metabolic risk factors

Box 3: Provide General Information

Explain Dementia:
"Dementia is a condition of the brain."
"Initially, dementia affects the memory."
"It is a progressive condition. As the condition progresses, it can affect bodily
functions."
Explain Vascular Dementia:
"Vascular dementia is caused by having multiple small strokes in the brain."
"Some people can also develop vascular dementia after having a large stroke in
the brain."

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Box 4: Provide Patient-Specific Information

Discuss Risk:
"From the information I have gathered, unfortunately, you do have some risk for
developing vascular dementia in the future."
Explain Risk Categories:
"We divide the risk into two categories: modifiable and non-modifiable risk
factors."
Explain Non-modifiable Risk Factors:
"Non-modifiable means we don't have control over them."
"For example, if you have a family member with dementia, like your sister, that's
a non-modifiable risk factor."
"Age is another non-modifiable risk factor. As we get older, the risk increases."
"If you've had some medical problems in the past like a stroke, mini-stroke, or
heart attack, these are also non-modifiable risk factors."
Explain Modifiable Risk Factors:
"Modifiable risk factors are things we can do something about."
"These include not eating healthy, not doing exercise, smoking, or if your
medical conditions like diabetes or psoriasis are poorly controlled."
Discuss Risk Reduction:
"To reduce the risk, there are things that you can do and things we can help you
with."
"What we can help you with is taking care of your medical conditions. We can
regularly monitor and give you medications to prevent complications and
control the conditions."
"What you can do on an individual level is make some changes in your lifestyle."
Suggest Lifestyle Changes:
"It's better to cook and eat at home rather than eating out frequently."
"Cut down on oily foods and red meat."
"Quit smoking if you smoke."
"Cut down on alcohol consumption."
"Do regular exercise. It's better to do 30 minutes of exercise 5 times a week."
Conclude:
"How does that sound to you, Mrs. Johnson?"
"Unfortunately, you do have some risk from both categories of risk factors. But
remember, there are things that we can help you with and things you can do
by yourself to reduce this risk."

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Stroke Scenario
Setting:
F2 doctor in GP practice

Patient Profile:
Older man named Zimmerman
NHS manager (stressful job)
Borderline high blood pressure (measured by nurses)
Smoker
Eats outside mostly, often Indian takeaways

Consultation Structure (Four Box System):

Box 1: Collect General Information

Initial Question:
Ask: "How may I help you today, Mr. Zimmerman?"
Expected response: "I am worried about stroke"
Explore Reason for Concern:
Ask: "Can I ask why you're worried about stroke?"
Expected response: "I saw a TV program that said if you have a family member
with stroke, you have higher chances of developing stroke or heart attack. My
brother had a heart attack, and my father had a stroke."
Assess Previous Knowledge:
Ask: "What is your understanding about stroke?"
Ask: "Do you know what a stroke is?"
Ask: "Do you know how stroke affects the body?"
Ask: "When somebody develops stroke, what sort of symptoms do they develop?"
Ask: "What is your understanding about the risk factors for stroke?"
Ask: "What sort of things can increase the risk of someone developing a stroke?"
Ask: "How do you think somebody can reduce their risk of stroke?"
Explore Expectations:
Ask: "In what ways are you looking for us to help you with this?"
Ask: "Is there any particular way you're hoping we should help you with this
concern?"

Box 2: Collect Specific Patient Information

Medical History (MAPTOSA):
Note borderline high blood pressure
Ask about other medical conditions
Ask about medications

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Family History:
Confirm brother's heart attack and father's stroke
Ask about any other relevant family history
Occupation:
Note: Patient is an NHS manager (potentially stressful job)
Lifestyle Factors:
Diet:
Ask about eating habits (note: patient mostly eats outside, often Indian
takeaways)
Ask: "What sort of food does that include?"
Explore: Fried food, oily food, carbohydrates
Exercise:
Ask about physical activity levels
Smoking:
Confirm smoking habits
Alcohol consumption
Stress levels (consider job stress)

Examination:
Check blood pressure
Measure BMI
Check for irregular heartbeat (relevant for stroke risk)

Box 3: Provide General Information

Explain Stroke:
"Stroke is a condition of the brain."
"People develop stroke due to interruption of the blood supply to the brain
cells."
"When someone develops a stroke, they can have weakness, speech problems,
numbness, or they can collapse."

Box 4: Provide Patient-Specific Information

Discuss Risk:
"From the information I have gathered, unfortunately, you do have some risk for
stroke."
Explain Risk Categories:
"We divide the risk into two categories: modifiable and non-modifiable risk
factors."
Explain Non-modifiable Risk Factors:
"Non-modifiable means we don't have control over them."

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"For example, having a family member who had a stroke or heart attack, like
your father and brother, increases your risk."
"Age is another non-modifiable risk factor."
Explain Modifiable Risk Factors:
"Modifiable risk factors are things we can change to reduce risk."
"These include diet, exercise, smoking, stress management, and controlling
medical conditions like high blood pressure."
Discuss Risk Reduction:
"There are things we can do to help, and things you can do yourself to reduce
risk."
"We can help by monitoring and treating your blood pressure and other medical
conditions."
"You can make changes in your lifestyle to further reduce your risk."
Suggest Lifestyle Changes:
"Try to cook at home more often instead of eating takeaways."
"Reduce intake of fried and oily foods."
"Cut down on carbohydrates."
"Quit smoking."
"Increase your physical activity."
"Find ways to manage stress from your job."
Safety Netting:
"It's important to be aware of the signs of stroke. If you ever experience sudden
facial weakness, arm weakness, or speech problems, call an ambulance
immediately."
Conclude:
"How does this information sound to you, Mr. Zimmerman?"
"Remember, while you have some risk factors, there are many things we can do
together to reduce your risk of stroke."

III. Important Points to Remember

Use the Four Box System for counselling scenarios:
Box 1 & 2: Collect information
Box 3 & 4: Give information
Tailor your approach to the specific scenario and patient concerns.
Focus on risk factors rather than differential diagnoses in these scenarios.
Be empathetic when discussing family history of conditions.
Provide clear explanations of the conditions (vascular dementia or stroke).
Differentiate between modifiable and non-modifiable risk factors.
Offer practical advice for lifestyle modifications.
Include safety netting advice, especially for stroke symptoms.
Be confident in your assessment and advice, avoiding unnecessary tests or referrals.

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Remember to adapt your communication style to the patient, speaking clearly and
avoiding medical jargon.
Don't personalize the consultation by feeling you need to ask every single question. A
few well-chosen questions are sufficient.
When discussing diet, don't specifically mention or criticize particular countries'
cuisines. Focus on the nutritional content instead.
Be aware of cultural sensitivities when discussing lifestyle factors.
Remember that these scenarios are about discussing possibilities and risks, not
diagnosing current conditions.
Avoid saying "hey" or using overly casual language when addressing patients or
colleagues.
Be prepared for patients to have varying levels of knowledge about their conditions or
risks.
Emphasize that while the patient may have risk factors, there are always steps that can
be taken to reduce risk.

Pregnancy Counselling Scenario (Captopril)

Patient Profile:
42-year-old lady
Primary hypertension
On Captopril

Consultation Structure:
Opening:
Patient: "Doctor, I wanted to get pregnant. What advice do you have for me?"
Initial Questions:
Ask: "Is there any particular reason you have decided to have a child now?"
Ask: "Are there any stresses or anything forcing you to make this decision?"
Note: Be sensitive, as there might be personal reasons (e.g., recent marriage,
promises to partner)
Pregnancy History:
Ask: "Do you have any children?"
Expected response: "No"
Ask: "Have you ever tried to have a child in the past?"
Ask: "Have you done any testing for pregnancies?"
Ask: "Have you had any consultations with doctors about this before?"
Ask: "Have you had any surgeries in your tummy?" (OB-GYN related question)
Ask: "Have you had any miscarriages or terminations?"
Menstrual and Contraceptive History:
Ask about periods: "Are your periods regular?"

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Ask: "What is your current method of contraception?"

Medical History:
Ask: "Do you have any medical problems, particularly high blood pressure?"
Ask: "How long have you been diagnosed with high blood pressure?"
Ask: "Is your blood pressure well controlled?"
Ask: "Are you on any medication for your blood pressure?"
Expected response: "Yes, Captopril"
Ask: "How long have you been on Captopril?"
Ask: "Have you tried any other blood pressure medications before?"
Complete MAFTOSA
Examination:
Check blood pressure
Measure BMI

Explanation and Management:

Explain Risks:
"Unfortunately, considering your age and having high blood pressure, you have
some risks for pregnancy."
"You may develop complications during pregnancy, such as pre-eclampsia or
worsening of your high blood pressure."
Specialist Referral:
"We need to get specialist advice on two things:
Is it safe for you to carry on with a pregnancy?
What is the best medication for you during pregnancy?"
Medication Concerns:
"The medication you're currently taking, Captopril, is not safe for pregnancy."
"It can cause deformities in the child if taken during pregnancy."
Immediate Advice:
"I advise you to continue your current contraception until you see the specialist."
"We will refer you to a specialist for review."
Medication Change:
"If the specialist approves your pregnancy plan, we'll need to change your
medication."
"We would likely switch you to a medication called Labetalol, which is safer in
pregnancy."
Contingency Plan:
"If you accidentally become pregnant or decide to stop contraception before
seeing the specialist, please come back immediately."
"In that case, we'll need to change your medication to Labetalol right away to
ensure the safety of the pregnancy."

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Additional Advice:
"Apart from medication, maintaining a healthy lifestyle, eating a balanced diet,
and regular exercise can help support a healthy pregnancy."

Thalassemia Scenario
Patient Profile:
40-year-old female
No symptoms
Sister has thalassemia
Blood test done as part of a well woman checkup

Test Results:
Haemoglobin: Slightly low
MCV: Low
Iron, Ferritin, B12, Folate: All normal

Consultation Structure:
Initial Questions:
Ask: "What sort of tests were done and why?"
Ask: "What was the reason these tests were done?"
Expected response: "It was part of a well woman checkup."
Symptom Check:
Ask about anaemia symptoms: "Have you been feeling unusually tired or short of
breath?"
Family History:
Ask: "Has anyone in your family been diagnosed with thalassemia or any blood
disorders?"
Note: Patient may only mention sister if asked directly about thalassemia
Ethnic Background:
Ask: "Are you from abroad?"
Ask: "Can I know your ethnic background? Are you from the Middle East, Asia,
or Africa?"
Note: Be sensitive when asking about ethnic background
Additional History:
Ask: "Have you ever been admitted to hospital or had any significant illnesses?"

Explanation and Management:

Explain Test Results:
"Your test results show that your haemoglobin is slightly low and your MCV
(Mean Corpuscular Volume) is low."

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"All other tests, including iron levels, are normal."

"These results could indicate a condition called thalassemia."
Explain Thalassemia:
"Let me explain what thalassemia is. In our blood, there are two types of cells:
red cells and white cells."
"Within the red cells, there's a component called haemoglobin that carries
oxygen."
"Some people, due to faulty genes, can have structural abnormalities in their
haemoglobin."
"This can cause low blood levels or anaemia."
"Thalassemia is caused by this genetic issue affecting haemoglobin production."
Referral and Further Testing:
"To confirm this diagnosis, we need to refer you to a haematologist, a blood
specialist."
"They will do a test called electrophoresis, which will give us a definitive
diagnosis."
Treatment Options:
"If you do have thalassemia, treatment depends on the severity."
"If your blood levels drop significantly, you may need blood transfusions."
"Due to the breakdown of abnormal cells, you may have higher iron levels in
your body."
"We may use medications called chelating agents to reduce iron levels if
necessary."
Current Management:
"As you don't have any symptoms now, you don't need treatment at this time."
"We'll wait for the specialist's confirmation before deciding on any treatment."
Family Planning Advice:
If relevant: "If you're planning to have children, it's important to discuss this
with the specialist, as thalassemia can be inherited."

Other Scenarios
Chronic Fatigue Syndrome Scenario
Key Diagnostic Criteria:
Fatigue not relieved by rest (>6 weeks duration)
Exercise worsens symptoms

Additional Symptoms to Ask About:

Flu-like illnesses (frequent)

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Stiffness when walking

Sleep disturbances (broken, shallow, altered pattern)
Cognitive issues (memory, confusion, word-finding difficulty, problems with
calculations, multitasking issues)
Weight loss (not typically present at diagnosis)

Differential Diagnoses to Consider:

Anaemia
Infections (TB, HIV)
Diabetes
Cancers
Depression
Electrolyte imbalances
Kidney problems
Liver problems
Heart conditions
Hypothyroidism

Consultation Structure:
Assess Fatigue:
Ask: "Does rest relieve your fatigue?"
Ask: "Even after taking sufficient rest, do you still feel tired?"
Expected response: "Yes, rest doesn't help."
Ask: "How long have you been experiencing this fatigue?" (Should be >6 weeks)
Expected response: "About six months."
Effect of Exercise:
Ask: "Does exercise help or worsen your symptoms?"
Expected response: "Exercise makes it worse."
Additional Symptoms:
Ask: "Do you often feel like you have flu-like symptoms?"
Expected response: "Yes, I had flu last week, last month, and last year."
Ask: "Do you experience stiffness, especially when walking?"
Ask about sleep: "How is your sleep? Is it broken, shallow, or has your sleep
pattern changed?"
Ask about cognitive issues: "Do you have any problems with memory, confusion,
finding words, or doing calculations?"
Ask: "Have you noticed any changes in your weight?"
Mood Assessment:
Ask: "How has your mood been lately?"

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Explanation and Management:

Explain Chronic Fatigue Syndrome:
"Based on what you've told me, this could be a condition called Chronic Fatigue
Syndrome."
"It's also known as Myalgic Encephalomyelitis or ME."
"This is what we call a functional condition. There's no structural abnormality in
the body."
"The general belief is that the body is not producing sufficient energy to cope
with daily demands."
"People with this condition feel extremely tired, and the tiredness isn't relieved
by rest."
"It can't be explained by other conditions and can significantly impact daily
activities."
Diagnostic Process:
"To diagnose this, we need to rule out other conditions first."
"We'll run blood tests to check for things like anaemia, thyroid problems,
diabetes, and other conditions."
"We'll check your salt levels, sugar, kidney and liver function."
Referral:
"After these tests, we'll refer you to a local Chronic Fatigue Syndrome clinic."
"You'll be seen by a rheumatology specialist who will confirm the diagnosis."
Treatment Approach:
"The main treatment involves learning energy management strategies."
"You may receive physiotherapy and occupational therapy."
"We'll give you advice on improving your sleep, like avoiding daytime naps and
excessive sleep."
"If these don't help enough, we might consider talking therapy as well."
Vitamin Supplements:
If asked about multivitamins: "Multivitamins are not a specific treatment for
Chronic Fatigue Syndrome."
"We'll check for vitamin deficiencies in your blood tests. If we find any, we'll
treat those specifically."
"However, if you have Chronic Fatigue Syndrome, it typically won't respond to
multivitamins alone."
"If we find vitamin deficiencies, that might actually point to a different
diagnosis, as Chronic Fatigue Syndrome can't be explained by other
conditions."

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Vitamin D Deficiency Scenario

I. Scenario Setting
F2 doctor in GP practice
Test results discussion

II. Patient Profile

55-year-old lady
Occupation: Teacher
Chief complaints: Tiredness and constipation
Thought she had hypothyroidism like her sister
Didn't go to school for the last two weeks due to tiredness

III. Test Results

Full blood count: Normal
Sugar: Normal
Thyroid function (TSH, T3, T4): All normal
Vitamin B12: Normal
Vitamin D: Low (16 or 14, normal range 90-100)

IV. Consultation Structure

1. Initial Approach (similar to hyponatremia scenario)

a. Explore Tiredness (ODIPRA)

Ask: "Can you tell me more about your tiredness?"
Explore Onset, Duration, Intensity, Progression, Relieving factors, Aggravating factors

b. Other Symptoms of Vitamin D Deficiency

Ask about:
Bone pain, especially back pain
Ask: "Have you experienced any bone pain, particularly in your back?"
Any recent fractures
Ask: "Have you had any recent falls or fractures?"
Muscle cramps or weakness
Ask: "Do you experience any muscle cramps or weakness?"
Mood changes
Ask: "Have you noticed any changes in your mood lately?"
Excessive sweating
Ask: "Do you find yourself sweating more than usual?"
Bowel symptoms (note: patient already mentioned constipation)
Ask: "Can you tell me more about your constipation?"

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Neurological symptoms
Ask: "Have you experienced any numbness, weakness, or abnormal sensations?"

c. Causes of Vitamin D Deficiency

Explore:
Dietary habits:
Ask: "Can you tell me about your diet? Do you eat foods like meat and eggs
regularly?"
Note: As a doctor, you should know at least five food items rich in vitamin D
Sun exposure:
Ask: "How much time do you spend outdoors, especially during spring and
summer?"
Sunscreen use:
Ask: "Do you use sunscreen regularly when you're outside?"
Explain: "Sunscreen is good for preventing melanoma, but it can interfere with
vitamin D production."
Fat absorption issues:
Ask: "Have you had any bowel surgeries or digestive issues?"
Explain if needed: "Vitamin D is fat-soluble, so problems with fat absorption can
affect vitamin D levels."

d. Complete MAFTOSA

2. Examination
Review test results

3. Explanation to Patient
Explain test results:
"I've reviewed your test results. Your thyroid hormone levels, including TSH, T3,
and T4, are all normal. Your sugar levels and full blood count are also
normal."
"However, your vitamin D level is low. It's 16 (or 14), while the normal range is
between 90 and 100."
Explain vitamin D function and symptoms:
"Vitamin D is important for calcium regulation in your body. It doesn't have a
direct function but works with calcium."
"Low vitamin D can cause tiredness, which explains your symptoms."
"It can also affect your bowels, potentially causing constipation. This is because
calcium, which is regulated by vitamin D, is needed for proper bowel
movements. When vitamin D is low, your bowels can become sluggish."

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"Vitamin D deficiency can also cause bone pain, muscle weakness, and even
neurological symptoms like numbness or weakness."
Address patient's concern about hypothyroidism:
"You don't have hypothyroidism like your sister. Your thyroid function tests are
normal."
"Your symptoms are due to vitamin D deficiency, not a thyroid problem."
If asked: "You don't need to take medication for thyroid problems."

4. Treatment Plan
Explain vitamin D supplementation:
"We need to give you vitamin D supplements to correct this deficiency."
"For the first six weeks, you'll take a high dose of 50,000 units once a week. This
is called a loading dose."
"After that, you'll switch to a daily dose of 1,000 units."
Follow-up:
"We'll follow up after six weeks to see if there's any improvement in your
symptoms and possibly recheck your vitamin D levels."

V. Important Points to Remember

Vitamin D deficiency can mimic other conditions, including hypothyroidism.
The approach to discussing vitamin D deficiency test results is similar to discussing
hyponatremia.
Always explore the main symptom (in this case, tiredness) using ODIPRA.
Be thorough in asking about other symptoms related to vitamin D deficiency, including
bone, muscle, mood, and neurological symptoms.
Explore potential causes of vitamin D deficiency, including diet, sun exposure, and fat
absorption issues.
Explain clearly why the patient's symptoms are not due to hypothyroidism, despite
family history.
Be precise about the treatment dosage:
Loading dose: 50,000 units once a week for 6 weeks
Maintenance dose: 1,000 units daily
Remember to explain how vitamin D deficiency can cause constipation through its
effect on calcium and bowel movements.
Always provide an opportunity for the patient to ask questions about their condition
and treatment.
Avoid dismissing the patient's initial concern about hypothyroidism; instead, explain
why their symptoms are due to a different cause.

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Vascular Conditions
Varicose Vein
Venous Ulcer (different from varicose vein)
Peripheral Vascular Disease (with intermittent claudication)
Note: Peripheral vascular disease should be studied separately.

Varicose Vein Scenario

Setting:
GP consultation
40-year-old female patient
Patient has varicose vein
Scenario requires counselling that surgery cannot be provided

Consultation Structure:
Opening:
Ask: "How may I help you? I understand you wanted to speak to one of the
doctors."
Expected response: "I have a swelling in my leg."
Explore the Swelling (MEDS approach):
Morphology:
Ask: "What sort of swelling is it? What's the shape?"
Ask: "Does it look like a blood vessel or a lump?"
Ask: "What's the size of the swelling?"
Ask: "What's the colour of the swelling?"
Evolution:
Ask about onset and progression
Duration:
Ask how long the swelling has been present
Symptoms:
This is crucial for determining if surgery is needed. Ask about:
Ulcer or past ulcer: "Have you had any ulcers in the past or
currently?"
Bleeding or oozing: "Is there any bleeding or fluid leaking?"
Pigmentation or discoloration: "Do you notice any skin colour
changes?"
Pain, discomfort, or itching: "Do you experience any pain,
discomfort, or itching?"

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Risk Factors:
Family history: "Does anyone in your family have varicose veins?" (Note: Her
mother had it)
Pregnancy history: "Did this start after a pregnancy?" (Note: Started after
pregnancy)
Gender: Being female is a risk factor
Occupation: "What's your occupation? Does it involve a lot of standing?" (Note:
She's a hairdresser, stands a lot)
Examination:
Mention: "I would like to examine your leg."
Note: A picture will be provided instead of actual examination

Explanation to Patient:
Diagnosis:
"This condition is called varicose vein."
Explain Varicose Vein:
"There are superficial blood vessels called veins in our body."
"These veins have valves to regulate blood circulation."
"When there's a fault in these valves, blood can't flow properly."
"The blood stays in the leg due to gravity, causing swelling."
"This is what we call a varicose vein."
Treatment Options:
Stockings:
"We'll offer you compression stockings."
"Wear them first thing in the morning and take them off before bed."
"Ensure they're the right size - not too tight, not too loose."
If patient says stockings are painful: "That might mean they're too tight.
We need to find the appropriate size for you."
Weight reduction:
"Losing weight can help alleviate the symptoms."
Exercise:
"Exercise can improve circulation."
Addressing Surgery Question:
If patient asks about surgery:
"Surgery is for severe forms of varicose veins or when there are
complications."
"You seem to have a mild form that can be treated with conservative
methods."
Addressing NHS Funding Question:
If patient asks if it's about saving money:

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"The decision isn't about saving money. It's about providing appropriate
treatment."
"Surgery involves cutting and removing the vein or using freezing
therapy."
"We cut the blood vessels, tie both ends, and remove them, or use liquid
nitrogen to freeze and close off the blood vessels."
"This completely removes the vein's function and can have disadvantages
like leg swelling."
"That's why it's not recommended for mild cases."
If Patient Mentions Family Member's Surgery:
"If your mother had surgery, she likely had a severe form with complications."
Occupational Advice:
"As a hairdresser, you may be standing for long periods."
"Try to take breaks and avoid prolonged standing or sitting."

UTI in Child Scenario

Setting:
A&E (Emergency Department)
3-year-old child
Mother brought child due to urinary symptoms

Presenting Complaints:
Smell of urine
Child cries when passing urine
Child refusing to drink water (likely due to pain when urinating)

Diagnostic Approach:
Perform urine dipstick test
Result: Positive for UTI

Treatment Plan:
Antibiotic: Trimethoprim
Duration: 3 days

Consultation Structure:
Explain Diagnosis and Treatment:
"Your child has a urinary tract infection."
"We'll treat this with an antibiotic called Trimethoprim for 3 days."
Addressing Duration Question:
If mother asks why only 3 days:

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"Urinary infections are caused by different bacteria than chest infections."

"They're treated with different antibiotics."
"Most people respond well to 3 days of antibiotics for UTIs."
"Chest infections are more complicated and need 7 days of treatment."
Addressing Gender Difference Question:
If mother asks why females get more UTIs:
"In females, the distance between the bladder and the outside is very
short."
"They have a shorter urethra, making it easier for bacteria to enter."
"Also, the distance between the front and back passage is shorter in
females."
"This makes it easier for bacteria from stool to contaminate the urinary
tract."
Addressing Admission Question:
If mother asks about admission:
"Admission isn't necessary at this point."
"If there's no improvement in 48 hours, bring the child back."
"We'll take a urine sample to send to the lab."
"If we find different bacteria, we may need to change the antibiotic."
Assessing Severity:
Note if the child is active and playful
Check for signs of dehydration
If no severe symptoms and child is active, reassure that admission is not needed
Remember:
Always take a urine sample in UTI cases to send to the laboratory.
Do not admit if the child is active, playful, and shows no signs of dehydration.
Be prepared for the mother to express concerns about the child not drinking water, but
if there are no dehydration symptoms, reassure and avoid admission.

Morning After Pill Scenarios

There are three morning after pill scenarios in PLAB 2:
Learning disability scenario
15-year-old girl scenario
25-28-year-old lady scenario (detailed below)
Scenario: 25-28-year-old lady with epilepsy
Patient is taking Carbimazole for thyroid condition
Requesting morning after pill

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Management:
Best advice: Inserting a device (IUD)
If patient doesn't prefer IUD:
Medication: Levonelle only
Dosage: Double the normal dose (3 mg instead of 1.5 mg)
Note: Other morning after pills haven't been researched with Carbimazole, so stick to
Levonelle.

Parkinson's Disease Scenarios

There are two Parkinson's scenarios:
First-time diagnosis
Parkinson's examination

Key Points for Parkinson's Scenarios:

Presenting complaint: "I'm finding it difficult to work"
Ask about walking difficulties:
"What sort of difficulties do you have?"
"Is it difficult to start walking or after walking for some time?"
"Do you have any pain, tiredness, or stiffness?"
"What is the main problem?"
Ask about other symptoms:
Hip problems, muscle issues, joint problems
Swelling in legs, arthritis
Back pain, injuries, falls
Muscle mass weakness, numbness
Upper body symptoms:
Weakness, numbness, abnormal sensations in hands
Tremors
Know 10 symptoms of Parkinson's (homework)
Family history: Sometimes the patient's father had Parkinson's
Examination findings will be provided on paper

Explanation to Patient:
"There is some stiffness in your hand (cogwheel rigidity)"
"There is some tremor or shakiness in your hand"
"You have a shuffling gait, taking small steps when walking"
"There is a general slowness of movement"
"Unfortunately, as your father had it, you could be having Parkinson's as well"

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Definition of Parkinson's:
"Parkinson's is a condition that affects the brain and the movements of the body. It's due to
a lack of a substance or hormone called dopamine in the brain."

Management:
Urgent referral to neurology, specifically to a movement disorder clinic
They will do MRI, CT scan, neurological examination
Treatment: Medication (carbidopa)
Multidisciplinary team involvement:
Physiotherapist
Occupational therapist
Speech and language therapist
Advise patient not to drive

Addressing hereditary concerns:

"Unfortunately, there are chances your son may develop this. The probability is higher as
your father had it and you've developed it."

First Fit Scenario

Setting:
GP consultation
Patient: 50+ years old (man or lady)
Presenting complaint: Had a fit yesterday while watching TV, lost control of bowel and
bladder

Key Points:
Analyse the fit: before, during, and after
Pure history and investigative scenario
Differential diagnosis order:
Brain tumour (consider first due to age)
Epilepsy
Infections (infectious mononucleosis, encephalitis, cerebral malaria)
Electrolyte imbalances (mainly sodium)
Sugar-related issues

Management:
Refer to "First Fit Clinic" (urgent 2-week referral to neurology)
They will do:
CT scan to exclude brain tumour
If CT normal, EEG to check for epilepsy

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Explain to patient: "Unfortunately, considering your age, it could be a brain tumour or

late onset of epilepsy. For a small proportion of people, we may not find a cause.
They might have a one-off fit due to unexplainable brain activity."
Ask about driving history

Trigeminal Neuralgia Scenario

Setting:
GP consultation
Patient complains of face pain

Key Points:
Clinical diagnosis (no tests needed)
Description of pain is crucial

Questions to Ask:
"What sort of pain is it?"
"Would you describe this as a sort of electrical shooting pain?"
"Can you locate the pain precisely?" (They usually can't)
Ask about radiation of pain
Ask about triggers (not aggravating factors):
Morning activities (brushing teeth, shaving, putting on makeup)
Blowing air, hair drying
Driving with air blowing on face
Ask about timing (usually occurs in the morning)

Differential Diagnosis:
Face injuries
Joint problems
Ear pain
Tooth pain
Eye pain
Headache

Explanation to Patient:
"This could be a condition called trigeminal neuralgia. Neuralgia means nerve pain. There's
a nerve in our face called the trigeminal nerve. Its main function is to sense temperature,
touch, and pain. When there's an abnormal or altered function of this nerve, it can sense
everything as pain. This is due to a problem with the action potential of the nerve."

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Management:
GP treatment: Carbamazepine (anti-epileptic medication for pain)
Start with low dose (100 mg)
Can increase weekly up to 600 mg
If no improvement, refer to neurology
Neurology options:
Add other medications (e.g., amitriptyline)
Inject numbing agent to nerves
Surgery (cutting the nerves)

Diabetic Ketoacidosis (DKA) First Presentation

Setting:
A&E department
Young patient (18-23 years old)
Presenting with tiredness and weight loss

Key Points:
Mother is concerned about weight loss
Ask about polydipsia and polyuria
Do urine dipstick test (will show ketones)

Management:
IV insulin
IV fluids
Explain DKA and its treatment to the patient

Teething Scenario
Setting:
Telephone consultation
7-month-old child

Presenting Complaints:
Child is clingy
Irritated
Wants to cuddle all the time
Looks a bit ill

Questions to Ask:
"What do you mean by clingy?"

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"Is the child biting everything or trying to put everything in their mouth?"
"Is there any drooling?"
"Do you think the child is in pain?"
"Any flushing of the face?"
"Any fever or diarrhoea?"
"Can you check the child's temperature?"
"Is there any swelling in the gums?"

Management:
Explain that it could be teething: "This could be teething. Teething means his teeth
have started coming out. He's reached the right age for this."
Recommend painkillers (paracetamol)
Suggest teething ring from pharmacy
Home remedies: Washed cucumbers or carrots for biting
Advise registering with a dentist

Safety Netting:
Advise about diarrhoea and recurrent infections

Recurrent Infections in Child Scenario

Setting:
GP consultation
3-year-old child brought by father
Father worried about possible immunological problem

Consultation Structure (Four Box System):

Box 1:
Ask: "Why are you concerned about an immunological problem?"
Ask about illnesses:
"Since when has he been getting ill?"
"How often?"
"How many episodes?"
"What sort of symptoms does he develop in each episode?"
Ask about treatments:
"How has he been treated so far?"
"Any antibiotic treatments?"
"Any hospital admissions?"
"Has he been seen by other healthcare professionals like a school nurse?"

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Box 2:
Medical history (MAFTOSA)
Paediatric history
Risk factors:
"Is anyone at home having similar symptoms?"
"Do you notice any pattern, like when the weather changes or when the child
starts school after holidays?"
Ask about other symptoms

Box 3:
Explain that examination is normal
"In children, immunity is lower compared to adults. When they go to school and mix
with other people, they easily get infections. This is how they develop their own
immunity and defence against infections."
"It's common for a child to develop about 6-7 infections like this in a year."
"This is a normal part of growing up."

Box 4:
Do not refer to a specialist at this point
Recommend blood tests
Explain: "If the blood test shows anything concerning, then we can consider a referral."
Do not recommend X-ray at this point

Diarrhoea in a One-Year-Old Child

Setting:
Telephone consultation
Important scenario to test decision-making skills over the phone

Patient Profile:
One-year-old child
Four episodes of diarrhoea today
No signs of dehydration
Child is active and playful

Key Points to Address:

Dehydration Assessment:
Ask about nappy wetness: "How many wet nappies has the child had today?"
Inquire about lethargy: "Is the child behaving normally or seem unusually tired?"
Check for fast breathing (lung): "Have you noticed any change in the child's
breathing?"

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Ask about fast heartbeat (heart): "Does the child's heart seem to be beating faster
than usual?"
Inquire about confusion or drowsiness (brain): "Is the child alert and responsive
as usual?"
Diagnosis:
Explain: "This could be a viral infection, most likely rotavirus. It's the most
common cause of diarrhoea in young children."
Management:
Advise on rehydration: "It's important to keep your child hydrated. Offer
frequent small amounts of fluid."
Recommend isolating the child from other children: "To prevent spreading the
infection, keep your child at home and away from other children for now."
Discuss hygienic practices:
"Wash your hands thoroughly with soap and water after changing
nappies."
"Ensure all family members practice good hand hygiene, especially before
handling food and after using the toilet."
Safety Netting:
Explain when to bring the child to the hospital:
"If you pinch the child's skin and it stays in that position instead of
quickly returning to normal, it shows severe dehydration. Bring the
child to the hospital immediately if this happens."
"Also, if the child becomes lethargic, stops passing urine, or if you're
concerned about their condition, please seek immediate medical
attention."
Duration:
If asked, explain: "Rotavirus diarrhoea typically takes about seven days to settle.
If it persists longer than this, please contact us again."
Follow-up:
"If the symptoms worsen or you have any concerns, don't hesitate to call back or
bring the child in for a check-up."

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Sexually Transmitted Infections (STI) Scenarios

Overview of STI Scenarios:
Two Chlamydia scenarios
Two Gonorrhoea scenarios
Two Trichomoniasis scenarios
Two Syphilis scenarios (already covered)
Three PID scenarios (already covered)
Three HIV scenarios:
First presentation in GP
Test result discussion in GUM clinic
Patient already diagnosed with questions for GP

Taking a Sexual History:

Introduction:
Say: "I would like to ask you some questions about your sexual life. This
information is important for your health care."
Key Questions:
"Are you sexually active?"
"Are you in a stable relationship?"
If married: "Who are you married to? Are they male or female?"
"Do you practice safe sex? By that, I mean do you use barriers like condoms?"
Other Partners:
For married individuals: "I'm sorry to ask this, but apart from your
wife/husband, have you had any other partners recently?"
If yes: "Are they male or female?"
"Do you practice safe sex with them?"
Additional Partners:
"Apart from the partner(s) you've mentioned, have you had any other partners in
the last six months?"
STI Symptoms to Ask About:
Discharge: "Have you noticed any unusual discharge?"
Burning sensation: "Do you experience any burning sensation when urinating?"
Redness: "Is there any redness around your genitals?"
Pain: "Do you have any pain around your genitals, labia, vagina, penis, or
testicles?"
Abdominal pain: "Have you experienced any abdominal pain?"
Swelling: "Have you noticed any swelling in the genital area?"
Lumps or bumps: "Are there any lumps or bumps anywhere on your body?"
Fever: "Have you had any fever recently?"

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Specific STI Scenarios:

Chlamydia in a Child
Setting:
GP appointment
22-year-old woman
Delivered baby 10 days ago
Child diagnosed with chlamydia at 7 days old
Consultation Structure:
Opening: "How may I help you today?"
Expected response: "One of your colleagues asked me to make an appointment."
Explain reason for appointment:
"Did anyone explain to you why you need to speak to the doctor?"
If no: "I understand your child has recently been diagnosed with an infection. I'd
like to discuss this with you."
Ask about the child:
"How is your child doing now?"
"What symptoms did the child have?"
"What tests were done?"
"What treatment was given?"
"How is the child responding to treatment?"
Inquire about delivery and feeding:
"Was it a vaginal delivery?"
"How are you feeding the baby? Breastfeeding or formula?"
Take mother's sexual history (as outlined above)
Explain chlamydia:
"Chlamydia is a sexually transmitted infection. Unfortunately, you may have this
infection, which is why we've called you in today."
Advise on testing and treatment:
"We advise you to get tested and treated. This involves going to a GUM
(genitourinary medicine) clinic."
"At the clinic, they will take a swab and blood test. If confirmed, you'll be given
treatment."
"For breastfeeding mothers, the treatment is usually an antibiotic called
azithromycin."
"Your child may need an antibiotic called erythromycin syrup for two weeks,
which will be given by hospital doctors."
Partner notification:
"We also advise you to inform your partner so they can get tested and treated."
Addressing Concerns:
If asked "Is he cheating on me?":

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Response: "I'm afraid it's not possible for doctors to tell whether someone is
cheating. Our understanding is that chlamydia is transmitted through sexual
contact from person to person."
If patient says they never had symptoms:
Explain: "Chlamydia can be a silent infection and stay in the body without
causing symptoms."
If patient insists they never had other partners:
Advise: "This is something we would advise you to speak to your partner about.
We would like you to have this discussion with your partner."
Follow-up:
Schedule one-week follow-up after GUM clinic referral

Chlamydia in a Man with Joint Swelling

Key Points:
Clear discharge
Joint pains
Doesn't practice safe sex
Management:
Diagnose as chlamydia
For joint swelling: Start with ibuprofen, if ineffective, consider steroid medication
Refer to GUM clinic
Treatment: Doxycycline for 7 days (remember: C for D, Chlamydia for Doxycycline)

Gonorrhoea Scenarios
Scenario 1: Telephone consultation
Presenting complaint: "I have a burning sensation when I urinate."
Ask: "Have you noticed any discharge? If yes, what colour is it?"
Expected response: Greenish discharge
Sexual history: Married, but had sex with a man two weeks ago
Diagnosis: Gonorrhoea
Treatment: Ceftriaxone (single injection)
Explain: "Gonorrhoea is treated with a single injection of an antibiotic called
ceftriaxone."

Addressing Concerns:
If patient asks: "Are you going to tell my wife?"
Response: "We won't tell your wife, but we advise you to inform her."
If patient says: "I don't want to tell my wife."

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Advise: "We always recommend informing all partners."

If patient says: "Since I had sex with the other guy, I didn't have sex with my wife. Do I
still need to tell her?"
Response: "We always advise informing all partners to get tested and treated. It's
difficult to tell where the infection came from. However, if you're concerned
about your relationship, and you're sure about the timeline, our advice is to
complete the treatment and get tested again before having any sexual contact.
This is called a 'test of cure'."

Scenario 2: Test results discussion

Patient is lesbian
Discuss gonorrhoea treatment as above

Trichomoniasis Scenarios
Scenario 1:
Opening: "How may I help you?"
Expected response: "My girlfriend sent me a message on Facebook saying she has a
sexually transmitted infection and advised me to get tested."
Ask: "Do you know what type of infection she has?"
Patient shows paper with "trichomoniasis" written on it
Ask about symptoms: "Have you had any symptoms yourself?"
Expected response: No symptoms
Take sexual history
Ask: "When did you and your girlfriend separate?"
Expected response: One week ago
Explain: "Trichomoniasis is a sexually transmitted infection. We advise you to go to a
GUM clinic to get tested and treated."
If patient refuses GUM clinic:
Response: "That's not a problem. We can test and treat you here in the GP
surgery."
Treatment: "The treatment for trichomoniasis is an antibiotic called metronidazole."

Scenario 2:
Symptoms: Redness at tip of penis, yellowish discharge
Take sexual history
Diagnose as trichomoniasis
If patient refuses GUM clinic (e.g., "My sister works there"):

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Response: "That's not a problem. We can test and treat you here in the GP
surgery."
Remember:
Always maintain a non-judgmental, compassionate approach
Respect patient confidentiality
Offer testing and treatment at GP if patient refuses GUM clinic
Emphasize the importance of partner notification and safe sex practices
Schedule follow-up appointments as necessary

HIV Scenarios
HIV First Presentation in GP
Patient Profile:
30-year-old man
Presenting complaint: "I have a swelling down below"

Consultation Structure:
Explore the Swelling:
Ask: "Can you please tell me where the swelling is exactly? Is it on your genitals,
on your penis, on your testis, or around your genitals, on the skin?"
Ask: "How many swellings are there?"
Use MEDS approach:
Morphology: "What does the swelling look like?"
Evolution: "How has it changed since you first noticed it?"
Duration: "How long have you had this swelling?"
Symptoms: "Are there any other symptoms associated with the swelling?"
STI Symptoms:
Ask about all STI symptoms
HIV Symptoms:
Ask specifically about:
Arthralgia (joint pain)
Diarrhoea
Rashes
Pain
Fever
Flu-like symptoms
HIV Risk Factors:
Take sexual history
Note: Patient went to Thailand and had unprotected sex with a male sex
worker

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Patient also has a wife and had sex with her after returning
Ask about:
Blood transfusions (especially abroad)
Recreational drug use and needle sharing
Complete MAPDOSA (Medical history, Allergies, Past medical history, Drug history,
Occupation, Social history, Alcohol/smoking)
Examination:
Say: "I would like to examine you now."
Note: Findings will show generalized lymphadenopathy (important finding)

Diagnosis and Management:

Deliver diagnosis:
Say: "Unfortunately, I'm sorry to tell you, this could be an HIV infection."
Explain: "HIV stands for Human Immunodeficiency Virus."
Avoid mentioning how they might have contracted it
Explain: "You can get HIV from unprotected sexual intercourse."
Referral:
Say: "We need to refer you to a GUM Clinic today."
Explain: "They will do tests today, and you'll likely be seen by a specialist within
48 hours."
If patient asks when to go, say: "Today."
If patient asks when results will be ready, say: "On the same day."
Treatment:
Explain: "Once confirmed, you'll be seen by an HIV specialist."
Say: "Treatment involves antiviral medication, which unfortunately is long-term."
Partner Notification:
Advise: "We will advise you to tell your partner, your wife."

HIV Test Result Discussion in GUM Clinic

Setting:
F2 doctor in GUM clinic
Test results: HIV 1 and 2 positive, Gonorrhoea and Chlamydia negative

Consultation Structure:
Opening:
Ask: "What sort of symptoms did you have that led to these tests?"
Ask about other HIV symptoms (remember to know 10 HIV symptoms)
Ask about other STI symptoms
Ask about HIV risk factors, including sexual history
Complete MAPDOSA

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Deliver Results:
Say: "I have your test results. Is it okay to discuss them with you today?"
Narrate: "As we understand, you came with these symptoms, and we did these
tests. Unfortunately, I don't have very good news regarding your test results."
Deliver diagnosis: "I'm sorry to tell you, the test result shows that you have an
HIV infection."
Note: Do not say "HIV test is positive" as it can be misinterpreted by the patient
Discuss Treatment:
Explain: "You'll be seen by a specialist within 48 hours."
Say: "Treatment is called antiretroviral treatment, which is basically antiviral
treatment."
Inform: "Unfortunately, the treatment is lifelong."
Answer any questions the patient may have

HIV Follow-up Questions in GP

Setting:
F2 doctor in GP
45-year-old man diagnosed with HIV last week
Patient has concerns and questions

Consultation Structure:
Opening:
Confirm: "I understand you have been recently diagnosed with an infection.
What have you been told?"
Empathize: "I'm really sorry to hear about that. It must have been very difficult."
Take control: "If somebody is diagnosed with HIV, they usually have lots of
questions. I believe that's why you made this appointment. I'm happy to
answer all your questions, but first, I'd like to get some information about
your general health. Is that okay?"
Take History:
Ask: "What made you have the test?"
Ask: "Have you had any symptoms at all?"
Ask about HIV symptoms
Ask about HIV risk factors, including sexual history
Complete MAPDOSA (Note: Patient works in IT)
Answer Patient Questions:
a. "Are you going to tell my wife?"
Response: "No, we are not going to tell your wife. Your information is
confidential."
b. "Do I need to tell my wife?"

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Advise: "We will advise you to tell your wife."

If patient says: "I don't want to tell my wife."
Ask: "Can I please ask you why you don't want to tell your wife?"
Patient may say: "It's going to cause problems in my marriage."
Respond: "That's understandable, but we still advise you to tell your wife."
Explain reasons for telling:
If you don't tell your wife, she can have this infection and develop complications which can
be life-threatening.
If she doesn't have treatment, your treatment will not be complete.
In the future, if she finds out that she got the infection from you, she can take you to
court. The court system can punish you. In the past, people have even gone to prison for
this.
c. "Can you help me tell my wife?"
Response: "Yes, we can help you in several ways."
Offer options:
Direct appointment together
Discussion over the phone
She can come alone for a discussion
Indirect method through partner notification program (anonymous message)
Say: "Whichever you prefer."
d. "Do I need to tell my employer?"
Response: "You don't need to tell your employer. As you work in the IT sector,
it's not required."
e. "Will I be able to have children?"
Response: "You should be able to have children. If the infection level (viral load)
is quite low, you should be able to have children."
f. "Is it AIDS?"
Response: "No, it is not AIDS. AIDS means Acquired Immunodeficiency
Syndrome. It is a late complication of HIV. People develop AIDS after
several years of having HIV infection. In this day and age, because of very
good treatment, people don't really develop AIDS."
g. "What does this mean for me?"
Explain: "This can have some impact on your health and your social life."
Health impact:
It's a lifelong condition.
You need regular testing, regular treatment, regular follow-up.
If the infection is not controlled properly, your immune system can go
down.
You can develop some infections like TB, or may develop some cancers
like sarcoma.
Social impact:

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You might have to inform your sexual partners before having sexual
intercourse.
h. "Is there any treatment?"
Response: "Yes, HIV infection has very good treatment. There is no cure, but
there is treatment. The treatment is antiviral treatment. It's for lifelong, but it
can be treated very well."

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