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Post-mortem examination
A post-mortem examination, also known as an autopsy, is the examination of a body after
death. The aim of a post-mortem is to determine the cause of death.
Post-mortems are carried out by pathologists (doctors who specialise in understanding the nature
and causes of disease).
Post-mortems provide useful information about how, when and why someone died, and they
enable pathologists to obtain a better understanding of how diseases spread.
Learning more about illnesses and medical conditions benefits patients too, because it means
they'll receive more effective treatment in the future.
When post-mortems are carried out
A post-mortem examination will be carried out if it's been requested by:
 a coroner – because the cause of death is unknown, or following a sudden, violent or
unexpected death
 a hospital doctor – to find out more about an illness or the cause of death, or to further
medical research and understanding
 Sometimes, the partner or relative of the deceased person will request a hospital post-
mortem to find out more about the cause of death.
Coroner’s post-mortem examination
A coroner is a judicial officer responsible for investigating deaths in certain situations. Coroners
are usually lawyers or doctors with a minimum of five years' experience.
In most cases, a doctor or the police refer a death to the coroner. A death will be referred to the
coroner if:
 it's unexpected, such as the sudden death of a baby (cot death)
 it's violent, unnatural or suspicious, such as a suicide or drug overdose
 it's the result of an accident or injury
 it occurred during or soon after a hospital procedure, such as surgery
 the cause of death is unknown
The main aim of a post-mortem requested by a coroner is to find out how someone died and
decide whether an inquest is needed. An inquest is a legal investigation into the circumstances
surrounding a person's death.
If someone related to you has died and their death has been referred to a coroner, you won't be
asked to give consent (permission) for a post-mortem to take place. This is because the coroner is
required by law to carry out a post-mortem when a death is suspicious, sudden or unnatural.
A coroner may decide to hold an inquest after a post-mortem has been completed. Samples of
organs and tissues may need to be retained until after the inquest has finished.
If the death occurred in suspicious circumstances, samples may also need to be kept by the
police, as evidence, for a longer period. In some cases, samples may need to be kept for a
number of months or even years.
The coroner's office will discuss the situation with you if, following an inquest, tissue samples
need to be retained for a certain length of time.
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Hospital post-mortem examination

Post-mortems are sometimes requested by hospital doctors to provide more information about an
illness or the cause of death, or to further medical research.
Hospital post-mortems can only be carried out with consent. Sometimes, a person may have
given their consent before they died. If this isn't the case, a person who is close to the deceased
can give their consent for a post-mortem to take place.
Hospital post-mortems may be limited to particular areas of the body, such as the head, chest or
abdomen. When you're asked to give your consent, this will be discussed with you. During the
post-mortem, only the organs or tissue that you've agreed to can be removed for examination.
You will be given at least 24 hours to consider your decision about the post-mortem
examination..
What happens during a post-mortem?
A post-mortem will be carried out as soon as possible, usually within two to three working
days of a person's death. In some cases, it may be possible for it to take place within 24 hours.
Depending upon when the examination is due to take place, you may be able to see the body
before the post-mortem is carried out.
The post-mortem takes place in an examination room that looks similar to an operating theatre.
During the procedure, the deceased person's body is opened and the organs removed for
examination. A diagnosis can sometimes be made by looking at the organs. Some organs need to
be examined in close detail during a post-mortem and these investigations can take several
weeks to complete. The pathologist will return the organs to the body after the post-mortem has
been completed. If you wish, you'll usually be able to view the body after the examination.
Once release papers have been issued, the undertakers you've appointed will be able to collect
the body from the mortuary in preparation for the funeral.
What happens after a post-mortem ?
After a post-mortem, the pathologist writes a report of the findings.
If the post-mortem was requested by the coroner, the coroner or coroner's officer will let you
know the cause of death determined by the pathologist. If the post-mortem was requested by a
hospital doctor, you'll have to request the results from the hospital where the post-mortem took
place.
That in some cases you will be asked to make some decisions. These may be to discuss any need
for consent, or to decide what happens to organs and tissue samples that may need to be removed
for investigation. Your wishes will be respected.
Any particular needs that you have, which could be cultural, religious or practical, will be taken
into account as far as possible. Where consent is not given for storage of organs or tissue
samples they are disposed of in a timely and respectful manner.
In some circumstances a Coroner may open an inquest into the death of an individual after a
post-mortem examination. If the Pathologist certifies that they have a bearing on the cause of
death, the Coroner may require that any retained organs and tissue blocks and slides are kept
until the Coroner’s function is complete. Similarly if there is a possibility of criminal
involvement in the death, tissue may be needed by the police as evidence, separate to the
Coroner’s requirements.
In both cases, the tissue samples, blocks and slides or organs may need to be kept for several
months, in some cases, years. As a result this may affect what you want to happen to them.
Why do organs and tissue need to be retained?
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In around 20% of adult post-mortem examinations and in most paediatric post-mortem

examinations, the cause of death is not immediately obvious. A diagnosis can only be made by
retaining small tissue samples of relevant organs for more detailed examination. The Pathologist
may need to retain a whole organ for a full assessment to allow an accurate diagnosis of the
cause of death to be made. When this happens the organ or tissue is normally sent to a specialist
unit. These full assessments often take weeks or even a few months to complete, depending on
the extent of the investigations required. Once they are complete, the Pathologist will produce a
report for the Coroner or the medical staff responsible for the care of the person before they died.
What happens when the post-mortem examination is complete?
When the post-mortem examination is complete, you will be told whether tissue samples and
organs have been retained. If tissue samples and organs have been retained then you should
expect to be given a choice about what happens to them when they are no longer needed by the
Coroner or the hospital. Your consent will be needed for any tissue samples or organs to be kept
for future use such as research or education and training of medical staff.
Blocks and slides
With your consent, the tissue blocks and slides may be stored as part of the record of the post-
mortem examination, sometimes called the pathology or medical record, in case they are useful
to your family in the future. If the post-mortem examination takes place in a Local Authority
Public Mortuary, rather than an NHS Mortuary, then your consent will be taken to mean that you
agree to the transfer and storage of the blocks and slides within the healthcare sector.
The samples may also be useful for one or more of the following: teaching, research, clinical
audit or quality assurance etc. The organisation storing the blocks and slides may dispose of
them.
If a funeral has already taken place, then the blocks and slides can be returned to you, usually via
your funeral director. There may also be health and safety issues that may prevent this option.
The blocks and slides may be returned with the body before the funeral. It is important to realise
that choosing this option could significantly delay the funeral. Some crematoria do not allow
blocks and slides to be cremated with the body.
Whole organs and tissue samples
Organs and tissue samples cannot be stored as part of the medical record in the same way that
blocks and slides are. They can be re-united with the body, or buried or cremated separately.
Alternatively they can be retained for future use in teaching, ethically approved research, audit
and other clinical purposes, but only with your consent.

Who can give consent for retention of organs?

The most important wishes to consider are those of the person who has died. If it is known that
the person who has died gave consent or specifically did not want to give consent to the retention
of tissue samples or organs, then those wishes must be respected.
If their wishes are not known, then a person nominated by them when they were alive, or
someone in a relationship with them or closely related, must give consent. The spouse or partner
is highest on the list, and a long term friend is at the bottom.

Post-mortem exam question

You are the FY 2 doctor in the medical department.
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Mr Peter Green 64 year old man was treated for Pneumonia by the GP with antibiotics
because he had shortness of breath for 2 weeks. He was hospitalised one week ago because
it got worse. He died of suspected Respiratory failure.
His wife Mrs Green want to talk to a doctor about this issue.
Talk to his wife Mrs Green and address her concerns.
( post mortem may not be mentioned in the question ).

Dr: Hello Mrs Green, I am Dr …. Junior doctor in the medical department? How are you doing
?
Wife: I am not feeling good doctor. I don’t know what happened to my husband suddenly he
died.
Dr: I am very sorry about it. I can imagine how you are feeling. I was told that you want to talk
to a doctor about it. Do you have any concerns?
Wife: I am just wondering doctor why this happened so suddenly. He was doing good.
Dr: We think it could be due to infection in his lungs which has led to failure of the lungs has led
to this. But we are not very sure about it. However we need to know more about this. Can you
please tell me what happened before he was brought into the hospital?
Wife: He was short of breath since last 2 weeks. We went to GP and he said he has chest
infection and gave him antibiotics. His was getting more ill since last one week and we brought
him to the hospital and he was admitted a week ago. Now suddenly this happened.
Dr: Did he have any medical conditions? Any operations done recently? Any medications ? Any
allergies?
Wife: Doctor, He had no medical problems at all. He has never been to the hospitals or GP
before this. He was completely fit and well. Why this happened doctor.
Dr: As I mentioned before. We think it could be due to infection in the lungs. We are not sure. I
think it is a better idea to do the post-mortem and find out about it. What do you think ?
Wife: My niece works as a nurse – she also told me that it is good to have the post-mortem.
Dr: OK, surely we can request for that if you wish to. Do you know what we do in the post-
mortem?
Wife: I don’t know ?
Dr: We do the post-mortem to find the exact cause of death when we are not sure about the exact
cause of death. We do that in an examination room that looks similar to an operating theatre.
Pathologists ( specialist doctor) does the post-mortem.
During the procedure, they open the body and remove the organs for examination. Sometimes
they know the cause of death by looking at the organs. Some organs need to be examined in
close detail during a post-mortem and these investigations can take several weeks to complete.
They also will take some tissue samples from the organs and keep it for future testing.
The pathologist will return the organs to the body after the post-mortem has been completed.
Wife: Who decide to hold the post-mortem?
Dr: It can be requested by a coroner (judge) or hospital or the close relative in this case like
you can request for the post-mortem.
Wife: When will you do the post-mortem?
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Dr: We usually do the post-mortem within two to three working days of a person's death.
Wife: Can I see him ?
Dr: Surely you can see him before we do the post-mortem if you wish to or you can see him after
the post-mortem also.
Wife: Will it delay the funeral ?
Dr: After the post-mortem they will give release papers and after that you can hold the funeral.
Wife: When will I get the death certificate?
Dr: They usually give the death certificate once they know the cause of death. However you do
not need to wait until you get the death certificate to hold the funeral for him.
Wife: Will they keep the organs?
Dr: Usually they return the organs back to the body after taking some tissue samples. If they
need to retain any organ they will ask your consent for that. Do you know what was your
husband’s wishes about the organs- did he mention any thing about what to do for the organs
before he died. If he had mentioned anything like that before he died - then his wishes will be
respected.
Wife: Which parts for the body do you open ?
Dr: We open only head, chest and tummy area only. We do not touch face, arms and legs. We
stitch it up once the organs are returned to the body. Stitched areas are usually covered by the
dressing of the body by the mortician.
Wife: How will this post-mortem help me doctor?
Dr: It will definitely help you a lot in many way.
1) First of all you will have a peace of mind if you know the cause of his death.
2) If it all he died of some genetically inherited condition, we can check for that problem
in his family members or if you have children we can check your children also and
maybe we will be able to treat them.
3) Also if it all he died of contagious disease we can protect others who came in contact
with him.
4) Also it helps us a lot in our studies and future training.
Wife: Will you request to do the post-mortem doctor?
Dr: Yes surely. I will talk to my Consultant and then we will request the concerned authorities to
do that.
Dr: Is there anything else I can do for you?
Wife: No doctor. You have been kind.
Dr: Thank you very much. We will keep you informed at every stage. I am very sorry again for
what happened to your husband. If you need any support we have bereavement support team in
the hospital you can contact them. They may be able to help you.
Wife: Ok thank you doctor. Dr: Thank you.
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Intussusception
Differential diagnosis for inconsolable cry in child

If symptoms started suddenly and recently, consider:

 Meningitis
 Intussusception, volvulus, strangulated hernia.
 Torsion of the testis.
 Corneal abrasion (such as from a scratch from the baby's nails).
 Non-accidental injury.

For more persistent crying, consider:

1. Constipation.
2. Transient cow's milk intolerance.
3. Transient lactose intolerance.
4. Parental depression or anxiety, or inability to interact normally with the baby.
5. Too itchy (for example eczema, or itchy clothes or clothes labels).
6. Nappy rash.
7. Wind (inadequate burping: try sitting a bottle-fed baby upright when feeding to reduce
air intake).
8. Woman's diet if breastfeeding (for example too much coffee, tea, or soft drinks that
contain caffeine, or too much alcohol or spicy food).

Differentials for acute diarrhea:

1. Viral gastro enteritis = watery diarrhea, contact ( others having same symptom),
food from outside
2. Bacterial – blood in stool, fever
3. Antibiotics
4. Meckel’s diverticulum – red colour stool but child is not ill, not crying.

Question Intussusception
GP referred a 20 month old child Andrew Collins because he was crying, lethargic, cold
and pale, but making enough urine.
Take history from child’s mother Mrs Samantha Collins and talk to her about the further
management.
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Dr: Hello Mrs Sarah Collins. I am Dr … junior doctor in the Paediatric department. How can I
help you?
Mom: My son has been crying a lot since almost 10 hours.
Dr: I am very sorry to hear that.
Dr: Do you know why he crying at all? Mom: No doctor
Dr: Did he fall or have any injuries ? Mom: No doctor
Dr: Has he got any symptoms?
Mom: He has been passing loose stools since yesterday.
Dr: How many times ? Mom: May be 3 to 4 times
Dr: What is the colour of the stool ?
Mom: It looks red doctor ( looks like red currant jelly )
Dr: Has been vomiting/ Mom : Yes 3 to 4 times
Dr: What is in the vomit ? Mom: It is green colour liquid
Dr: Did you notice any lump or swelling in his tummy ?
Mom: Yes his tummy looks bloated
Dr: Has he got high temperature? ( meningitis) Mom: No
Dr: Has he got any rash anywhere? Mom: No
Dr: Is he shying from light ? Mom: No
Dr: Is the first time these things are happening to him? Mom: Yes
Dr: Does his urine smell bad ? ( UTI) Mom: No
Dr: Has he got any swelling in the groin ( obstructed hernia) ? Mom: No
Dr: Any swelling or redness in the scrotum? ( torsion testes) ? Mom: No
Dr: Do you give him breast milk or bottle milk ?
Mom: Bottle milk / breast milk
Dr: Any change in his diet ? ( milk allergy) Mom: No
Dr: Any change in your diet ( if she is breast feeding – intolerance to dairy products if mother is
drinking too much coffee tea, dairy products)
Dr: Does he have any other medical condition? Mom: No
Dr: Did he have any problem in the tummy before? Mom: No
Dr: Did he have any operations in the tummy? Mom: No
Dr: Is he on any medications ? Mom: No
Dr: Was there any problem during his birth or development ? Mom: No
Dr: Do you have any other children? Mom: No
Dr: Any medical conditions in the family members ? Mom: No

Dr: Mrs Collins I need to examine your child’s tummy. ( examiner may say there is mass in the
abdomen)

With what you are telling me, I think your son has a condition what we call as
Intussusception. Do you anything about this? Mom: No

Dr: It is a condition in the tummy where part of the bowel goes inside another part of the
bowel like a telescope which causes bowel obstruction. This quite a serious condition if we
do not treat immediately. This condition is usually seen in children between the age or 3
months to 24 months.

Mom: Why did this happen?

Dr: Sometimes this can happen for no known reason. Sometime if he had any other medical
condition affecting the bowel can cause this. ( Meckel's diverticulum (75%), Polyps,
Henoch-Schönlein purpura (3%), Lymphoma and other tumours (3%), Cystic fibrosis, An
inflamed appendix, Foreign body, Postoperative ).

Mom: What are you going to do doctor?

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Dr: First of all we need to do some tests to confirm whether this is the problem.

We will do some blood tests to check whether he is dehydrated because sometimes the children
can be very dehydrated with this condition. Also we will do X ray of his tummy and ultrasound
scan of his tummy ( USG - may show doughnut or target sign, pseudo kidney/sandwich
appearance). Is that OK

Mom: OK

Dr: Please do not give him anything to eat or drink now until we tell you to do so. To treat him
initially we will give some fluids through his veins to hydrate him. There are different ways to
treat the condition. Our Radiology specialist doctors may try to push the bowel back to the
original position by giving some type of air enema ( air and water double contrast enema) with
high pressure. If it is not possible to correct with the enema or if there are any other problems in
his tummy we may need to do the operation ( indications for laparotomy: Peritonitis,
Perforation, Prolonged history (>24 hours), High likelihood of pathological lead point, Failed
enema.

Mom: Can you leave it like that doctor ? Won’t it become normal on its own ?

Dr: It is very rare that it will correct itself. Since he already has severe symptoms it is very
unlikely it will correct itself now. If we leave it like that for long time it can cause damage to the
bowel wall and we may have to do the operation.

Mom: When can I take him back home ?

Dr: If it corrected by enema, you can take him back home in a day or two. If we have to do the
surgery to correct the problem then we need to keep him in the hospital for about 3 to 4 days.

Mom: Will there be any problem after the treatment?

Dr: Usually there is no problem after the treatment.

Mom: Will it happen again?

Dr: Very rarely it can happen again ( recurrence rate : 5-15%)

Dr: Any other concerns ? Mom: No

Dr: Thank you very much. I will try to arrange the tests now and keep you informed
 80

Hypertension – Losartan
Question: Mr Pat Brown 50 year old man was admitted to the hospital 4 weeks ago and
was noted to have high blood pressure and treated for HTN with medications. He was
discharged 2 weeks ago and he has come back for follow up of blood pressure.
He also has diet controlled diabetes.

Measure his Blood pressure and Address his concerns.

Dr: Hello Mr Pat Brown, I am Dr … How are you ?

Dr: I understand you had high blood pressure last time when you were in the hospital ? Can I
please check your blood pressure now ?
( examiner says – his blood pressure now is 165/95).
Dr: Mr Brown your blood pressure is still quite high ? Are you taking your blood pressure
medications?
Pt: I stopped taking them few days ago.
Dr: Why ?
Pt: They are giving me too much cough. I can’t sleep and my wife also can’t sleep because I
keep coughing too much
Dr: I am very sorry to hear that. Can you please tell me which medications are you taking?
Pt: I am taking these doctor ( he will show Aspirin, Enalapril and Simvastatin)
Dr: Do you have any other problem other than cough ? Pt: No
Dr: Any fever ? ( Pneumonia) Pt: No
Dr: Any sweats in the night time ? ( TB) Pt: No
Dr: Have you noticed any change in your weight ? (TB) Pt: No
Dr: Have been diagnosed with Asthma before ? Pt: No
Dr: Do you have any other medical condition? Pt: Yes I have diabetes.
Dr: Do you take any mediation for that? Pt: No
Dr: Are you allergic anything including to any medications ? Pt: No

Dr: OK let me check the book and let you know. Check the BNF
It is Enalapril medication is giving you cough. One of the side effect of this medication is cough.
Mr Parker it is very important to take this medication to control your blood pressure. Do you
think you can continue taking this medication. You may get used this cough after some time.
Dr: No doctor I don’t want this medication. It is causing me too much problem.

Dr: OK don’t worry. We have some other medication to treat what we call Losartan
( Angiotensin receptor blocker – ARB). That will help to control your high blood pressure as
well as it is good for the kidneys also. However if you have any problems in your heart or liver
this medication may not be good. Do you have any problem in the heart or liver ? Dr: No
doctor
Dr: Ok then this should be good for you.
Pt: How do I take it ?
Dr: It can be taken by moth with or without food. Dose will be 50mg once a day but then we
will adjust the dose according to your blood pressure.
Pt: Will there be any side effects for that.
Dr: Unfortunately one of the side effects of this medication is also cough but it is not as much
as Enalapril. Very rarely it can cause allergic reaction – in that case you should stop it. It can
also cause body pain – please tell your GP if that happens.
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Dr: It is very important to take medications regularly. You should not stop taking medications on
your own without talking to your doctor. If you do not take medications regularly your blood
pressure can shoot up and it can cause other serious problems.
Dr: Any other concerns Pt: No
Dr: Mr Parker – Do you want to know about your other medications ?
Pt: No doctor

[ If he says he wants to know then talk about them -ASPIRIN:- This is a blood thinner tablet. It
reduces the risk of clots forming in your blood. This reduces your risk of having a stroke or heart
attack.

Dose as mentioned in the prescription. ( 75 mg one tablet, Once a day, by mouth, after food )
SE - Can cause tummy irritation, slight bleeding in stomach and you may notice dark stool if it
happens please inform your GP.

SIMVASTATIN: 20 mg nocte . This lowers the cholesterol ( bad fat).

Take one dose of simvastatin each day, in the evening.
You can take simvastatin before or after food.
SE – Can cause Muscle cramps - can be serious problem some times ( inform your GP). Can
also cause hair loss, Headache, Dizziness. These medications are taken life long].

Dr: Mr Parker it is very important that you should keep your blood pressure under control.
Otherwise it can cause serious health problems like heart problems and even stroke.
Dr: Do you do exercise ? Pt : No
Dr: You should go for regular exercise – jogging or at least brisk walk for 30 min at least every
day for about 5 days a week. This helps to keep the blood pressure under control.
Dr: How is your diet ?
Pt: I eat fast food/ healthy food .
Dr: You should eat less of foods which contains high fat like red meat. Instead you cna eat
chicken and fish. You should also eat more of fruits and vegetables.
Pt: Ok
Dr: Since you have diabetes it is important to keep the sugar also under control otherwise high
blood pressure and diabetes combined together can cause serious health problems.

Dr: Do you smoke ? Pt: No Dr: Good

Dr: Do you drink alcohol ? Pt: Not much Dr: Good.
Dr: Any other concerns ? Pt: No
Dr: Thank you very much. We will keep following you up. If you need any help any time please
do come back.
 82

Hyperthyroidism Weight loss

22 year Miss Emilia Mills was brought in by her boyfriend because of loss of weight.

Take a detailed history and discuss further investigations with the patient.

TSH 0.2 mU/L ( Normal - 0.4 - 4.0mU/l (milliunits per litre)

T4 - 35 pmol/l ( Normal - 9.0 - 25.0 pmol/l (picomoles per litre)
T3 - 6 pmol/l (Normal - 3.5 - 7.8 pmol/l (picomoles per litre)

D/D

1. Thyrotoxicosis - heat intolerance, palpitation, ↑appetite, anxiety, family history of

thyroid disease or weight loss.

2. TB – cough, night sweats, travel history, contact,

3. Diabetes – Increased thirst and hunger, increased frequency of urination. Family

history of diabetes.

4. Cancer – lumps & bumps, change in bowel habit, cough, haemoptysis, Breast lumps,

5. HIV – sexual Hx, drugs.

6. Depressions - ↓mood, early morning awakening, suicidal thoughts. Recent job,

changes/loss, separation from partners

7. Anorexia nervosa – intentional, insight (do you think you have lost weight or only

others telling you this), role model. dieting, exercise, laxatives, diuretic, vomiting

(purging)

8. Drugs – metformin, opiates. slimming agents,

9. Alcohol/smoking
 83

10. Malabsorption- difficult to flush the stool in the toilet.

11. Malnutrition – how is the diet ( healthy eating habits)

12. Addison’s disease – weakness, dizziness. ↑d pigmentation over palmer crease.

13. Coeliac/crohn’s – diarrhoea with blood mucus, pain abdomen

Positve Hx - How much, how long - Lost 5 kg in 2 months, ↑appetite, Palpitation,

Examination

Miss – I need to examine your hands, eyes and your neck.

( examiner did not give any finding’s)

Invt.

TFT - T3 N, T4 ↑, TSH ↓

Isotope scan (swallow radioactive substance in capsule or liquid) , Technetium

Rx – thionamides (carbamazole, prophylthiouracil)

Beta blockers

Radio-iodine – shrinks Thyroid – so ↓ hormones

Surgery – if recurrent overactive thyroid.

Back Pain - Secondary in the vertebra

You are the FY 2 doctor in the Orthopaedic department.
50 year old Mr Daniel West presented to the hospital
complaining of back pain.
Take a brief history and talk to him about the management.

Differentials
A) Secondaries –
1) Prostate – nocturia, increased frequency, hesitancy, dribbling, poor stream.
Haematuria. Weight loss.
2) Lung – cough, haemoptysis, smoking, weight loss.
3) Kidney – problem passing urine, loin pain.
4) Thyroid, Swelling in the neck.
5) Breast – lump in the breast ( in females)
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B) Prolapsed disc – lifting heavy weights, pain radiating to the legs, Cauda equina -
Bowel incontinence ( not able to control bowel movements) and bladder
incontinence ( leakage or urine).
C) Leaking abdominal aneurysm – did you have any ultrasound scan before which
showed any abnormality in the blood vessels inside your tummy.
D) Osteo arthritis – morning stiffness in the back,
E) TB - Pottts disease ( cough, night sweats, fever, weight loss. Contact, travel.
F) Sprain – trauma, twisting suddenly, after sports
G) Multiple myeloma – tiredness weakness ( anaemia), easy bruising or bleeding.
H) Ankylosing spondylitis – stiffness, pain and swelling in the other parts of the body.

I) Renal stones – past Hx of stones.

J) Pancreatitis – if pain coming from front – alcohol

Positive findings in the history – back pain for 3 months, slight weight loss,
Nocturia.

After history
Tell the patient – I need to examine your tummy, back and your back passage
Examiner may say – Prostate enlarged or Prostate normal.

Diagnosis – I think you may be having cancer in the prostate gland which is located
at the lower part of the urine bladder which has spread to the back bones which is
causing back pain.

We will have to do some test to confirm the diagnosis – X Ray of your back, Blood
test specific for the prostate gland, USG or prostate with taking tissue sample from
the prostate gland and CT scan of your tummy, MRI scan of your back.

If the patient ask of treatment - We will treat according to the test results. If it is
prostate cancer then we may treat with surgery and special cancer medication (
chemotherapy) and special X Ray treatment ( radiotherapy)

TIA
65 year Lady had Weakness of arm, speech problem ( dysphasia), and facial weakness
lasted for 2 hours. Brought in by her husband. Talk to him.
Her BP is 150/90

She had no previous medical condition except diet controlled Diabetes

Ask about other symptoms – dysphagia, vision problems, dizziness,

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( Differential – Multiple sclerosis – did she have multiple sclerosis)

No previous Hx of Cholesterol, HTN, TIA or Stroke or heart conditions ( abnormal heart
beats or heart racing).
Husband not sure of her family history.
She exercises 5 days a week.
Diet excellent, No –Smoking,
Diagnosis – Unfortunately your wife has a condition called TIA also called as Mini stroke.
It is due to sudden occlusion of blood flow to the brain. Sudden occlusion may be due to
narrowing of the blood vessels in the neck which supply blood to the brain which may be
due to collection fat plaques inside the blood vessels. It can be also due to a heart condition
abnormal rhythm in the heart ( AF).
Husband – Is this stroke?
No this is not stroke. But the symptoms are the same - TIA symptoms usually resolves
within a day and in Stroke it persists may be even lifelong which is very dangerous
condition. TIA by itself is not dangerous but it can lead to Stroke. The risk of that
happening in your wife is very high.
We need to keep her in the hospital and do test – Blood tests – cholesterol, Sugar (
diabetes),
ECG, Ultrasound scan of blood vessels of the neck. CT scan and MRI scan of her brain.
We will treat her with Aspirin to tin the blood and prevent future stroke.
We will refer her to the Neurologist. He will see her within 24 hours.
We will give her Aspirin and Medication to control for high blood pressure
She should follow healthy life style to prevent stroke
Advise about – Diet, Exercise, sugar control, cholesterol check, Smoking, alcohol, Aspirin.
FAST once discharged later.
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 87

Papilloma
25 year female presented with swelling on shoulder. Take relevant history and talk to her

about the management. Take informed consent for surgery. There is no need to fill up the

consent form.

Dr – how can I help? Pt- I have a swelling on my shoulder.

Dr-Since when? Pt- many years.

Dr- what made you worry about it now?

Pt- it looks ugly. I am getting married soon. It will be visible when I wear my

wedding dress. I want it to be removed.

Dr – have you shown it to any doctor so far? Pt- No.

 88

Dr- do you know how it started? Pt – I do not know.

Dr- any pain? Pt- No.

Dr- itching? Fever? Bleeding? Discharge? Pt- no

Dr- what colour? Pt- pinkish

Dr- any change in colour and size? Pt- No.

Dr- Is it on an exposed area is it usually covered with the dress ?

Pt – it is covered with my dress but for wedding I will be wearing a dress below my

shoulder level so it will be visible.

Dr – Have you tried to treat it in any way so far? Pt – No.

Dr – Do you have any such swelling anywhere else in body Pt – No

Dr – Did you have any such swelling before? Pt- No.

Dr – do you have any medical conditions? Any surgery before? Any medications?

Pt – No.

Dr – Any of your family members had any such problems? Pt – No.

Dr- What do you do for living?

Dr- I need to examine you to see what exactly it is?

Pt – OK. Dr. I have a picture. [ patient shows a picture]

Dr- It looks like a small non- cancerous type of growth. It could be what we call as

papilloma otherwise called warts or verrucas or skin tags. This is caused by

infection with a virus called human papilloma virus (HPV).

 89

Pt – How will you remove it?

Dr: There are several ways it can be removed we can either do a small operation to

remove it or freez it with liquid nitrogen and then it falls off after few days. Since it

is slightly bigger to be removed by freezing it may better to remove by doing an

operation.

Dr- We will give local anaesthesia to the area to numb it and make a small cut on

the skin, then remove the lump.

Pt – how long is the procedure? Dr- 10 – 15 minutes.

Pt – will it leave a scar?

Dr – we have expert team of surgeon to do the operation. There will be small thin

scar may not noticeable.

Pt – will it come back?

Dr- Sometimes they can come back unfortunately. Any other concern.

Pt: any complication –?

Dr: Very rarely there could be infections. As I mentioned it may come back some

times. Any other concerns? Pt – No

Dr- ok. I will talk to my seniors and we will arrange further tests and the date for

the procedure. Good luck with your wedding.

NAI – child
You are the FY 2 doctor in the Paediatric department.
Miss Henna Smith brought in her 4 month old son Mitchell with swelling on his left
arm.
X Ray shows spiral fracture of left humerus.
 90

Take history from her and discuss management with the mother.

Dr: Hello Miss Henna Collins, I am Dr …. How are you doing ?

Miss Smith: I am fine thank you.
Dr: Can you please tell me what brings you to the hospital ?
Miss Smith: In the morning, when I came home, I noticed swelling on Mitchell’s arm.
Dr: I am sorry to hear that. Do you know how this happened ?
Miss Smith: I don’t know.
Dr: Were you not with your child last night ?
Miss Smith: No I was at work.
Dr: Who was looking after your son at that time ?
Miss Smith: I asked my boyfriend Connor to look after Mitchell.
Dr: Did you ask your boyfriend about this swelling?
Miss Smith: I could not ask him because he was sleeping. / I asked him but he said he
did not know anything / I could not ask him because he had already gone to his work.
Dr: What time did you notice this?
Miss Smith :In the morning at …
Dr: Did he have that swelling before you went for your work ?
Miss Smith :No he didn’t have that swelling.
Dr: OK. Has he got any other injuries ?
Miss Smith : I don’t think so. I saw only swelling in his arm
Dr: What did you do immediately after you saw the swelling?
Miss Smith : I brought him here.
Dr: You have done very good thing. We will definitely help him.
Dr: Did Mitchell have any injuries in the past at all? Miss Smith :No
Dr: Has he got any medical conditions at all? Miss Smith :No
Dr: Is he taking any medications? Miss Smith :No
Dr: Is he allergic to anything ? Miss Smith :No
Dr: Did you have any problem when you were pregnant with him?
Miss Smith :No
Dr: Any problem during birth ? Miss Smith :No
Dr: Any problem with his development ? Miss Smith :No
Dr: Where is his father ? Miss Smith : I don’t know ?
Dr: Is your boyfriend is his father ? Miss Smith :No
Dr: Do you have any other children ? Miss Smith :No
 91

Dr: What work do you do? Miss Smith : I work in an Off license shop
Dr: How is your finance – any problem with that at all ? Miss Smith :No
Dr: What does your boyfriend do ? Miss Smith : He works as ..
Dr: Does anyone of you use drugs or drink alcohol ? Miss Smith :No
Dr: Is there anything else you think you want to tell me ? Miss Smith :No
Dr: Miss Smith, We have done the X ray. Unfortunately it shows that he has fracture in
his left arm bone.
Miss Smith :OK. What are you going to do?
Dr: We will have to keep him in the hospital and treat him. We will inform the
Orthopaedic doctors. They will manage him.
Miss Smith : OK.
Dr: Also we may need to do the X Ray of his whole body and also CT scan of his head. I
will inform my seniors and we may need to involve social services.
Miss Smith :Why involve social services.
Dr: I am very sorry to say this. This fracture looks very suspicious. This type of fracture
usually do not happen due to injuries. It usually happens if someone has twisted his arm.
So we need to involve the social services. They will look into this.
Miss Smith : Do you mean to say I am hurting my child. I am going to take my son back.
I am the mother you can’t stop me.
Dr: I don’t mean that. You have brought your son immediately here. It shows you are
very caring mother. I am very sorry if I hurt your feelings. I do understand how you may
be feeling. I mean there are chances that someone has done this to your son.
Mother: Do you mean to say my boy friend has done this?
Dr: We do not know who done that. You said you were not there when this happened. So
it is for your son’s benefit that we need to involve the social services to see how this
would have happened ? Don’t you think it is good to involve the social services so that
these things may not happen to him again? What do you say?
Miss Smith :OK doctor.
Thank you very much.

Elderly Abuse
Causes of falls
Elderly lady brought in her mother with history of falls.
 92

Non Medical Medical

Poor vision Balance problem ( cerebellar)
Poor light Postural hypotension ( medications)
Slippery floor Heart arrhythmia
tripping Diabetes
Pushed( Abuse) Alcohol
Osteoporosis
Dementia

Causes of bruise
Accidental injuries Medical
Non Accidental Bleeding disorder
Medications -Steroids, Blood thinners

Social history

Where does she live, with whom. Who looks after, Does daughter work, Is she busy, Are you
able to look after your mother, or do you find it difficult, How does your children get along with
your mother, Any one else at home,
Any past injuries, past medical problems, past Hx of bruises.

Elderly lady

Daughter has 2 teenage daughters.

Fell on radiator, Daughter does not know how she fell. Daughter says she does not know how
mother got bruises. Mother has no medical condition. Can I take her home –asked twice. Says I
wish I had help to look after. Sometimes says I am bit harsh on my mother.

Diagnosis – we need to check why does she keeps falling and why does she has bruises. We need
to do some tests also find any medical causes.
We need to admit her for these reasons.
Do you need any help to look after your mother Yes doc.
We will arrange that.
Also we need to involve social services to look into this matter of why does she fall and see why
does she has bruises.

Postural Hypotension - Fall in elderly

Non Medical Medical
Poor vision Balance problem ( cerebellar)
Poor light Postural hypotension ( medications)
Slippery floor Heart arrhythmia
tripping Diabetes
Pushed( Abuse) Alcohol
Osteoporosis
Dementia
Question Elderly lady with history of falls. History and management with the patient.

Elderly lady fell few times in the last 2 weeks when she goes out. Suddenly fall. Not sure
whether she had LOC. She likes to go out with friends
 93

She has HTN. GP changed medications before the symptoms started. Can’t remember the name
of medication. Ask for prescription or medication box.

I need to examine your chest and heart and also need to check your BP while you are standing
and lying down.
Examiner said BP while lying is 150/90 and on standing is 110/70. ( postural hypotension if
standing blood pressure is drop is more than 20/10 compared to lying down).

I need to check your heart tracing. Examiner gave ECG - normal

I need to check your blood sugar – normal

Mrs… I think you are falling may be due to the medication what you are taking for the high
blood pressure. These medications drops your blood pressure when you stand up which makes
you weak and fall.
We will stop this medication and give some other medication which does not cause this problem.

However you still need to be careful for some time because this problem can last for few more
days even if change the medication.
If she is living alone - admit until her blood pressure sorted out and no more falls.
If she lives with someone – advise to take care not to fall. Don’t stand up suddenly from bed or
chair. Do not go out for some time until this problem sorted out. Once the problem is sorted you
can go out with your friends and enjoy your life.

Intracranial bleed in adult. BBN

You are the FY 2 doctor in the medical department.
62 year old man Mr… presented to the hospital with headache and the CT scan of
his head showed huge intracranial bleed due to berry aneurysm. Neurosurgeon has
decided that active intervention is not useful. So your Consultant has decided for
palliative care.
Talk to his wife and address her concerns.

Dr: Hello Mrs….. I am Dr. …. How are you doing?

Wife: I am OK.
Dr: I am one of the junior doctor in the medical department looking after your husband
Mr…., I am here to talk to you about his condition.
Dr: Do you know anything about his condition?
Wife: He had headache doctor.
Dr: That is right. We did a CT scan of his head and he got the result. Did anyone discuss
the CT scan result with you ?
Wife: No doctor ?
Dr: Do you have any idea what may be happening to him ?
Wife: No doctor.
Dr: I am very sorry to say this it is not a good news. He has a very serious condition. Do
want to know about it?
Wife: Yes doctor.
Dr: Do you want any of your family members to be with you when we discuss this?
Wife: No it is OK doctor.
Dr: Mrs…., CT scan of his head showed there is massive bleeding inside his head. This
is a very serious condition.
Wife: But don’t you have any treatment for that?
 94

Dr: Sometimes we can do surgery to treat this condition. We have discussed his
condition with the Neurosurgeon but he thinks the surgery or any other treatment will
not help for your husband’s condition because the bleeding is very huge. Unfortunately,
we will not able to treat his condition. So he is in a very critical stage. It is a life
threatening n condition.
Wife: Do you mean to say he is going to die ?
Dr: I am very sorry to say this – yes that is true.
She may cry – offer tissues and water.
Wife: Why did this happen doctor?
Dr: There various reasons this condition can happen. In his case he had some abnormal
blood vessels in his head which were kind of swollen and thin that blood vessel suddenly
ruptured and caused this heavy bleeding. Sometimes this condition can run in the family
members. Can I ask you few questions about his health before this happened ?
Wife: Yes doctor?
Dr : Did he have any medical conditions at all? Like High blood pressure ? Diabetes?
Any heart conditions or kidney problems? Any stroke or mini strokes before? Any
problems in his head ?
How was he before ? Was he working ? Was he very active ?

Wife: Are you not going to do anything?

Dr: Mrs … unfortunately we will not be able to save his life but our Consultant has
planned to give him palliative treatment means we will do everything possible to keep
him comfortable.
Wife: When do you think he may die?
Dr: It can happen any day any minute unfortunately.
Wife: Can I take him home doctor ?
Dr: Yes surely Mrs... We will make all the arrangements so that you can take him home
and we will provide all types of support you need to look after him as long as he lives.
Dr: Is there any other concerns?
Wife: No doctor.
Dr: If you need any kind support like psychological or any other of kind of support we
have bereavement team in our hospital they will help you. Once again I am very sorry to
give you this bad news.
Wife: Thank you doctor
Dr: Thank you very much Mrs... If you need any help please do let us know.

Aorto - Femoral bypass surgery. BBN

You are the FY 2 doctor in the surgery department.
Mrs 64 year lady had Aorto-femoral bypass surgery. She developed heavy bleeding in the
drain after the operation. She has been transfused with 6 units of blood.
She is taken to the theatre now. Your Consultant is in the theatre.
Talk to her husband Mr. and address his concerns.
This complication was not unexpected.
 95

Dr: Hello Mr I am Dr…. one of the junior doctor in the surgical department.
How are you doing?
Pt: I am Ok
Dr: I am one of the team of doctors looking after your wife Mrs.
I am here to talk to you about her condition. Do you anything about how is her condition now?
Pt: She had a surgery. I just came to see her now. I don’t know doctor how she is now. Pt: How
is she doctor?
Dr: I am very sorry to say this she is in a very serious condition now.
Pt: Why doctor what happened ?
Dr: After the surgery she was moved to the ward then we noticed that she started bleeding
heavily. We already transfused her 6 bags of blood. Unfortunately bleeding has not stopped. So
we have shifter her to the operation theatre again to try to stop the bleeding. My Consultant is
with her in the theatre. Our whole team is trying our best to stop the bleeding.

Pt: OK. I need to go for my work now. Shall I come back after she is back from the theatre?
Dr: Mr. I am very sorry to say that this condition is very serious because we may not be able to
stop the bleeding and it is a life threatening situation now.
Pt: What do you mean ? Do you mean she may not make it ?
Dr: Unfortunately that is true Mr. We are trying our best to stop the bleeding but it is very
difficult to stop the bleeding in such situation and if we do not succeed in stopping the bleeding
she will not survive.
Pt: But why this happened?
Dr: Unfortunately sometimes this type of complications do happen after the surgery.
Pt: Didn’t you know this problem can happen before the surgery?
Dr: These types of problems are expected to happen after this type of surgery. Usually we are
prepared to handle this type of problems by operating again but in your wife’s case it is very
difficult to control the bleeding.
Pt: If you did expect this problem before then why did you do the surgery?
Dr: Unfortunately her condition was so serious that if we did not do the surgery it would have
definitely been life threatening. There was some chances of saving her life if we do the surgery.
So we had to do the surgery by taking this risk.

Pt: Why is that you say it is difficult to stop the bleeding? Where is she bleeding from?

Dr: Let me explain her condition and what operation we did on her and you can understand
where she is bleeding and why it is difficult to stop the bleeding.
Before that can I ask you few questions to see why she would have had this condition ?
Since when she had this problem ? Did she have any medical conditions ? Did she have high
blood pressure or diabetes? Was she smoker ? Was she active and well before all this problem
started ?

Dr: She had a blockage in the big blood vessel I her tummy. Blood was not flowing from her
heart to her legs. If left untreated that could have been life threatening. That is why we did the
surgery. We had to remove the blocked part of that blood vessel and replace it with an artificial
tube so that the blood can flow from heart to the legs. Most of the time we do succeed to restore
blood flow to her leg by doing this operation. However sometimes bleeding happens and may
become uncontrollable. Bleeding usually happens where we join the artificial tube to the
original blood vessel. Because the operation was done on the big blood vessel sometimes it is
very difficult to stop the bleeding. However my seniors are doing their best to stop the bleeding.
Let us hope they will succeed.

Pt: Doctor I have two sons. Do you think I should inform them?

Dr: Mr … Yes surely you can tell them that is in a serious situation.
Pt: Should I tell them to come here ?
Dr: Can I please ask you where are your sons ?
Pt: One of my son is in London other one is in Australia.
Dr: You can tell your son who is in London to come here as soon as possible. That will be good
for you too as you also need some support now but about your son in Australia – you can surely
tell him that she is in a critical condition – but for whether he should come here now or not – let
 96

me please ask my consultant and see if any progress has been made to stop the bleeding.
However if they are still not able to stop the bleeding you can tell him to come here as soon as
possible.
[ sometimes he may say one is in London and the other is in Somerset – then both can come here
soon]
Pt: OK. Thank you doctor.
Dr: Once again I am very sorry to give this bad news. Let us hope that she will be fine. If you
need any kind of help please do let me know. Thank you very much.

ACS – ECG normal

You are the FY 2 doctor in the medical department.
44 year old Man Mr … presented to the hospital with severe chest pain.
Take history from him and discuss the further management with him.
Dr: Hello Mr …. I am Dr … one of the junior doctor in the medical department. Can
you please tell me what is happening to you ?
Pt: Doctor I am having severe chest pain.
Dr: I am very sorry to hear that. How severe is your pain – in the scale of 1 to 10 one
being the mildest and 10 being the most severe pain?
Pt: Doctor it is 10 out of 10.
Dr: I see, don’t worry, we will give you some strong pain killer medication and you will
be better.
Ask examiner – I want to give pain killer to my patient what can I do ?
Examiner says – assume doctor.
Dr: Mr… We have given pain killer. Are you any better now?
Pt: I am slightly better.
Dr: Are you comfortable to talk to me now?
Pt: Yes doctor, I can talk to you now.
Dr: Can you please tell me more about your chest pain?
Pt: Doctor, I was just sitting on sofa and watching television. Suddenly the pain started.
It is almost 3 hours now. I took paracetamol, it didn’t help me at all doctor.
Dr: Anything more can you tell me ?
Pt: I don’t know what else to tell you.
Dr: OK. Can you please tell me where exactly is this pain in your chest ?
Pt: It is here over the central part of my chest doctor.
Dr: OK. What type of pain is that?
Pt: I feel as if someone is crushing my chest.
Dr: Does the pain go anywhere else at all.
Pt: Yes doctor I am having pain my left jaw also.
Dr: Does it go to your left hand? Pt: No
 97

Dr: Does it go to your back between your shoulder blades ? Pt: No

Dr: Does the pain gets relieved on leaning forward ? Pt: No
Dr: Do you have any other symptoms other than pain? Pt: Like what ?
Dr: Any vomiting ? Pt: No Dr: Fever? Pt: No Dr: Cough ? Pt: No
Dr: Pain in your calf ? Pt: No
Dr: Do you feel short of breath at all? Pt: No
Dr: Did you have a long journey flight just recently ? Pt: No
Dr: Did you have any surgery recently? Pt: No
Dr: Do you get heart burn ? Pt: No
Dr: Did you have any injury on your chest ? Pt: No
Dr: Did you have this type of problem before ? Pt: No
Dr: Do you have any medical problems at all ? Pt: No
Dr: Like high blood pressure ? Pt: No Dr: Diabetes ? Pt: No
Dr: High cholesterol? Pt: I don’t know. Dr: Any heart problem ? Pt: No
Dr: Did you have any blood clots in your lungs or legs before ? Pt: No
Dr: Do you smoke ? No Dr: Do you drink Alcohol ? Pt: No
Dr: Do you use any recreational drugs ? Pt: No
Dr: Do you take any kind of medications at all ? Pt: No
Dr: Are you allergic to any medications? Pt: No
Dr: Any of your family members have any medical conditions? Pt: No
Dr: Any heart problems in family members ? Pt: No
Dr: Is there anything else you think that may be important that we need to know?
Pt: I don’t know doctor.

Dr: Mr… I need to examine your chest and heart and also need to check your pulse and
blood pressure.
Examiner says – chest is clear. Pulse and BP stable. Thank the examiner.

Dr: Mr… I think you a serious condition in your heart. I am sorry to say that you could
be having heart attack. However, I need to do your heart tracing (ECG) to confirm
that.
ECG – examiner shows ECG. ECG – normal.

Dr: Mr… Your heart tracing looks normal. However it still looks like heart attack. Do
you know what heart attack means?
Pt: I heard of it but I don’t know what exactly it means.
Dr: Let me explain. Heart needs it’s own blood supply for its muscles to survive. This
blood supply is provided by some blood vessels called coronary arteries. In heart attack
this blood vessel get blocked suddenly for various reasons and the heart muscles will not
get blood supply which causes serious damage to the heart muscles. Sometimes this
condition is life threatening as you may know. However, you don’t need to worry. You
are in a safe place now. We are going to look after you. You will be fine.

Pt: What are you going to do for me ?

Dr: Heart attack usually need urgent treatment to open the blockage in the heart muscles
to restore the blood supply to the heart muscles. For this we do a procedure called
angioplasty. However in your case since the ECG is normal we do not need to give you
that treatment now.
We will admit you in the hospital and repeat the heart tracing and also we will do some
blood tests to check some heart attack markers to see whether you need that procedure
at all.
I will inform my seniors and they will advise further.
For now we will give you Oxygen and Aspirin tablet to chew and some medication
called GTN spray under your tongue and a strong pain killer medication called
Morphine as injection to relieve your pain.
 98

Are you following me? Is that OK? Do you have any questions ?
Pt: No doctor. Thank you very much.
Dr: Thank you very much. I will arrange for all these medications for you. If you need
any help please let me know.

Lady with bowel cancer –

Son does not want mother to know.
You are the FY 2 doctor in the medical department.
72 year old lady Mrs Ali was recently been diagnosed as bowel cancer. She had a
short period of confusion. Information was revealed to her daughter. Now Mrs Ali
has recovered from the confusion and she has the mental capacity.
Her son Mr. Mahdi wants to talk to you.
Talk to her son.
Mrs Ali has given consent to talk to him about her condition.

Dr: Hello Mr. Mahdi, I am Dr…. one of the junior doctor in the medical department.
How are you doing?
Son: I am, fine doctor.
Dr: I am one the team of doctors looking after your mother Mrs Ali. I was told that you
want to speak to me about her. Is that right ?
Son: Yes doctor.
Dr: How can I help you Mr..
Son: How is my mother now doctor.
Dr: She has recovered from her confusion now and she is much better now.
Son: I was told that she has bowel cancer, is that right doctor?
Dr: Yes that is right Mr. I am very sorry about that.
Son: Have you told her that she has cancer?
Dr: No, not yet. We could not tell her because she was bit confused but she is fine now
so we are just about to tell her now.

Son: Doctor please don’t tell her that she has cancer.
Dr: Why do say that Mr..
Son: Doctor my dad also had cancer. She was looking after him for a long time and she
has seen all the suffering what my dad went through. My dad has died now. If she comes
to know that she also has cancer she will be very distressed.
Dr: Mr.. I am really sorry to hear about your dad. I can certainly imagine how you are
feeling. I do understand she will be distressed to hear the news. However, Mr. we need
to tell her that she has a cancer because needs to know about her condition.
Son: Doctor please tell her some other condition other than cancer.
Dr: Mr… if we tell her the truth we need to be honest with our patients. She has a right
to know about her condition.

Son: OK doctor - if you have to tell her then tell her that she has some abnormal growth.
Dr: I can certainly see how caring son you are. I do certainly appreciate your concerns to
your mother. Your opinion really very important for us. However, Mr… She is in a right
frame of mind to understand everything. She has a mental capacity to understand and to
take decision for herself about her treatment. To give her the right treatment we need her
consent. We need to tell the name of her condition to offer the right treatment. Unless
we tell the name of the real condition we cannot get her consent to treat her.
Son: But why can’t tell her abnormal growth?
 99

Dr: Mr abnormal growth has different meaning it can be cancerous or noncancerous

growth. People usually know the word cancer. People may not understand any other
word for this condition other than the word cancer.
Even if we tell her that she has abnormal growth she can ask us what is that abnormal
growth and that time we have tell her that it is cancer type of growth.

Son: Doctor, I am her eldest son. Now I am the eldest in the family. In our culture it is
the elder person who takes decisions. Doctor you don’t need her consent. I am telling
you that you treat her without telling her the word cancer. I am giving you permission.
Anyway she is going to ask me only about what to do.
Dr: We do respect all cultures and family relationships. However when we take medical
decisions it has to be person’s own decision if they have the mental capacity.

Son; You doctors are only care about your duty but you don’t understand our feelings.
You don’t care for our feeling’s at all?
Dr: Mr… I am really sorry I make you feel that way that we don’t care about your
feelings. We definitely care for the feelings also. However if we don’t tell her the name
of the condition then we may not be able to offer her right treatment with which we may
be able to prolong her life or if she is in pain we may not be able to provide her right
kind of medication and she will suffer more and she will be more distressed. I am sure
you don’t want her to be distressed and suffer a lot with her condition isn’t it?
We are trying to do the best for her and I am sure you also want the best for her ?
What you say ? You tell me should we tell her or not ?

Son: Yes doctor I can understand.

Dr: Mr… As I said your input is very important for us to manage her condition. If she
agrees, you can also join us when we discuss with her about her condition and all the
treatment options. I am sure she needs your support to cope with this condition. Thank
you very much.

Diarrhoea – Bowel cancer

Causes of diarrhoea:
Acute Chronic
Gastroenteritis – vomiting, change in Bowel cancer – loss of appetite, loss of
diet, travel hx, contact hx., fever. weight, blood in the stool, mucus, pain
abdomen, constipation, anaemia
symptoms, smoking hx.
Medications – Antibiotics, PPIs, Diverticulosis – altered bowel habits,
Cemetedine, cytotoxics, NSAIDs, left side pain relieved by defecation,
Digoxin puss, (fever if diverticulitis)
Laxative abuse IBD – blood and mucus in the stool,
pain abdomen, joint pains, puss
 100

Alcohol IBS – altered bowel habits, stress,

mucus
Malabsorption – difficult to flush the
stool
Colonic polyp – blood and mucus,
family hx

50 year old man Mr… presented to the hospital with a history of passing lose stools
for the last 2 months. Take history and do the necessary examinations and discuss
further management with him.

Patient gives history of diarrhoea of 2 months, mild pain on the left lower abdomen and
loss of weight.
No blood, no mucus, family hx negative, no fever.

Tell the patient – I need to examine your tummy and back passage.

Can you please undress below the waist and lie on the bed.
Inspection – No abdominal distension, no visible peristalsis, mass or veins.
Palpation – Superficial palpation – mild tenderness on the left iliac fossa.
Deep palpation – no palpable mass.
Percussion – No fluid thrill.
Auscultation – bowel sounds normal
Tell the examiner – I need to examine the back passage.
Examiner says – no abnormal findings.

Tell the management to the patient.

Mr …. With the information what you have given and after examination I think you have
a serious problem in your bowel – it looks like you have bowel cancer. I am sorry to say
this. However, we need to do some tests to confirm this. We will be doing some blood
tests (increase ESR) and Colonoscopy – we pass a tube with a camera attached to that
through your back passage into your colon and will have a look inside and if there is any
growth we will take a tissue sample and send it to the lab for testing. We will also do a
CT scan of your tummy to check whether the cancer has spread. Do you understand?
Is that okay?

Treatment : If the test confirms that it is cancer we may treat with some type of surgery
or medications or radiation therapy to prolong your life and to relieve the symptoms.
However, unfortunately there is no cure for cancer. Thank you very much.

Ureteric calculus
Risk factors
Several risk factors are recognised to increase the potential of a susceptible individual to
develop stones. These include:
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 Anatomical anomalies in the kidneys and/or urinary tract - eg, horseshoe kidney,
ureteral stricture.
 Family history of renal stones.
 Hypertension.
 Gout.
 Hyperparathyroidism.
 Immobilisation.
 Relative dehydration.
 Metabolic disorders which increase excretion of solutes - eg, chronic metabolic
acidosis, hypercalciuria, hyperuricosuria.
 Deficiency of citrate in the urine.
 Cystinuria (an autosomal-recessive aminoaciduria).
 Drugs - eg, diuretics such as triamterene and calcium/vitamin D supplements.
 More common occurrence in hot climates.
 Increased risk of stones in higher socio-economic groups.
 Contamination - as demonstrated by a spate of melamine-contaminated infant milk
formula.

Indications for hospital admission

 Fever.
 Solitary kidney.
 Known non-functioning kidney.
 Inadequate pain relief or persistent pain.
 Inability to take adequate fluids due to nausea and vomiting.
 Anuria.
 Pregnancy.
 Poor social support.
 Inability to arrange urgent outpatient department follow-up.
 People over the age of 60 years should be admitted if there are concerns on clinical condition or
diagnostic certainty (a leaking aortic aneurysm may present with identical symptoms).

Indication for urgent outpatient appointment

 Pain has been relieved.

 The patient is able to drink large volumes of fluid.
 Adequate social circumstances.
 No complications evident.

Initial management of acute presentation

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 Non-steroidal anti-inflammatory drugs (NSAIDs), usually in the form of diclofenac IM or PR,

should be offered first-line for the relief of the severe pain of renal colic. NSAIDs are more effective
than opioids for this indication and have less tendency to cause nausea. However, if parenteral
morphine is required in severe renal colic pain, this works quickly and can provide pain relief in the
time taken for an NSAID to work.
 Provide anti-emetics and rehydration therapy if needed.
 The majority of stones will pass spontaneously but may take 1-3 weeks; patients who have not
passed a stone or who have continuing symptoms should have the progress of the stone monitored at
a minimum of weekly intervals to assess the progression of the stone.
 Conservative management may be continued for up to three weeks unless the patient is unable to
manage the pain, or if he or she develops signs of infection or obstruction.
 Medical expulsive therapy may be used to facilitate the passage of the stone. It is useful in cases
where there is no obvious reason for immediate surgical removal. Calcium-channel blockers (eg,
nifedipine) or alpha-blockers (eg, tamsulosin) are given. A corticosteroid such as prednisolone is
occasionally added when an alpha-blocker is used but should not be given as monotherapy.

Managing patients at home

 All patients managed at home should drink a lot of fluids and, if possible, void urine into a container
or through a tea strainer or gauze to catch any identifiable calculus.
 Analgesia: paracetamol is safe and effective for mild-to-moderate pain; codeine can be added if
more pain relief is required. Paracetamol and codeine should be prescribed separately so they can be
individually titrated.
 Patients managed at home should be offered fast-track investigation initiated by the hospital on
receipt of a letter or email completed by the general practitioner.
 Patients should ideally receive an appointment for radiology within seven days of the onset of
symptoms.
 An urgent urology outpatient appointment should be arranged for within one week if renal imaging
shows a problem requiring intervention.

Surgical

 Approximately 1 in 5 stones will not pass spontaneously and will require some form of intervention.
 If the ureter is blocked or could potentially become blocked (eg, when a larger stone will fragment
following other forms of therapy), a JJ stent is usually inserted using a cystoscope. It is a thin hollow
tube with both ends coiled (pigtail). It is also used as a temporary holding measure, as it prevents the
ureter from contracting and thus reduces pain, buying time until a more definitive measure can be
undertaken.
 Procedures to remove stones include:
 Extracorporeal shock wave lithotripsy (ESWL) - shock waves are directed over the stone to
break it apart. The stone particles will then pass spontaneously.
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 Percutaneous nephrolithotomy (PCNL) - used for large stones (>2 cm), staghorn calculi and
also cystine stones. Stones are removed at the time of the procedure using a nephroscope.
 Ureteroscopy - this involves the use of laser to break up the stone and has an excellent success
rate in experienced hands.
 Open surgery - rarely necessary and usually reserved for complicated cases or for those in
whom all the above have failed - eg, multiple stones.
 Several options are available for the treatment of bladder stones. The percutaneous approach has
lower morbidity, with similar results to transurethral surgery while ESWL has the lowest rate of
elimination of bladder stones and is reserved for patients at high surgical risk. [7]

Complications

 Complete blockage of the urinary flow from a kidney decreases glomerular filtration rate (GFR)
and, if it persists for more than 48 hours, may cause irreversible renal damage.
 If ureteric stones cause symptoms after four weeks, there is a 20% risk of complications, including
deterioration of renal function, sepsis and ureteric stricture.
 Infection can be life-threatening.
 Persisting obstruction predisposes to pyelonephritis.

Prognosis

 Most symptomatic renal stones are small (less than 5 mm in diameter) and pass spontaneously.
 Stones less than 5 mm in diameter pass spontaneously in up to 80% of people.
 Stones between 5 mm and 10 mm in diameter pass spontaneously in about 50% of people.
 Stones larger than 1 cm in diameter usually require intervention (urgent intervention is required if
complete obstruction or infection is present).
 Two thirds of stones that pass spontaneously will do so within four weeks of onset of symptoms.
 A stone that has not passed within 1-2 months is unlikely to pass spontaneously.
 The following features predispose to recurrent stone formation:
 First attack before 25 years of age.
 Single functioning kidney.
 A disease that predisposes to stone formation.
 Abnormalities of the renal tract.

Prevention
Recurrence of renal stones is common and therefore patients who have had a renal stone should be advised
to adapt and adopt several lifestyle measures which will help to prevent or delay recurrence:

 Increase fluid intake to maintain urine output at 2-3 litres per day.
 Reduce salt intake.
 Reduce the amount of meat and animal protein eaten.
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 Reduce oxalate intake (foods rich in oxalate include chocolate, rhubarb, nuts) and urate-rich foods
(eg, offal and certain fish).
 Drink regular cranberry juice: increases citrate excretion and reduces oxalate and phosphate
excretion.
 Maintain calcium intake at normal levels (lowering intake increases excretion of calcium oxalate).

Depending on the composition of the stone, medication to prevent further stone formation is sometimes
given - eg, thiazide diuretics (for calcium stones), allopurinol (for uric acid stones) and calcium citrate (for
oxalate stones).

Question : 45 year old man presented to the hospital with abdominal pain.
Take history and discuss the management with the patient.

Offer pain killer.

Differentials of left sided abdominal pain:

Kidney or ureteric stone – loin groin pain, hematuria. previous Hx of kidney stone.
R/o UTI and Pyelonephritis – Fever, burning sensation, increased frequency, smelly
urine.
Diverticulitis – Diarrhoea, pain relieved on defeacation.
Pancreatitis – pain from front to back. Alcohol.
Bowel cancer – change in bowel habit, weight loss.
Dissection of abdominal aortic aneurysm - did you ever had any scans of your tummy
and was told that you have abnormal blood vessels in your tummy.

In the Hx include risk factors

In problem in kidney before ( stones, horseshoe kidney)
Any parathyroid gland problem ( bone pains, pathological fractures – fractures without
trauma)
Any high blood pressure, Hx gout,
Family Hx of any kidney problems
Medications?

Any vomiting ? Are you able to drink? Are you able to pass urine?
I need to examine your tummy. (No response from the examiner)
Diagnosis
Mr… I think you have a stone in the ureter. Ureter is a tube which drains urine from the
kidney to the urine bladder.

Investigations: We need to do some tests like CT scan of your tummy area to confirm
that. Also we need to test your urine to check whether it shows any blood and any
infection markers ( examiner says – urine test shows blood). We need the check your
blood to check how your kidneys are functioning and also check some chemicals like
for calcium, phosphate and other things.

Treatment: If the tests confirm that it is stone we treat it. We have various options to
treat it.
Sometimes this stone will pass out on its own if it is very small.
 105

We will give you very good pain killer medication what we call as Diclofenac as a
suppository through your back passage.
If your pain is relieved and you are able to eat and drink and able to pass urine then you
can go home. Drink plenty of water and the stone may pass out on its own. If possible,
you should pass urine into a container or through a tea strainer or gauze to catch any
identifiable calculus. We will give you an appointment for follow up within a week.

However, if your pain is not relieved and if you keep vomiting continuously or if the
scan shows some abnormality in the kidney then we will keep you in the hospital and
treat you.

We can give you some fluids through your veins or medications ( tamsulosin or
nifedipine) which will help to flush out the stone in the urine.
If that does not work then we have something what we call as shock wave treatment
where break the stone into smaller pieces by giving some type of shock and then it will
flush out easily.
If these things do not work then either we can do a key hole surgery and remove it or
rarely we may have to do open operation to remove it.

If we get the stone we will send it to the lab for further analysis. Depending on the
composition of the stone we may give medication to prevent further stone formation. [
eg, thiazide diuretics (for calcium stones), allopurinol (for uric acid stones) and calcium
citrate (for oxalate stones).

This condition can happen again. To prevent stones in the future

 Drink plenty of fluid.

 Reduce salt intake.
 Reduce the amount of meat and animal protein eaten.
 Reduce oxalate intake (foods rich in oxalate include chocolate, rhubarb, nuts) and
urate-rich foods (eg, offal and certain fish).
 Drink regular cranberry juice: increases citrate excretion and reduces oxalate and
phosphate excretion.

Do you follow me? Any concerns?

Thank you.

Pre- operative assessment

Object is to make sure whether the patient is suitable for the elective operation as well as for
anaesthesia and to optimise his condition for the operation. In some cases surgery may need to be
postoned until the patient is optimised.
Assessment consist of taking a full history, examining to see whether any new changes has happened
since his operation was decided. To do necessary investigations to help in anaesthesia and to
prescribe some pre op medications if needed.
Also patient needs to be explained about the procedure and the need for operation and to take his
consent.
History taking.
Any changes Any changes in symptoms, health or situations since the operation
was decided.
Present Any symptoms now ( Feve, SOB, Diarrhoea, Pain anywhere etc)
 106

Past Any medical conditions ( if so – is it controlled, any medications)

Past surgery – ( if so – what, when , what Aneasthesia, any problems)
Personal Smoking, Alcohol Rec drugs, Sexual history
( Have done any tests for Hepatitis, HIV)
Period LMP,
Pregnancy Any chance of pregnancy
Pills Any Pills
Medication Any medication including the over the counter
Allergy Any allergies to medication or plaster or latex
Family history Any medical conditions in family members
Occupation What do you do for living, Sick note
Social history Any to look after after surgery, Stairs, toilet
Aneasthesia related Any dentures, Neck problems
Any thing important

Drug History: Steriods, antihypertensves, for diabetes, Thyroid medications.

Anti-coagulants, Antibiotics. Oral contraceptive pills ( should be stopped 4 weeks before surgery
and alternative contraception should be prescribed.

Systemic enquiry.
In order to make sure you do not miss any new acute symptioms, you may want to go through
the following list of symptoms with your patient.
Cardiovascular: chest pain, shortness of breath, paroxysmal nocturnal dyspoea, oederna,
palpitations.
Respiratory: cough, sputum, haemoptysis, wheeze stridor
Gastrointestinal : nausea, vomittin gdysphagia, acid reflux, haematernesis, abdominal pain,
abdominal swelling, altered bowel habit, melaena/rectal bleed, weight loss, appetite.
Genitourinary: Dysuria, haematuria, dribbling, voiding difficulties, incontinence, nocturia.
Neurological : fits or seizures, faints, funny turns, loss of poer, vision, or sensation. Any problems
in the neck.
Investigations
Recommended tests before an operation (just a guide )
Test Patients

Full blood count All patients over 40

Urea and electrolytes Patients over 60 having major surgery Diuretic therapy , high
blood pressure , congestive cardiac failure, renal failure , gut
/urology, surgery, dehydrated
Electrocardiogram All patients over 40
Coagulation studies Patients on Warfarin , alcohol excess , hepatobiliary disease
Glucose Diabetes , Arteriopathies
Liver function Liver disease , alcohol excess , hepatitis
Calcium Malignancy
Urine analysis DM, UTI,
Sickle cell testing Where needed
Pregnancy testing All females of child bearing age group
Chest x ray Patients over 60 having major surgery congestive cardiac
failure and chronic obstructive airways disease with localising
signs, high blood pressure , malignancy
Arrange Cross matched blood Depends on operation
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Pre-operative Management
Diabetic patients having surgery need close blood glucose (BM) control peri-operatively. The
anaesthetist will usually advise when this is to be started. This is usually achieved by using a
sliding scale insulin infusion or a glucose –potassium-insulin (GKI) protocol depending on local
preference. Generally this should be continued until the patient is eating and drinking normally in
the postoperative period, at which point the patient’s usual diabetic medication can be restarted.
Ideally, all diabetic patients should be first on an operation list.
Oral medication:
Metformin: It should not be discontinued and it should be given following surgery as soon as the
patient can take oral medication.
Gliclazide, glipizide etc : need to be stopped on the day of operation.
Recommencing oral medication :
All tablets should be given on the first postoperative day to control the blood sugar. The patient
should remain on a dextrose/saline infusion until they are drinking adequately.
Patients on iv sliding scale :
Patient should remain on an IV sliding scale for up to 48 hours, after which it can be stopped.
Patients taking steroids
Change to IV hydrocortisone to avoid adrenal shutdown, and recommence when eating normally.
It is essential to appreciate that any patient on long-term steroids will have impaired adrenal
function and is likely to cope badly with the stress of surgery when endogenous steroid production
is increased. This means replacing oral steroids with IV steroids to avoid an addisonian crisis.
Patients on anticoagulation:

 International normalised ratio (INR) should be < 1.5 for most operations, and 1 if a
spinal/epidural is to be used.
 Stop warfarin 3 days before surgery
 Intravenous heparin needed while off warfarin if patient has a prosthetic heart valve.
Maintain activated partial thromboplastin time (APTT) ratio at 2-3
Patients taking antiplatelet medication (Clopidogrel, Aspirin)

 Discuss with anaesthetist

 Stop 1 week prior to surgery
 In the emergency setting a platelet transfusion will reverse effects
Women on hormone replacement therapy/ Oral contraceptive pill :

 Combined OCP needs to be stopped 1 month before operation

 Progesterone only OCP can be continued
 HRT needs DVT prophylaxis (LMWH)

Alcohol dependent patients requires vitamin supplementation and sedation.

Jaundiced patients requires Vitamin K.
May need DVT prophylaxis.
Consent ( Ideally the person who operates should take the consent).

Day case surgery

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Day surgery is best defined as ‘the admission of selected patients on the day of the
operation to the hospital for a planned surgical procedure, returning home on the
same day.

Common operations done as Day case surgery

Inguinal Hernia
Varicose veins
Termination of pregnancy
Cataract
SMR
Extraction of wisdom teeth
Cystoscopy/TUR of bladder tumor
Arthroscopic menisectomy
Excision of dupuytren’s contracture
Myringotomy / grommets
 Assess patient’s home circumstances, and for certain types of surgery,
access to the patient’s home.
 Check that an emergency contact number has been given, and that the
patient understands what to do should a problem arise. Post-operative
support: 24-hour support should be provided from the day surgery unit.
 Patients with stable chronic disease such as diabetes, asthma or epilepsy are
often best managed as day cases to ensure minimal disruption to their daily
routine.
 Patients should usually be able to mobilise themselves before discharge
although full mobilisation is not always essential.

Criteria for Day case surgery

1. Age less than 70 years
2. ASA Grade 1 or 2
3. BMI less than 30
4. Availability of a responsible adult to care
5. Access to a telephone
6. Live within an hour’s travelling time from the hospital
7. Patients requiring extensive investigation are not suitable
for day case surgery

GENERALLY OPERATIONS SHOULD BE:

 Short duration
 Low incidence of postoperative complications
 Not require blood transfusion
 Not require major postoperative analgesia

Day case surgery – Pin removal [ exam question]

 109

Mr Alex Thomas 50 year old man had fracture ankle one year ago which was fixed with the
pins. Now the fracture has healed. He has come for pin removal.
Do the pre - operative assessment to check his suitability to bring him as day case surgery
and also tell him the preparation for the operation and post operative management.

Dr: Hello Mr Thomas. I am Dr ….. How are you doing ? -- Pt: I am fine doctor.
Dr: How is your ankle now ? Pt: It is good doc . I can walk on that without any problem.
Dr: Good. it is time now to pull out the pins from your ankle.
Dr: We need to do a small operation to pull out the pins. You need to be fit in regards to your
health as we need to give general Anaesthesia ( put you to sleep during the time of the operation).
I am here to see whether you are fit to undergo this operation and well as to see whether this can
be done as a day case procedure.
Dr: Do you know what is day case surgery ? Pt: No doctor.
Dr: Well we will give you a date for the surgery. You need to come to the hospital on the same
day of the surgery and after the surgery we will discharge you on the very same day if everything
is fine. Pt: OK
Dr: I need to ask you few questions regarding your health and I will be examining you later and
also we may do some tests on you. Is that Ok? - Pt: Yes doctor.
Dr: How is your general health at the moment? Pt: It is OK doc.
Dr: Do have any medical problems at all now or did have any medical problems in the past ?
Pt: Yes doc I have diabetes.
Dr: Do you take any medications for that ? Pt: I take Insulin doc.
Do you keep checking your sugar regularly and is controlled well at least in the last few months ?
Pt: Yes doc.
Dr: Did you have any problems during or after the last surgery when we fixed the fracture. --No
Dr: Do you have any other medical conditions apart from diabetes? Pt : No
Dr: Do you have any symptoms like Fever? Shortness of breath? Diarrhoea? Pt: No
Dr: Do you smoke ? Pt: No
Dr: That is good. Do you drink alcohol ? Pt : No
Dr: Good. Are you taking any other medications ? Pt: No
Dr: Are you allergic to anything at all? Pt: No
Dr: Do you have any one to look after you after the operation ?
Pt: Yes, my neighbour will pick up and drop me back to home after the operation.
Dr: You should have some adult to look after you at home at least for 24 hours after we send you
home. They should stay at your home to look after you. Do you have any one like that to look
after you?
Pt: Ok doctor I will ask my neighbour. They will do that. ( If patient says he cannot arrange any
one to stay at his home to look after him – tell him that we may not be able to do it as day case
surgery then we may need to keep you in the hospital for a day at least before we can discharge)
 110

Dr: How faraway do you live from the hospital ?

Pt: It is about 10 minutes drive from the hospital doc.
Dr: Is there anything else which may be important that we need to know ? Pt: No
Counselling:-
Dr: Mr Thomas, with the information what you have given it seems that you are fit to undergo
this operation and we can bring you for day care surgery. However, after I examine you, and check
your height and weight and do some tests like Blood tests ( like your sugar and other tests), ECG
and Chest X Rays we will tell you whether you are definitely fit for this procedure and for day
case surgery.
You need to come prepared properly for this surgery. You should be on empty stomach at least for
6 hours before we do the operation. So please do not have your breakfast and your morning Insulin
on the day of the surgery. When you come to the hospital we will check the sugar and give the
Insulin if required.
After the operation once you recover from the Anaesthesia you can have some food and take your
usual Insulin if you take at that time and wait for some time and if everything is fine, we will
discharge you on the same day. Please make sure that you do not drive for at least 24 hours after
the procedure and do not sign any important documents or work near heavy machinery at least for
24 hours. Also make someone stay with you to look after you at least for 24 hours after the
procedure. After the operation – when you go home we will give you our telephone number – you
can contact us if you need any help after the operation. Are you ok with these ? Pt: Ok Dr:
Any other questions? Pt: No
Thank you.
 111

WARFARIN
Question: Mr/Mrs 48 year old lady/man has been diagnosed as DVT.
He/She is being discharged from the hospital today. Your consultant has
commenced her on warfarin tablets.
Talk to the patient and address his/her concerns.

Greet the examiner. ( Warfarin packet, BNF and INR book may be kept inside the
cubicle)
Check the Warfarin dose ( usually 5mg OD) also check the BNF briefly for the side
effects.

Dr - Good morining Mrs Jones. I am Dr .... One of the junior doctor in the medical
dept.
Dr - How are you doing today. Pt - I am well doctor. I am going home today.
Dr - Congratualtions. My consultant has prescribed some medications which you need
to take at home. I am going to explain to you how to take them at home.
If you do not understand any thing any time please do let me know. Is that OK ?
Pt – Ok doc.
Dr - I need to ask you few questions before I explain these medications to you.
a) Any allergy to any medications - Pt - no
b) Do you ahve any other medical conditions - Pt – No
(CI for warfarin - Liver disease, Peptic Ulcer, Sever HTN)
c) Are you taking any other medications – Pt – No ( Sometimes he may say I
take mini Asprin).
d) Any chance of Pregnancy, breast feeding , or taking OCP – Pt – No
( warfarin should not be given in first and third trimester pregnancy).

Explain medicines to the patient

Dr: This warfarin tablet is a blood thinning tablets. This stops blood from clotting. (
patient may say you are using big words – then explain clotting means blood may become
thick again like what you already had)
This should be taken regularly, everyday same time for about six months. Better to take
it in the evening. You need to take it by mouth. It is important to take it every day without
forgetting.
( If patient is mentally challenged – ask - Can you remember to take the tablet. Can you
keep an alarm to remind you to take it every day, or do you have any one to remind you
to take the medicine every day. If so I will explain everything to that person. If no one
to remind - then we will do something to remind you take it every day).

Warfarin can be taken with or without food.

Dosage will depend on the blood test what we do on you regularly. This is called as INR
for which you will have to come to the hospital every week or so and bring the INR
booklet
 112

( yellow booklet) with you.

Pt: What will I do if I miss taking the tablets ?

Dr: First of all - it is very important that you should take this every day without
forgetting, otherwise you may develop blood clot again which may travel up to the lungs
which can be life threatening.
If Keep a regular alarm to remind you every day.
If you are taking evening dose and if you forget to take it in the evening but remember
before midnight on the same day, take the missed dose. If midnight has passed, leave
that dose and take your normal dose the next day at the usual time.

Pt - Doctor, what if I forget to take the medicines with me when I go on a holiday ?

Dr – If you forget to take the medicines with you when you go on a holiday you should
go to the hospital there and get the medicine and take it every day.

Side effects –

Bleeding - Since this a blood thinning medicine so you are prone for bleeding.
Be careful while handling sharp objects ( do not injure yourself). If you notice bleeding,
black stool, bruising on the skin, please report to your GP.
Other uncommon side effects are Skin rash, Jaundice, Hair loss, Diarrhoea - please
inform your GP.

If you develop chest pain or shortness of breath (PE), please call the ambulance and
come to the hospital immediately.

Specific advise:-

If you need pain killer, you can take Paracetamol but not Aspirin. [ If patient is taking
mini Aspirin – you will have to stop it. I will inform my seniors about it].
If you are going to see a new doctor or dentist, please tell them that you are taking
warfarin.

[ If the patient is sexually active lady taking combined pill – may be the pill itself has
caused the clot and the pill can interact with the warfarin and reduce the effect. Please
stop taking combined pill and talk to your GP for other suitable contraception.
For sexually active young lady not using any contraception – please use some
contraception.
Do not become pregnant when you are taking this medicine].

Changing your diet suddenly can affect your INR, especially if you begin to eat
more vegetables and salad. So do not keep changing your diet frequently.

Drink Alcohol in moderation if she is drinking alcohol. Never binge drink.

It is best if you avoid cranberry juice altogether.
 113

If you still have time left then tell the following :

Advice on illness
a. Wear pressure stockings
b. Avoid long journey flight

Back Pain - Secondary in the vertebra

You are the FY 2 doctor in the Orthopaedic department.
50 year old Mr Daniel West presented to the hospital complaining of back pain.
Take a brief history and talk to him about the management.

Differentials
K) Secondaries –
6) Prostate – nocturia, increased frequency, hesitancy, dribbling, poor stream. Haematuria.
Weight loss.
7) Lung – cough, haemoptysis, smoking, weight loss.
8) Kidney – problem passing urine, loin pain.
9) Thyroid, Swelling in the neck.
10) Breast – lump in the breast ( in females)

L) Prolapsed disc – lifting heavy weights, pain radiating to the legs, Cauda equina - Bowel
incontinence ( not able to control bowel movements) and bladder incontinence ( leakage
or urine).
M) Leaking abdominal aneurysm – did you have any ultrasound scan before which showed
any abnormality in the blood vessels inside your tummy.
N) Osteo arthritis – morning stiffness in the back,
O) TB - Pottts disease ( cough, night sweats, fever, weight loss. Contact, travel.
P) Sprain – trauma, twisting suddenly, after sports
Q) Multiple myeloma – tiredness weakness ( anaemia), easy bruising or bleeding.
R) Ankylosing spondylitis – stiffness, pain and swelling in the other parts of the body.
S) Renal stones – past Hx of stones.
T) Pancreatitis – if pain coming from front – alcohol

Positive findings in the history – back pain for 3 months, slight weight loss, Nocturia.

Examination: I need to examine your tummy, back and your back passage
Examiner may say – Prostate enlarged or Prostate normal.
 114

Diagnosis – I think you may be having cancer in the prostate gland which is located at the
lower part of the urine bladder which has spread to the back bones which is causing back pain.
Investigation and
We will have to do some test to confirm the diagnosis – Blood tests check some chemicals like
calcium, X Ray of your back, Blood test specific for the prostate gland, USG of prostate with
taking tissue sample from the prostate gland and CT scan of your tummy, MRI scan of your
back.

Treatment:
We will treat according to the test results. If it is prostate cancer then we may treat with surgery
and special cancer medication ( chemotherapy) and special X Ray treatment ( radiotherapy).
For your back pain - We also give pain killer medication and Bisphonates or radiation therapy to
back or surgery to back bones for your back pain.

Sub Arachnoid Haemorrhage

Headache - history and management
54 year old lady Mrs Joan presented to the hospital with severe headache.
Take history, examine her and discuss the further management with her.

Dr: Hello Mrs Joan, I am Dr…. one of the junior doctor in the medical department. Can
you please tell me what brings you to the hospital?
Pt: I am having severe headache.
Dr: I am very sorry to hear that. Can you please tell me how severe is the pain – in the scale
of one to ten one being the mildest pain and ten being the most severe pain ?
Pt: It is 10 out of 10 doctor.
Dr: Do you want me to give you some pain killers ?
Pt: Yes please doctor.
Offer pain killer.
Dr: Can you please tell me more about your headache ?
Pt: Doctor this headache started suddenly. This is the worst headache of my life. I felt it
like thunder clap / I thought someone hit the back of my head.
Dr: Do you mean to say you used to have headaches like this before ?
Pt: Yes doctor, I have migraine.
Dr: Is this different than migraine headache ?
Pt: Certainly doctor. I never had headache like this before.
Dr: Where exactly in the head you have this headache.
Pt: Back of my head doctor.
Dr: Since when are you having this headache ?
Pt: Almost 2 hours now.
Dr: What were you doing when you got this headache ?
Pt: Doctor I was doing …. (subarachnoid haemorrhage sometimes happens during physical
effort or straining – such as coughing, going to the toilet, lifting something heavy or having
sex).

Dr: Did you take any medications for your headache ?

Pt: Yes I took paracetamol but it didn’t help me at all.
 115

Dr: Do you have any other symptoms other than headache ?

Pt: I feel sick doctor but not vomited.
Dr: Anything else ? Pt: Like what?
Dr: Any fever ? ( meningitis) Pt: No, Dr: Neck stiffness? Pt: No Dr: Rash on the body?
Pt: No.
Dr: Any head injury recently? Pt: No
Dr: Any pain on the side of your head when combing hair ? ( GCA) Pt: No
Dr: Any pain in your jaw ? ( GCA) Pt: No
Dr: Any vision problem ? ( SAH, GCA) Pt: No Dr: Any coloured halos in your vision?
( glaucoma) Pt: No
Dr: Any watering of the eyes ? ( cluster headache) Pt: No
Dr: Do you get headaches in the morning ? ( SOL) Pt: No
Dr: Any weakness on any part of your arms or legs ? ( SOL, stroke, SAH) Pt: No
Dr: Any speech problems ? ( Stroke SAH) Pt: No

Dr: Do you have any medical conditions ? Pt: No

Dr: Have you ever had any medical conditions in the past ? Pt: No
Dr: Diabetes ? Pt: No Dr: High blood pressure ? Pt: No
Dr: Any strokes or mini strokes in the past ? Pt: No
Dr: Any kidney problem ? Pt: No
Dr: Do you smoke ? Pt: No Dr: Do you drink alcohol ? Pt: one bottle wine a day
Dr: Do you use any recreational drugs? Pt: No

Dr: Are you taking any regular medications ? Pt: No

Dr: Are you allergic to any medications ? Pt: No
Dr: Any of your family members had headaches like this or had bleeding in their brain ?
Pt: No
Dr: What do you do for living ? Pt: I am an accountant.
Dr: Is there anything else you think may be important that we need to know?
Pt: I don’t think so doctor.

Examination:
Dr: Mrs Joan I need to examine you now and check your pulse and Blood pressure.
Examiner says – examination is normal. Her BP is 150/90, Pulse normal

Diagnosis
Dr: Mrs Joan, I think you have a condition what we call as Subarachnoid haemorrhage -
that is bleeding in the brain. Are you following me?
Pt: Yes, but why do I have that doctor?
Dr:There are several reasons why this can happen. This usually happens because there is
some abnormal blood vessels in the brain which blood vessels becomes thin and they bulge
out what we call as aneurysm. Sometimes these blood vessels suddenly rupture and cause
severe headache like what you had. Sometimes this condition can run in the family.
Unfortunately this is a very serious condition and sometimes this could be even life
threatening. Do you follow me?

Pt: Yes doctor. Are you sure that is what I have ?

Dr: We need to do some tests to confirm that. We will have to do CT scan of head.( CT
scan is the first line investigation – shows bleeding in 98% of cases but negative in 2%
cases)
Examiner said – CT scan is normal. What will you do?

Dr: We will do Lumbar puncture which is usually done after 12 hours of oncet of
headache to look for Xanthochromia ( Lumbar puncture should ideally take place over 12
 116

hours after the onset of the headache because if there are red cells in the CSF, sufficient
lysis will have taken place during that time for bilirubin and oxyhaemoglobin to have
formed - xanthochromia (yellow discolouration of the spinal fluid ).

Examiner says : What will you do if the Lumbar puncture is positive for SAH ?
Dr: We will admit her in the ITU and transfer to the neurosurgical ward.
Do further investigations to find out the exact location shape and size of the abnormal
blood vessels like
 CT Angiography
 Magnetic Resonance Angiography (MRA)
 ECG

Treatment: One of problem with SAH is Cerebral ischemia due to vasospasm.

Treat her with calcium channel blocker – Nimodipine ( 60 mg four-hourly - this is
normally taken for three weeks, until the risk of secondary cerebral ischaemia has passed )
to relax the blood vessels in the brain to improve blood circulation to the brain.

Labetolol - to treat hypertension; the level should be low enough to prevent rebleeding
whilst high enough to maintain cerebral perfusion.

Patients should not be given an antifibrinolytic agent or steroids.

She needs operation on the brain either clipping or coiling.

We can give her pain killers ( morphine, cocodamol, anti-emetics, and anticonvulsants - if
she has fits)

There is 50 % mortality even with the treatment.

Complications
- Rebleeding
- Epilepsy ( 1 in 20)
- problems with certain mental functions, such as memory, planning and
concentration
- changes in mood, such as depression

- Hydrocephalus,

- Delayed cerebral ischaemia

Thank you very much to the patient and examiner.

Differential diagnosis for SAH

 Other causes of stroke.

 Meningitis (rarely features thunderclap headache).
 Trauma.
 Thunderclap headache of other aetiology.
 Primary sexual headache.
 117

 Cerebral venous sinus thrombosis.

 Cervical artery dissection.
 Carotid artery dissection.
 Hypertensive emergency (severely raised blood pressure).
 Pituitary apoplexy (infarction or haemorrhage of the pituitary gland).

SMOKING
You are the FY 2 doctor in the medical department.
Mrs Joan Thomas has been planned for angioplasty.
She is a chronic smoker.
Talk to patient and advise her to quit smoking.
Dr: Hello Mrs Joan Thomas, I am Dr ..... one of the junior doctor in the medical
department. How are you doing ?
Pt: I am OK.
Dr: I am here to talk to you about your condition.
Pt: If you have come here to tell me not to smoke, please don’t talk to me.
Dr: It seems that you have been annoyed by others, don’t worry I am not going to
annoy you. I am here to talk to about your health condition and to advise you how
you can prevent that problem in the future. Is that OK ?
Pt: OK
Dr: Mrs Thomas, Can you please tell me how much do you know about your
condition?
Pt: I was told there is some problem in my heart.
Dr: That is right. You had some thing like a minor heart attack. Let me explain that to
you.
Heart needs its own blood supply for it to survive. Blood supply is provided by some
blood vessels specially for the heart muscles. These blood vessels have become
narrowed in your case which has caused reduced blood supply to your heart muscle.
That is why you had this pain in your chest. We are doing a procedure called
angioplasty where we are widening this blood vessels in our heart to restore the blood
supply to the heart muscles. Do you follow me?
Pt: Yes
Dr: Do you know why this blood vessels would have become narrowed?
Pt: No
Dr: There several reasons why this blood vessels can become narrow. Sometimes this
happens with those people who do not eat healthy balanced diet or who do not do
exercise or who have some medical conditions like high blood pressure or diabetes.
Can I ask you how is your diet?
Pt: I eat healthy diet doctor.
Dr: That is very good to know. Please continue eating healthy food. Do you do
exercise ?
Pt: Yes doctor.
 118

Dr: That is very good. Please do continue doing execrcises. ( If she said no – I advise
you to do some good exercises . That will be very good for your heart and your health).
Pt:OK
Dr: Do you have any medical conditins like high blood pressure or diabetes?
Pt: No
Dr: That is excellent. That means it is non of these problems which are causing the
problem in your heart. One other reason why people get this problem in the heart is
smoking for long time.
Can I ask you do you smoke Mrs Thomas.
Pt: Yes
Dr: Can I ask you what do you smoke and how much do you smoke ?
Pt: 20 cigarettes a day.
Dr: For how Long?
Pt: For about 20 years now.
Dr: Well Mrs. Thomas, there is very high chance that this smoking habit has caused
the problem in your heart. Cigarette contains harmful substances like - Tar: A
substance that causes cancer, Nicotine: it is addictive and increases bad fat cholesterol
levels in your body and Carbon monoxide: which reduces oxygen in the body. I
sincerely advise you to stop smoking so that you do not get this problem again.

Pt: Why do you say it is smoking caused this? My dad was smoking whole of his life
he had no health problem at all ? ( there are so many people smoke they do not have
any health problem)
Dr: I am really glad to know that your dad had no health problem at all despite
smoking for many years. However, Mrs Thomas there is evidence that people who
smoke for long time do get lot of health problmes like stroke, cancers, high blood
pressure and including heart attack. In some people skin becomes more wrinkled.
Also people stay near to you get passive smoking which can hppen even to your
children if you have at home. You may be spending lot of money on smoking I guess.
You already had some minor heart problem in your heart now. If you continue that
you can get major heart attack next time and it may be even life threatening. I am sure
you don‘t want that to happen to you isn’t it ?

Pt: You said you are going to widen the blood vessels in my heart. So why should I
get this problem again?
Dr: Mrs Thomas we are treating this condition now, but if you continue smoking blood
vessels in your heart will become narrow again and it can cause serious problem next
time.
There are many benefits of stopping the smoking:
Carbon monoxide and nicotine will be eliminated from the body, blood circulation
will improve. Lungs start to clear out smoking debris. Skin loses its grey pallor and
becomes less wrinkled. Coughing and wheezing stop.
Excess risk of heart attack and lung cancers reduces by half. Also you could save lot
of money which you spend on buying cigarettes and you can use that money for
something else.

Pt: But doctor I enjoy smoking? I can’t stop it.

Dr: I do understand. Many people say that they enjoy it but that enjoyment comes at
the expense of your health. If you want to enjoy your life you need to remain healthy.
You can try doing some other things to enjoy life which will be good for your health
 119

– may be going for some exercise classes, relaxation therapy or yoga classes where
you meet lot of people and you may enjoy that.
If you wish we can help you in stopping smoking. We have some thing called as
smoking cessation clinic. I can refer you to them. There are support help groups.
You may be benefitted from that.
We also have some medicines called Bupropion and Varenicline which can help in
stopping the craving for cigarettes, but at the end of the day it is your willpower that
is the most important thing. What do you say Mrs Thomas ? Do you want to consider
this ?
Pt: I will think over it.
Dr: That is really good. Please do let us know and we will do every thing possible
from our side to help you.
( if she said no I can’t stop smoking - I can understand that it is not easy to give up
the habits. However, you may need more time to think over that. I advise you to think
about it seriously and let us know any time if you need our help, we are always here
to help you.
Thank you very much.

[ do not mention - I will tell my seniors – they will come to talk to you]

BENEFITS FROM SMOKING CESSATION WITH TIME SINCE

QUITTING.
Time since BENEFITS
quitting
20 minutes Pulse return to normal.
8hours Nicotinelevelisreducedby90%, carbon monoxide levels in the
blood reduce by 75%, and oxygen levels return to normal,
circulation improves.

24hours Carbon monoxide and nicotine are eliminated from the body.
Lungs start to clear out smoking debris.
48hours All traces of nicotine are removed from the body. Sense
of taste and smell improves.
72hours Breathing is easier. Bronchial tubes begin to relax and energy
2–12weeks levels increase.
Circulation improves.
1month Physical appearance improves owing to improved skin
perfusion. Skin loses its grey pallor and becomes less wrinkled.
3–9months Coughing and wheezing declines.
1year Excess risk of heart attack reduces by half.
10years Risk of lung cancer falls to about half that of a continuing
15years smoker.
Risk of MI falls to the same level as someone who has never
smoked.

ISSUE SOLUTION
 120

 “All the damage is “There are immediate benefits from the day
already done”. you quit”.
 I am already 70, I want enjoy the You are only 70, you have many more
rest of my life. years to live happily. You can enjoy your
 “A lot of doctors smoke”. life
“Verybetter
fewifdoctors’
you aresmoke
healthy.
andIt many
have given
laquwialways
more up”.
benefit

 “I’ve switched to a low tar “The health claims about low tar cigarettes
cigarette”. are very misleading. People tend to inhale
more deeply and more often. Low tar
cigarettes have no effect on heart disease
in smokers and any tiny effect on lung
 “I smoked in my last pregnancy cancer rates is probably
“Each pregnancy offsetIt’s
is different. by increases
like
and my baby was a normal in other cancers”.
gambling with your baby’s health”.
weight”.
 Problem–Stress Recommend simple relaxation
exercises, e.g. “Take a slow, deep
 Many patients use tobacco breath and, as you breathe out, say to
to cope with stress. yourself “relax” .Give a stress
pamphlet or refer to a relaxation class.
 Problem–Weight Gain Stress that the health benefits of
[Smoking appears to lower quitting smoking far exceed the risks of
the efficiency of caloric the average weight gain.
storage and/or to increase There are better ways to reduce weight
metabolic rate. after cessation, rather than smoking cigarettes.
average weight gain is only Or First, the patient should quit tobacco
2.3kg.] while allowing the weight to accumulate;
Second, when the habit is gone for good,
he/she should focus on losing weight.
You can join a gym or start jogging which
can help in reducing weight effectively.
 121

Ankle Sprain
You are the FY 2 doctor in the A&E department.
30year Mrs Anna Henley presented to the hospital in the morning
because she fall on grass while she was going home from work.
She had pain swelling, and bruise in her ankle. X Ray was done
in the morning.
She has come back to get the X Ray result.
Take history and talk to her about the further management.

How, when happened,

Pain and swelling in ankle
Were you able to put weight on that ankle immediately after the incident.
Past injuries to ankle
Pt: Doctor I work as a cleaner (contract worker) in a school. I told you in the morning
that I fell outside the school on the grass on the ground. I want you to change and write
that I fell inside the school.
Dr: Why do want us to change the story ?
Pt: It is a mistake. I was not thinking properly in the morning when I said that.
Dr: Unfortunately we cannot change what we already wrote in our notes. However if
you I can that requested us to change the story. Do you want that ?
Pt: No then they will think I am doing it for some benefits. Please change the story in
the morning notes.
Dr: I afraid I cannot do that. We are supposed to be honest.
Look at the X Ray. – which is normal.
Diagnosis: Miss…. I have looked at your X Ray.
Good news for you is that X ray does not show fracture. You have a sprain in your ankle that
is because of stretching of ligaments in the ankle. Ligaments are strong bands of tissue around
joints that connect bones to one another.

Treatment
You can take painkillers such as paracetamol or Brufen.

PRICE stands for:

 Protection – protect the affected area from further injury by using a support or,
wearing shoes.
 Rest – Avoid activity for the first 48 to 72 hours. We can give you crutches to help you
to walk.
 122

 Ice – for the first 48 to 72 hours after the injury; apply ice wrapped in a damp towel to
the injured area for 15 to 20 minutes every two to three hours during the day. Don't
leave the ice on while you're asleep, and don't allow the ice to touch your skin directly
because it could cause a cold burn.
 Compression – We will put elasticated bandage to the ankle to limit the swelling and
movement that could damage it further. You can use a simple elastic bandage or an
elasticated tubular bandage. Remove the bandage before you go to sleep.
 Elevation – keep the injured area raised and supported on a pillow to help reduce
swelling.

You should avoid ( HARM )

 Heat – such as hot baths, saunas or heat packs.
 Alcohol – drinking alcohol will increase bleeding and swelling, and slow healing.
 Running – or any other form of exercise that could cause more damage.
 Massage – which may increase bleeding and swelling.

Generally, you should try to start moving a sprained joint as soon as it's not too painful to do
so.
Generally, after an ankle sprain you'll probably be able to :
walk a week or 2 after the injury.

use your ankle fully after 6 to 8 weeks,

Avoid driving until strength and mobility have returned which may take 6 to 8 weeks.
to return to sporting activities after 8 to 12 weeks.

Contact your GP if your injury doesn't improve as expected or your symptoms get worse.
Surgery – is not needed to treat sprains unless the injury is very severe.
 123

Epilepsy

You are the FY 2 doctor in the medical department.

Mr Sandeep Singh 28 year man was diagnosed with epilepsy few weeks ago. He
has come for follow up.
Take history and address his concerns.

There may be medication box written as Sodium Valproate 300 mg BD and BNF

Dr: Hello Mr Sandeep Singh, I a Dr… one of the junior doctor in the medical department. How
are you doing? Pt: I am OK doctor.
Dr: I understand you were diagnosed to have epilepsy. I am sorry about it. How is your
condition now ? Pt: Doctor I had fits again after that.
Dr: I am sorry to hear about it. When exactly was that ?
Pt: Once few days ago and once about a week ago when I was in the party. Why did that
happen doctor ?
Dr: There could be many reasons why people still have fits even after treatment. Can I ask you
few questions to see why this would have happened to you? Pt: Yes doctor.
Dr: Have been given medications for that ? Pt: Yes
Can I ask you which medications ?
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Pt: I take this doctor. (Patient may show Sodium Valproate tablets).
It is written 300mg twice a day here. Are you taking the same dose ? Pt: Yes.
Dr: Let me check the book whether the dose is right for you. ( check the BNF for dose and
side effects). Mr Singh – dose seems to be right for you. Are you taking these medications
regularly ?
Pt: Yes I am.
Dr: Are you taking it as prescribed by us ? Pt: Yes
Dr: Please tell me when do you take it?
Pt: Whenever I have fit I take it doctor.
Dr: Does it mean that you do not take every day. Pt: Yes that is right ?
Dr: Can I ask you why you are not taking it daily ? Pt: I forget to take it.
Dr: Mr Singh, It is very important to take these medications regularly every day even when you
do not have fits. There should be certain amount of medications in your blood all the time to
prevent you from getting fits. I advise you to keep alarm to remind you to take this
medications regularly. Is that OK?
Pt: OK doctor I will do that.
[sometimes patient may say – I was told to take the medications only when I have fits. – I am
sorry if that is what was told. There could be some misunderstanding].

Sometimes this problem can happen if the medications are not absorbed into the system if
people have vomiting or diarrhoea. Do you have vomiting or diarrhoea ?
Pt: No doctor.
Dr: Do you have any other medical conditions at all ? Pt: No
Dr: Are taking any other medications? Pt: No
Dr: Sometimes people can get fits if the dose is not enough or the medications do not work for
them. In that case we need to change the medications. We will see that again after sometime
if you still get fits after taking the medications regularly. Pt: Ok doctor
Dr: There are reasons also why people can fits like if they are exposed to some triggering
factors like exposure to too much light in cinema, watching TV for long time ?
Do you go to cinema or watch TV for long time? Pt: Yes doctor. Dr: I advise you to avoid
them
Dr: Do you work on the computers for long time?
Pt: I am student doctor. I have to work nearly 5 to 6 hours every day on the computer.
Dr: Again I advise you to avoid looking at the computer continuously for long time. It is
better to take print outs and use them.
Dr: Do you go to pubs where there are flashing lights ? Pt: Yes doctor
Dr: I advise you to avoid that because flashing lights can trigger fits.
Also sometimes lack of sleep or starving for long time also trigger fits. I advise you to sleep
well and have food at regular intervals - do not starve for long time.
Dr: Do you drink alcohol? Pt: Yes
Dr: Alcohol also can trigger fits, please avoid drinking alcohol. Pt: Ok

Dr: You need to be careful when you have fits. Avoid going near the fire.
Who cooks food for you ?
Pt: I live with few other friends. I cook food.
Dr: May be your friends cook food for you and you can do some other work for them.
Also avoid using gas cookers. Electric cookers are better. When transferring the food to plate
please take the plate to the pan and not hot pan to the plate.
You should be careful when taking shower. Do not take bath in bath tub instead take a shower.
Pt: OK
 125

Do you swim ? Pt: Yes.

Dr: If you are swimming in the swimming pool or sea or river please tell the lifeguards that
you have this condition. Swimming in the river or sea is more risky than swimming in the pool.
Pt: OK

Dr: Do you drive ?

Pt: I am about to take a practical driving test next week.
Dr: I am afraid you should not drive may be for about a year now. Please inform the DVLA
about it and they will advise you when you can start driving.

Please inform your friends at your college if he is a student ( or colleagues at your work place
if he is working) that you have this condition and let them know how to help you. Please wear
your bracelet all the time. Any other concerns ?
Pt: No doctor.
Dr: Thank you very much. Hope you will not have the fit again.

If the patient is a young lady – ask about Contraception

[ sodium valproate does not affect the combined pills - so she can continue.
Carbamazepine reduces the effects of combined pill so they should increase the
dose 9double the dose) of oestrogen in the combined pill and also use other forms
of contraception.]

contraception and epilepsy

Some methods of contraception may be less effective in preventing pregnancy for women
taking certain anti-epileptic drugs (AEDs). This is because some AEDs (enzyme-inducing
AEDs) affect how well methods of contraception work. Non-enzyme-inducing AEDs are
unlikely to affect contraception.

Enzyme-inducing AEDs – carbamazepine, phenobarbital, phenytoin

Enzyme-inducing AEDs may affect methods of contraception that contain hormones, such as
the Pill or contraceptive implants. This is because they increase the level of enzymes that break
down hormones in the body. This means the hormones in contraceptives are broken down more
quickly than usual, so they stay in the body for less time and are less effective in preventing
pregnancy.

If you take an enzyme-inducing AED, you may be advised to use a method of contraception
that is not affected by your AED, such as a barrier method, or to use more than one method to
help prevent pregnancy.

Non-enzyme-inducing AEDs are unlikely to affect any form of contraception.-

sodium valproate, acetazolamide, gabapentin, vigabatrin
 126

Lamotrigine - a special case - Lamotrigine (Lamictal) is a non-enzyme-inducing AED. But

unlike other non-enzyme-inducing AEDs, it needs special consideration.

There is no evidence that the Pill affects epilepsy directly, but there is evidence that the Pill
lowers lamotrigine levels in the blood. This could reduce seizure control and lead to seizures
happening.

Research suggests that lamotrigine can lower the amount of progestogen from the combined
oral contraceptive pill in the blood, but not the oestrogen. However, there is currently no
conclusive evidence that lamotrigine reduces the effectiveness of the Pill.

If you take lamotrigine, it is important to talk to your doctors before starting any contraception
that contains the hormones progestogen and oestrogen.

The combined oral contraceptive pill – ‘the Pill'

The combined oral pill contains the hormones oestrogen and progestogen. For any woman
there are risk factors such as age, weight, high blood pressure and smoking that can cause side
effects with taking the Pill.

Some AEDs can affect how well the Pill works:

 non-enzyme-inducing AEDs do not affect the Pill so it can be a good type of contraception
to use
 enzyme-inducing AEDs cause the hormones in the Pill to be broken down more quickly, so
the Pill may not be effective.
If you are taking an enzyme-inducing AED, you should to take a double dose of the Pill with
30µg (micrograms) of oestrogen (so that you take 60µg of oestrogen in total), especially if the
Pill is your only method of contraception.

Even with a higher dose, the Pill on its own may not be completely effective in preventing
pregnancy. It is often best to use other methods of contraception as well, such as a barrier
method.

If you bleed between your periods, it may mean that the dose of oestrogen is not high enough
to prevent pregnancy.

Oestrogen can have a pro-convulsant (seizure-causing) effect in some women. So when a

woman’s levels of oestrogen are high, there may be a higher risk of seizures happening. Taking
 127

the Pill can further increase your levels of oestrogen but your body gets rid of the oestrogen
from the Pill quickly so this doesn’t make you more likely to have seizures.

The progesterone-only pill – the ‘mini pill'

The mini pill is less effective against pregnancy than the combined pill, particularly if you take
enzyme-inducing AEDs. Therefore the mini pill is not recommended as a form of
contraception if you take enzyme-inducing AEDs.

Emergency contraception

The morning-after pill

The ‘morning-after’ pill is a type of emergency contraception that is taken after unprotected
sex. It can be prescribed by GPs, pharmacists and family planning clinics.

If you take enzyme-inducing AEDs, this may reduce the effectiveness of the morning-after pill
in preventing pregnancy. So you will need double the dose of the morning-after pill than other
women (two pills rather than one).

Emergency intrauterine device or coil

A different type of emergency contraception is the emergency intrauterine device

(IUD). The IUD is not affected by taking AEDS. This IUD is placed inside the womb to
prevent pregnancy and needs to be fitted by a trained doctor or nurse.

Contraceptive implants

Contraceptive implants, contain progestogen and are implanted under the skin in the upper
arm. Implants can be affected by enzyme-inducing AEDs so they are not recommended if you
take enzyme-inducing AEDs.

The contraceptive patch

The contraceptive patch contains oestrogen and progestogen and so works in a similar way to
the combined pill. Like the combined pill, it may not be an effective form of contraception if
you take enzyme-inducing AEDs.

The vaginal ring

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The vaginal ring is a flexible plastic ring that is inserted into the vagina. It works by releasing
oestrogen and progesteron over 21 days. The vaginal ring may not be an effective form of
contraception on its own if you take enzyme-inducing AEDs.

Methods not affected by AEDs

The following methods of contraception do not affect, and are not affected by, AEDs.

Barrier methods

Barrier methods of contraception create a physical barrier against becoming pregnant. They
include condoms, femidoms, caps and diaphragms, and are not affected by AEDs. However,
for any woman, barrier methods on their own may not be effective in preventing pregnancy,
and you may be advised to use them along with another contraceptive method.

Intrauterine devices (IUDs)

IUDs are devices that are fitted into the womb. IUDs are not affected by AEDs because they do
not contain hormones.

Intrauterine systems (IUSs)

IUSs are devices fitted into the womb. Unlike IUDs, IUSs contain the hormone progestogen.
An example of an IUS is the Mirena coil, which contains a slow-release progestogen called
levonorgestrel.

Although IUSs contain progestogen, they are not affected by AEDs because the hormone is
released straight into the womb, rather than travelling around the body where an enzyme-
inducing AED can cause it to break down more quickly.

There is a risk that a woman could have a seizure while the IUS is being inserted. This is rare,
and the risk is low. If you are concerned about having an IUS fitted, you can discuss this with
your doctor.

Contraceptive injections

Contraceptive injections, such as Depo Provera, contain progestogen and are given at regular
intervals. Although they contain progestogen, they are not affected by AEDs because they are
broken down in the blood, rather than in the liver where they could be affected by enzyme-
inducing AEDs.
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