Station 4: Communication- Talk with the wife of a newly dx HD, concern- children & wanted to

inform children

Husband was found heterozygous on genetic testing

________________________________

*introducing

*confrim identity.

*any permission from husband that we can share this infrom with u ? Yes am NOK.

*can u please what's going on with ur husband?

He is Forgetting things we went to GP who gave him some vit which didn't help, then he dev
eloped some sort of abn movement of the hands and legs ,his GP then referred him to neuro
dr , as his condition is getting worse , his dr suggested gentic test and am here to recive th
e results.

*ask how symptoms developed ?

How he was donig before ?

*Do u have any idea of this cond?

*ask about family history before telling the results .

*so the Report is with me right now , it's not as we hope unfortunately it has come back to b
e positive , explain the condition more and it's progressive nature ABCD A for abnor movement
, B for behavioural abn , C for concentration problems , D dementia and depression , tell abt
manag of those 2 condition, if she asked i want to know more go deep don't mention that h
e would die early unless she asked about that specifically

*we don't have any ttt for this cond we will do our best to ttt each problem he may develop ,

*regarding genetic screening of childern :one should not offer test not advisable to do the test
, even after 18 ymo of age , because even if it's positive nothing to do , the pt will be in a fe
ar , causes severe level of emotional trauma may lead to suicide ,can be offered after 18 but n
ot advisable
*if she asked abt chance of children being affected ?

Each one of his children has a 50% chance to get the diease , but u have to explain pros an
d cons , pros here u can know earlier but what then u can't ttt him or her , explain that the t
est is not going to make him better it will put him on much pressure and depression even b 4
developimg the condition, no one is going to give him a job , he will lose his insurance aspec
ts of life will be very bad ,

*AD LPA in dementia should be discussed in dementia but not in details ,

*most imp part in care is specialist dementia , 24 hour nursing, social hx , problem that might
develop in future, med can help abn move to some extent but no cure for this diease .

Referral for genetic counseling is for whom have family history of genetic disease or have a gen
etic disease and concerning family planning.

Whenever you are discussing about genetic testing:

- Confirm the test confidentiality

- Explain the test

- Explain pros and cons

- Consent

Confidentiality

- Reasuure that the test is totally confidential and the result will be released personally by hand
s.

Pros

- One will know that he might develop the disease at a time.

- Early recognition n follow up.

Cons

- Worries and anxiety specially for whom have NO symptoms

- No one can know when symptoms will start or how much will be sever

- if the test is positive, work n insurance should be informed as some changes could be applie
d

- if the test is negative, this doesn’t mean freeing of the disease and it should be repeated aga
in to rule out or confirm.

St4)75 year old male, was prescribed antidepressants by GP, developed arrythmias, he was admit
ted and treated for same, recovered , but while on the ward he developed cardiac arrest and w
as given CPR which was not on notes and not discussed with patient while an inpatients, but p
atient had signed DNAR with the GP some while ago.

Discuss this with his Son, Mr Andrews.

_____________________________
*Confirm identity

*check understanding

*NOK

*i have been told that my father died but am shocked that he recieved resuscitation am not ha
ppy about that.admitted last 2 days due to heart condition was doing very well then st wrong
happened he was given resuscitation i don't know why CPR was done for him inspite that he si
gned a DNR document unfortunately my father had painful death.

*do u have LPA

*what medical illnesses he had

Bp , he went to GP and was given some ttt for sleeplessness.

*Probably he suffered from Depression and his GP gave him some antidepressant med , every
med has some advantages and some side effects, this med caused abnormal ryth of the heart
he was brought to ER we addressed him very well and ttt given in his best in terest given appr
opriate manag all inves done on time because of that he rocovered. Then He had Heart arrest
, the team looking after him didn't follow the DNR status, they did heart compression for him s
o the heart can beat back into normal but instead of recovering he passed away.

*CPR is quite traumatic as far as i know , he didn't want that , u gave him undignified death .

I was not there at the time when CPR was given , i need to go back and look at the notes to
know why CPR was given maybe there was a communication gap .

*what is ur concern at the moment? i don't want this to happen to anyone else .

*write incident report , will arrange meeting involves the ttt team , nurse encharge and to know
why CPR was given despite fact that DNR was signed by ur father.
Will do route cause analysis, cotact GP to take document of DNR to provide it as a document
ary evidence, will keep u apdated about the feedback , to make sure that such thing will not
happen again .

*Anyway to complain ?

Sure u can complain through PALS in our hospital will guide u to the office will keep in touch
with u about the progress ,arrange nxt meeting will get back 2 u

*Negligence or error?

We have to do route cause analysis if we found DNR was not mentioned so CPR done in the
best interest but we have to respond pt Autonomy also we should contact GP to get the notes
to find out whose mistake is it , to r/o negligence but am not sure at the moment that negli
gence had happened as it was not written in the notes that why drs proceed for CPR this is w
hat we should have checked it.

(Another opinion 😃)

Negligence when ends up in a way that harms the pt and in this case the patient had traumati
c death so there's harm here, also Advanced directive should be respected in every situation an
d inspite that DNR was signed by the pt , medical team resuscitated him so it's negligence.
Station 5 ) 25y o male with fever after travelling to his home country temperature 38.5

______________________________

Pt was in zambia developed diarrhea occurred 10 days after returning bk ,fever 39 not continuo
us, loose motions , 7_8 days ,fever improves after paracetamol , no diurinal variation, fatigue w
ith the fever , apetite decreased, abdo pain , no wt change , no itching, no lumps , recieved
vaccination for malaria b4 travelling , i didn't have any fever there , full course continued as GP
prescribed, many insect bites , tap water , single , no sexual relations there , no tattooing, no
hx bld transfusion, smoker , alcohol 3/u daily , no rash

*Examination :

Vital signs HR is 105

JVP

Abdomin

*Dx:
Enteric fever salmonella

*DD:

Shigella but no bleeding

*What's the Definition of acute diarrhoea?

three or more stools per day of decreased form from the normal, lasting for less than 14 days.

*what are the indications of inves in diarrhoea?

Bloody diarrhoea high grade fever elderly ,immunosuppressed

*Inves of Enteric fever:

Basic CBC RFT UE ESR CRP

blood culture , stool c/s

Bone marrow aspirate and culture is superior to blood culture, since the bacterial concentration
in bone marrow is 10 times that of peripheral blood. S typhi or S paratyphi may also be isolate
d from urine, rose spot biopsy, or gastric or intestinal secretions.

*Management:

Admit (according to what mentioned in the feedback) close observation of vital signs hydration

Azithromycin preferred over quinolone if severe IV ceftriaxone.

Station 2 )25 years old female has rash in face and hand for last 2 months. Gp referred. Plz ta
ke history and manage pt concerns.

________________________________
Last 2 months , affeting face and hands , fatigue , red not itchy ,resolved now by itself, was in
trip started there , no fever , no wt loss , no GIT sym , no other skin lesions , are they relate
d to sun exposure? Yes increasing, no skin tightness, no nail changes , hand joint pain but r
esolved on pain killer , no visual problem, job engineer, affecting her work , no oral ulcer, no
finger color change , no PMyopathy no muscle pain , no hair loss , hx of abortion twice , sm
oke occasionally, alcohol occasionally, Fhx nil , pmhx previous episode during honeymoon , d
rugs pain killer ,no sore throat , no LL swelling .

*Concern

1)I want to get pregnant

U have condition called lupus means ur defensive system is directed against ur own tissues ,
miscarriages also related to the same problem , before starting any ttt we need to screen u wit
h blood test ,urine test ,xray hands, MDT ,joint dr, physio , occupational therapists, gynecologi
cal joint , blood dr , I would ask u to delay pregnancy as long as the disease get controll ed af
ter that the woman and joint dr can make the decision regarding pregnancy ,for joint pain will
give u pain killer and for skin rash ttt sun block umbrella ,

2)will I be able to get pregnant ?

yes there's a very good available ttt , after ttt most of pt with this kind of problem can get pre
gnant but u have to be followed very carefully by woman dr .

*Dx :

SLE with APS

*DD:

sle

Drug rash

Photosensitivity rash

PCT nothing fits in scenario

DM but no Ms pain
*Inves:

CRP ESR CBC RFT ANA , AdsDNA , coag profile complete ab screen , rheumatoid profile, an
ti cardiolipin AB , lupus anticoag ,Ab to B2 glycoptn1 , urine 24 hr ptn

*Management :

As mentioned above

For APS ASA + heparin during pregnancy and postpartum resumption by warfarin

Station 5)35years old male presented with numbness and tingling in his left hand kindly examine
n address his concern

________________________________

Only lt hand , no diurinal variation , last 2 fingers of lt hand only extends up to elbow , weakn
ess in last 2 fingers , on pain killers , painter affecting job , alcohol 2 units/day , smoker 15 /da
y for 15 years , ask about vasculitis symp (rash joint) , No hx taruma , ask about cases of MN
M

*Examination:

Inspection wasting of hypothern

No scars

No joint deformi

ulnar nerve exam

*Concern :

Ulnar nerve pasly , maybe ur job is the cause as ur using ur hand too much , will do some i
nves to confirm dx , refere to occupational health worker , smoking cessation clinic , advise to
rest his hand
*Dx

Ulnar nerve palsy due to excessive hand use.

*Inves :

Xray elbow joint us of MRI of cubital tunnel

NCS FBC RFT LFT FBS CRP ESR screen for any underlying MMN

*management:

MDT referral physiotherapy occupational health physician nerve dr neurosurg ،splinting, NSAI
D

https://youtu.be/kPuXds-QUso

Station 2 : (came also as st5)

38 yo male patient known DM

HTN

smoker

B asthma

Referred to u with shaking hand

For your help

__________________________

Tremors for the last 10 years caused by inhalers , 2 weeks back changed in character , affectin
g both hands, present all the day ,more apparent on movement while catching objects , no gait
 problem , no relation with stress , working as a bank accountant , job affected , B.Aasthma co
ntrolled , DM controlled on insulin, HTN controlled , on hydrocholorthiazide lisinopril insulin ,m
ood changed recently on lithium started 6 months bk , has travellar diarrhoea for the last 2 mo
nths , no thyroid sympt , father also had tremors diagnosed as parkinson in his 50s , drinks a
lcohol 4units , smoker 20 cig/day 20 years ,

*Concern:

1)Is it dangerous condition?

Most probably u have Lithium toxicity, some of ur drugs can precipitate this condition ,will ad
mit u ,may need to do haemodialysis , will stop lithium ACEI diuretics , yes dangerous if left un
ttt

2)Do i have parkinson ?

No as there's no evidence from ur history suggesting that u have such condition, all ur sympto
ms go with lithium toxicity.

*Dx :

Iithium toxicity precipitated by ACEI diuretics and diarrhoea.

*DD :

Lithium toxicity

Cerebellar stroke DM smoker HTN

Anxiety

B agonists

Thyrotoxicosis (diarrhoea tremors mood )

*Management :
Admission , lithium level , ECG U&E LFT TFT , stop lithium diuretics, change ACEI with amlodipi
ne, rehydration, involve psychiatric team , haemodialysis if lithium level more than 4mEq/l , mo
re than 2.5 in the presence of symptoms or renal failure

*How can lithium cause tremors ?

Cereballar syndrom

(If came as station 5 )

*Ex:

Cerebellar syndrom signs gait imp

Check for Dehydration

Pulse

Thyroid if time permits.

Station 2 ) 35 yo female known DM on insulin since 20 years presented with hypo and hyper g
lycemic attacks

And also on ocp

She waiting u in clinic to discuss her medical issue

Cover her concern and answer her Q.

_______________________________

Dm for 20 years , uncontrolled blood sugar for 3 months , using insulin , diet not change , no
extra exercise staff nurse for 15 years , dizzy attacks with fainting , needed admission recovered
after receiving fluids and sugar, high and low blood sugar readings , following insulin map , n
o skin changes ,checking blood sugar regularly sometimes high st very low , on thyroxin 500 mi
c/gm , tummy pain , started 4 months back , on/off , lasts for 2/3 days ,, no numbness no tin
gling no visual sym ,no wt loss , not driving .ask about other AI diseases , on OCP why ? As
a replacement therapy she has amenorrhoea and wants to conceive (premature ovarian failure)..

*Concern :

1 )what's going on with me ?

Ur symptoms may be due to diminished secretion of a special hormone called steroids from gla
nds located above ur kdineys mostly due to disturbance of ur defensive system. Admission , rep
lacement therapy , MDT gland and obstetrician, bracelet, steroid card , increase steroid dose if
ill .

2) what about pregnancy ?

May be ur ovarian Glands which is responsible for conception are being attacked by ur defensiv
e system , this will be cleared to us after doing some tests if came as positive will refer u to o
bstetric physicians and they can manage u accordingly.

*Dx :

autoimmune polyglandular syn

*DD :

Fainting due to Postural hypotension and hypoglycemia

*Is it safe for the pt to go home now ?

No as she may develop addisonian crisis

station 5 female patient yesterday sudden tongue swelling difficulty of breathing admitted

today u are coming to discusef with her regardung what happened

give u vital haemodynamic stable now saturation ok

________________________________

enlarged toung suddenly swallowing around eyes , no chest pain , no tummy pain , no loose
motions, first time to happen, no relation to specific diet or perfumes , no hx of asthma, FHx
nil , DM on metformin , started on glitazones 2 months bk ,HTN on ACEI since a year bk
??? house wife , not smoking , alcohol occasionally ,

*Examination :
Rashes

BP RR

Chest for wheezes

Tongue and eye swelling

*Concern :

Most probably u have a condition called HAE it's a hereditary condition causes attacks of swelli
ng and often pain in specific parts of vody including stomach , throat and face , due to deficie
ncy of a specific ptn or may be related to ur medx we need do some blood test 2 confrim dx
, u have tk stop med now and revise with ur dr.

Will admit u To make sure that ur health is good , avoid triggers like stress and trauma

*Dx:

Hereditary Angioedema

*DD:

Hereditary Angioedema.

ACEI induced Angioedema.

Hypersensitivity reaction.

*What's the deficient enzyme causing this condition?

C1 esterase inhibitor

*Inves:

C1 esterase inhibitors level during attack , c4 in between

*TTT :

Avoid triggers

Stop all recently taken medx

IV fluids , airway support maybe required

During attack : C1 INH , FFP , ecallantide

Between attack: Danazol

St2 65 yrs old male came with fatigue for the last 6 months, he has Hx of DM ,HTN ,IHD for
one yr, CBC was done &it's normal, plz see &advice

________________________________

Fatigue For the past 6 months blood test came as normal , presents all the day , no ptosis , n
o symptoms of hypothyroidism , no bleeding from anywhere, no shoulder pain , no P.Myopat
hy , DM HTN more than 10 years, heart attack 1 year back , on metformin aspirin glibenclamid
e atorvastatin lisindopril plavix bisoprolol for 1 year , , stopped smoking fot 1 year , alcohol oc
casionally , has problem in intimate relationship, going to the toilet many times at night , ask
about last HBAIC micro macro

*Concern:

impotence

Most probably related to uncontrolled DM bcz u r not following well with ur dr will refere u to
diabetes dr to revise ur med and give u proper management, diabetic nurse

*DD:

Uncontrolled DM

BB

CFS
Depression

*What's the cause of impotence here ?

Bblockers , DM

*If we considered that this patient is Wroking in an constructor office what will u advice him ?

VIT D as he is not exposing to the sun

*management :

MDT gland heart specialist DM nurse , psychiatrist, stop BB

Station 5)30 years old male presented with multiple joint pain for 2 months.. Plz consult the pt
and address the concern..

__________________________________

2 months back started with hand joints , then involved other joints , no ridness ,there's pain
and swelling , morning stiffness For 1 hour , no skin rashes, no eye problem , no ulcers ,pain i
mproves on walking, no cough , no tummy problems, no change in bowel habits, med on
paracetamol, iboprofen , no wt loss no night sweats , no PMhx , no recent travel , FHX norma
l , low back stiffness mainly , ask for any hx of urinary infection ,sexual history..

*Ex :

Hand joints
Eyes any redness

Mouth ulcers

Skin rashes

Chest and heart exami

Back and neck

*Concern :

What's going on with me ?

As , related to over immune system

*Dx :

Seronegative arthropathy most probably ankylosing

*DD :

Ankylosing spondylitis

Psoriatic with ankylosing pattern

Enteropathic

Reactive arthritis

*Inves :

CBC UE ESR CRP ANA hand xray , lumbar spine XRay HLB 27 MRI sacroiliac joint if xray came
as normal

*Management :

NSAID if no impo DMARS and biological

Non pharmacological PT PE PC OT
St 2 ; 19 year old was been diagnosed as bronchial asthma.. Referred to u with history of recur
rent chest infections admitted 5 times last year... Take history and manage the concerns

____________________________

3 years well controlled on inhaler, last 3 years symptoms getting worse and had recurrent ches
t infection , using the blue one only , recieved one course of steroids for 7 days last year , ha
d chest infections 5 times last year needed hospital admission , no ICU admission, cough , so
metimes have got fever ,large amount of phlegm, yellowish ,a sample found pseudomonas , n
oisy chest , no chest pain, No LL swelling, there's abd bloating , loose motions,

PMHX , surgeries, blood transfusion , FHX all non significant, not smoking , not drinking alcoh
ol, no pets at home , wt not increasing, not having kids dr did test to semen came as abnor
mal ,

*Concern :

What's going on with me?

Could be related to a problem called primary ciliary dyskinesia this problem can run in famliy n
eed to do more test to confrim , will arrange another , infrom MTD involving chest , bowel an
d gland dr

*Dx :

Bronchiatsis

*DD :

PCD

Kartagner

Cystic fibrosis

CVID

Bronchiatasis
What about loose motions ?

Related to cystic fibrosis and CVID

*Inves :

CBC CRP ESR CXR CT chest (signet ring and cysts) sputum study LFT ABG immunoglobulins gen
etic test sweat test saccharine ciliary motility test

*Management :

PE PC PT MDT chest dr gland dr

AB for exacerbation BD

according to the underlying cause

st4)You are registrar of cardiology team and your patient is 71 year old male with STEMI & had
two DE stents last night, starts having new headache. Brain imaging shows there is intra paren
chymal bleeding with mass effect and possibly on a background of space occupying lesion very
suggestive of brain tumour. His daughter is very concerned about the complex situation told to
her by your house officer and wants to discuss further.

______________________________

*Confirm identity of relative

*Anybody else to join our meeting

*Next of kin ?

*What do u know abt ur father's condition ?

He had Chest pain suddenly then I called the ambulance immediately , he was taken to hospital
and there drs told me that my father had Heart attack , stent and Angiogram done for him,
then he deteriorated and became confused more and more and now he is unconscious , some
head scans done to him of I want to know the results.
*U r very right to be upset , but i want to know when the drs told ur father about Angiograph
y did they explain to him what they are going to do ?

yes there was some talk to my father

I will Tell u what happened , usually when we r donig this procedure we r telling the pt what
we r going to do unfortunately ur father's condition deteriorated then we did scan of his head
and showed some blood in the brain

*What's going on dr ? Is it bad ?

Probably ur father was infromed by drs that after stent we are using blood thinning medx and
they can cause bleeding in the brain , and this is not always happening in all patients but unfo
rtunately happened in ur father's case.

*Why y r so careless dr ?

I understand ur feelings if u allow me to explain the situation to u , ur father came in a vey cri
tical situation and every single step was taken in ur father's best interest and actually this is th
e protocol blood thinning is given to prevent clots and heart attack which is in ur father's ben
efits , there are some side effects of this med as it can cause bleeding into brain , That's why
am asking u what's ur father had been told before proceeding further to stent , in such situatio
ns we r taking conset from the patient after explaining everything to him , i can go back to se
e the notes and to check whether his consent was taken or not.

*Did ur father comp of any headache in the past , visual problem , diagnosed of any medical c
ondition ?

Yes dm HtN

*Does he have Growth in the brain?

as we did head scan and it revealed that he has growth in his brain and this put him in a risk
to bleed after receiving blood thinning med

*Is it a Bad growth dr ?

I can't tell this growth is bad or not , we need to do further tests and invest to figure out is i
t CA or not

We r not sure now but in the scan it looks like a growth , but we need to do more tests to
know what type of grow it is.

*How u going to manage?

Am sorry to tell u that Ur father is not in a good condition just i want to know any advance d
irective ? did he ever spoke about artificial breathing ?

No dr we r not prepared for this , is he in a critical situation? Will he die ?

This is the thing we need to decide now as it might happen at any time his heart may stop t
herefore we may need to do chest compression, we r going to call brain surgery drs they are
the one to tell u the prognosis, but yes as far as i know what can i tell u that ur father may
die.

*what about the blood thinning med dr ?

Once we saw bleeding in his scan we stopped the medx , will arrange meeting with heart brai
n drs to decide whether to continue or stop.

*What's ur Task ?

Breaking bad now

Explain about bad prognosis why these things happened

*Ethical :

Autnomy: next of kin has the right to know every detail of his father condition why his conditio
n deteriorated.

Justice
Beneficence not to harm , blood thinning given in the best interest

Non maleficence

*What may be the cause of brain bleeding here?

Brain tumor makes father more susceptible to bleed with blood thinner medx , some brain tum
ors can bleed by itself without any blood thinner medx ,, HTN , 3 possibilities here

*Is it Case of negligence or medical error ?

As i told u from history nobody knows that the pt is having growth in his brain and blood thin
ning med given in the best interest of the patient.

*will u stop blood thinning? it's a difficult decision should be done through MDT to decide wh
ether to stop or consume .

*DVT ?

pneumatics compr device , ICV filter if patient has DVT

*If u knew about brain tumor before giving bld thinner will it make any difference in ur manag
ement plan?

Probably will not differ , we should sit with the pt to discuss pros and cons of blood thinning a
nd what will happen if not given , if pt signed high risk consent after explaining pros and con
s management will not differ

We may not do thrombolysis and just offer double anti platelet medx
Station 5 )65 /m with history of back pain for 10 years presented with shortness of breath for
last 3 months . Kindly see the Patient and address his concerns

______________________________

Difficulty in breathing for the past 3 months , started gradually, more on exertion, progressing
, no chest pain , no cough , no LL swelling, taking NSAID occasionally, any inves done to ur b
ack pain in the past ? I forgot the name of the condition, no history of HTN or DM , not sm
oking, not drinking alcohol , retired, ask about back pain site , stiffness, complication of AS
heal pain eye problem palpitation

*Examination :

End insp crackles , fixed crackles (fibrosis but it was basal not apical)

Heart exm normal LL for edema

Back and neck movement

*Concern:

What'sthe cause of this SOB ? Related to a condition called AS will invest u and do imaging to
ur chest refer u the chest physician

*Dx:

Ankylosing spondylitis complicated by lung fibrosis.

*Investigation :

CBC ESR CRP RFT LFT UE CXR

PFT HRCT ABG

*management :

PE PC PT chest referral

Station 5 ) 40 /female presented with weight gain , hypertension and in prediabetic range . She
had been treated for the skin condition previously . Kindly see the Patient and address her co
ncerns

_____________________________
I have been diagnosed with skin disease 6 months ago , but i have been gaining wt , BP is hig
h and high blood sugar , what type of skin condition u have ?, not really sure about the name
, had blisters over my hands inside my mouth also , difficulty in getting up from chair , no diz
ziness , gained 6 kg , thin skin , PMHx not significant, not smoker, occasionally alcohol , ask
about CTS , O.arthritis, OSA in any wt gain.

*Exm:

BP

Black Pigmentaion

Interscapular Pad of fat

Shoulders for PM

Cataract

Abd Striae

Acanthosis nigr

*Dx :

Cushing disease

*Skin condition :

Pemphigus

*Will stop steroids?

No we have to taper it off, as pt can develop adrenal crisis

*Concern :
Condition related to medx u take called cushing disease ,this med causes increase in hormone l
evel causing wt gain , will do inves and will refer to gland dr , skin dr to replace it with other
type of med

*will it revcover?

Yes will recover after tapering steroids.

*TTT:

Tapering steroids skin specialist may Use steroids sparing drugs

HTN ttt , dietitian referral and excersie monitor his blood sugar

*DD

Polycystic ovary

Pseudo cushing

*inves:

24 hr urinary cortisol

Overnight dexa supp test

60 /male with weight loss, fatigue and dysphagia for 3 months . He was investigated for dyspha
gia and it has shown hiatus hernia . He has past history of melanoma removed 2 years back s
urgically . His ESR is 54 mm in 1st hour . Please take history and address his concerns .

__________________________________

Difficult in chewing, un intentional wt loss , no change in diet , headache for the last 3 month
s , diffused headache mostly on rt , pain and stiffness in shoulder mostly in the morning, no s
ymptoms of P.Myopathy , no fever , no night sweats , no joint pain , thigh ms pain , no SOB
no cough , water work fine , no weakness , pmhx melanoma 2 years back , surgeries only mela
noma resection, not on med , fhx fine , not smoker , alcohol occasionally only , mood ok , no
visual problem , apetite good ,

*Concern :
Could be due to recurrence of my ca ?ur symptoms are not related to ur skin cancer , u have
condition called PMR it's some sort of inflammation of blood vessels supplying ur head and ms
however will role out any possibility of recurrence , is it dangerous? Yes If not ttt,

*Dx :

PMR with GCA

Recurrence of melanoma

*Inves:

CBC CRP ESR biopsy from temporal artery .u/s abdomen LFT RFT , Dexa

*TTT:

Oral steroids with PPI ,dexa scan Ca and ViTD , medic alert bracelet , double the dose in case
of infection , refer to rheumatological and opthalmic dr

(No need for admission as there's no visual problem)

Bcc 1 young 30 year female with known case of dm on treatment came with frequent attack of
hypoglycemic unawareness

_______________________________
Am diabetic for the last 20 years am not aware of my hypoglycaemic attacks , my blood sugar
was checked during these attacks and was very low ,happened 2 times in the last 6 month , lo
st my consciousness , any change in ur doses or medication u r using ? Am taking regulary am
following my dr's instruction , what medx u r on ? am from the start on insulin , any recent s
urgery? No , any weakness of any part , no , any Numbness tingling no , dizziness when sta
nding up from setting position no, no chest pain , no tummy pain , not feeling sick, water wor
k fine , how is ur blood sugar control , is quite fine my recebt HBA1c within the normal range,
last checked 3 months ago , on mixtard insulin , fluoxetine , why u r taking fluoxetine? my
dr diagnosed me with anxiety disorders, do u drink alchol? Yes , 3_4 units /day , did u ever t
hink to quit this alcohol ? What's ur

*concern ?

Why I had these attacks?

U r taking fluoxetine and at the same time ur using alcohol , drinking alcohol along with this
med can cause unawareness of low blood sugar, if u cut down ur alcohol intake ur condition
will improve.

*Diagnosis:

Unawareness of hypoglycemia, due to large amount of alcohol consumption

fluoxetine

Autonomy neuropathy addison , very tight contol of blood sugar

*Ex :

Skin Pigmentaion

BP standing and setting

*Management :

MDT approach, psychology support refere to acohol rehab , tell the pt it's better to talk with p
pl u r living with so if this happened again they will be aware and give u candies , take candie
s all the time in ur bocket , bracelet, diabetic nurse appointment

Bcc2 55 year male with history of HTN came with early morning headache

_________________________________

when i get up in the morning i feel that am not fresh, started 6 months bk , on daily basis,
headache all around head , low mood fatigue, any , i fell asleep while watching TV , had one c
ar accident before , snoring, no increase in body wt , no apetite change , no change in ring or
shoe size , no hot ot cold intolerance , no constipation or loose motion , pmhx HTN for the l
ast 10 years on enalapril controlled , fhx father is diabetic mother Hypertensive , work as sal
e man , smoker , i will refer u to smoking cessation clinc ? Drinking alcohol occasionally,

*Ex:

Pulse BP

Heart pHTN

Visual acuity

Visual field normal

I want to check collar size

Look at the tonsils

*Concern :

Why i have thia headache and fatigue?

U have disease called OSA this most likely related to ur body wt , this is one of the cause of
early morning headache and fatigue , smoking also will make ur BP uncontrolled and may affe
ct ur condition as well

Stop driving at the moment

*Dx:

Osa

*Inves:

Overnight oxymetry , polysomnography, sleep study

Epworh sleep scale

*management :

Non pharm

Stop smoking reduce body wt refer to dietitian involve him in excersie program , Cpap

Pharma

Modafanil

Station 2

Tiredness and abdominal pain not anaemic

__________________________

Pain not localised to any particular area generalised and vague , No GIT symptoms other than
recent constipation , mild back pain , no symptoms suggesting hypothyroidism , hx of breat CA
5 years ago completely ttt , no lumps or pumps , fhx father died of colon CA , not on any me
dx , no change in water work , no mood change.

*Diagnosis :

Hypercalcaemia (recurrence of breast CA )

*DD :
MM patient is not anaemia so MM less likely

Hypothyroidism

*Management :

Admission iv fluid bisphosphonate

*Concern :

What's going on with me?

Am worried u might have high ca level i have to role out any possibility of CA , will do some i
nves to ensure u r ok before discharge u .

*If this pt found to have Hypercalcaemia will it be related to breast ca or colon ca ?

I want to role out breat ca recurrence first because the chance of having hereditary colon Ca is
much lower as the age of diagnosis of colon ca of her father is 80.

st4)Young age male k/c/o Bronchial ashtma recently been uncontrolled and had recent admissio
n for exacerbation of his asthma adress his concern and talk about benefits of steroids

___________________________
*Why my ashtma is not controlled at the moment ?

When diagnosis of BA was made ? who diagnosed u ? diagnosed with blow test ? what ttt u a
re on now ? He is on blue inhaler , ask about triggers like infection, change in housing , smo
king pets job , medx

Will refere u to Asthma nurse she is very specialised in this conditions, will arrange further app
ointment to figure out what could be the cause of ur recent exacerbation , we want to introduc
e a preventive medx called steroid , (refused by the patient) , ask about reasons of refusal , ha
d a bad experience before with oral steroids , try to convince him by explaining that this med
has a different route of administration it's an inhaled one and targeted to the lung with very mi
nimal systemic absorption and therefore very minimal side effects , Spacer and gurgling will mini
mise side effects .

*Concern:

Will my children have BA?

asthma not hereditary but ur children might be more susceptible to have asthma but there is n
o direct hereditary connection .

*Management plan :

Regular meetings , refere to asthma nurse

*Ethical issues :

Autonomy

Beneficence

Non maleficence : spacer and gurgling to minimise side effects of inhaled steroids.

Justice
*What would u advise the patient to do to know the cause of exacerbation?

Asthma diary

50yrold Hypertensive Mr Albert referred by his gp for evaluation of deranged LFTs.

Plz evaluate n address concerns

_______________________________

St5 )No yellowish dis of eyes or skin, discovered on routine inves , year back there were a bit
on the upper side , no itching, no change in water work no change in bowel work , Hyperte
nsive well controlled and diabetic not well controlled for 7 years and high cholesterol , overwei
ght, knee pain , no heart problem no chest pain , alcoholic, smoker , fhx not significant, ere
ctile dysfunction, on statin for 2 years ramipril , oral hypoglycemic med , ask about risk factors
of hep B and C .

*Concern :

Is it something serious?

Very early to answer this question , as long as u have no symptoms , deranged lFT can be rela
ted to fat deposition in ur liver causes enlarged liver and deranged liver function , also could
be related to acohol or statin , will need to do blood test and imaging , refer u to dietitian ,
quit smoking excersie healthy diet , right now stop statin .

*Exm:

Check for stigamata of chronic liver disease,

Parotid enlargement, dupy contarx for alcohol

Palpape liver

*DD:

Fatty live disease

Alcohol

Statin

Haemochromatosis

*Why suspect haemochromatosis?

Deranged LFT erectile dysfunction and knee pain

*Management

Alcohol cessation

INR albumin hep B C serology anti mitochondrial AB auto liver US

St5)65y has psoriatic arthritis on treatment that had been changed recently 2 weeks back

Presented with nausea vomiting n diarrhea. Vitals are ok. Plz see n advice

________________________________

Started 2 weeks back , suddenly, opening bowel 6 times /day , got sick twice ,is it difficult to
be flushed ? No (Pancreatitis excluded), no fever , didn't eat from outside , no blood in stools ,
k/c/o psoriasis for 10 years was on methotrexate but few months back his psoriasis was getting
worse , try to explore the triggering factors for this ? Increased smoking rate , his dr shifted hi
m to azathioprine , recieving some pain killers , no history of fever , diarrhoea appeared few da
ys after starting azathioprine, businessman, affection of job , smoker 10 cigarettes /day for the
last 10 years , alcohol 6 units /week , he is single, living with family, no eye redness no neck
pain , ask about other side effects of azathioprine in terms of anaemia symptoms, recurrent i
nfection any yellowish dis for hepatitis.
*Examination:

Abdomen exm

No abd tenderness

Typical psoriasis rashes , purpuric rash over legs and arms , no joint swelling

Look for Azathioprine toxicity signs , eyes throat

Asses volume state

Vital signs

*Concern

Most probably this diarrhoea related to the new med will carry some blood works

Regarding psoriasis stop smoking refer to smoking cessation clinic

Will give u some medx for loose motions and tummy pain

Stop this medx refer to the joint dr to to give alternative medx

will check for Blood count according to the result will decide whether to admit u or not

*Diagnosis :

Azathiprine side effects

Azathioprine toxicity

Opportunistic infection on top of neutropenia caused by Azathiprine

Simple GE

*Management :

Stop azathioprine

Diarrhoea stool analysis and C/S , correction of any electrolyte imabalance

CBC

smoking cessation clinic referral.

St5)57 y has palpitation after drinking 6 glasses of wine. Vital signs and ECG are normal.

Plz see n advise.

______________________________
Had been started 6 months back , frequent attacks of palpitation , occur suddenly, lasts for ma
ybe few minutes maximally one hour ,feel it irregular terminating by its own, associated with c
hest pain , many investigations done in the from of ECG echo holter , have u ever been diagn
osed with a condition called AF? Yes dr .. no dizziness at the time of episodes, no wt loss ,
no hot intolerance, no hand tremors, no loose motions , medx felcainide 50 mg twice revarox
20 mg twice daily atorvastatin ARBs metformin , GP told me i had a problem with cholesterol
and BP ,drinking alcohol 40 units /week , compliant with his medx , smoker , fhx no sudden
heart death in family , job affection .

*concern :

Is it related to alchol as the GP told me ?

Could be related to large amounts of alchol u r taking also could be related to high BP , Diab
etes, smoking and high cholesterol

*Investigation :

Repeat some blood works , ECG , Echo why ? To r/o regional wall motion abnormality (IHD), EF
, R/o alcohol induced cardiomyopathy

*Ex :

Pulse is regular 80/min

BP

Heart examination normal

*DD :

Paroxysmal AF precipitated by alcohol or related to his other risk factors in terms of HTN , ob
esity , DM and high cholesterol

*Management :

Non pharmacological :

control other risk factors (BP , cholesterol etc)

MDT alcohol society grp to cut down his alcohol.

No need for admission

*Do u think that flecainide is working ?

Yes and recurrence of sympt is due to large amount of alcohol he is taking.

*Wht if alcohol stopped and symptoms not controlled on medx ?

Cardiologt Referral for ablation

*other cardiac side effects related to alcohol ?

St5)65 yrs old male came c/o fever for 1 day it's 39 °c plz see &advice

_____________________________

Started last night recieved paracetamol but came again had 3 episodes of fever , no wt loss ,
no fatigue,, no cough , no skin rashes , no joint pain , no pain during water work , no tumm
y pain , pmhx RA , pt on NSAID and adilizumab started 2 weeks ago , no hx of TB or contact
with TB patient , no insect bite , no recent travel , married, no extra marital relationships , FHx
not significant , retired,

*Concern :

What's going on with me ?

Ex: ???

*Diagnosis:

Neutropenia sepsis due to adilimumab

*management plan :
CBC RFT LFT full septic screen analgesia ab fluids

Admission

Stop med

Revise with joint dr to replace with another

Start ABs 4th generation cephalosporin

Isolation if neuro less than 0.5

GSF

Analgesia

Fluids

*Investigation :

CBC RFT LFT full septic screen analgesia ab fluids

st2)40 Yrs lady with multiple visits with sob and wheeze, smoker. GP found wheeze at examinati
on And no DVT. Please see and advice

_______________________________

*analysis of the complain :

Symptoms started 6 months ago , increasing, SOB increased during winter , having noisy chest
, i think symptoms are getting worse at the night , walking up at the night searching for air ,lyi
ng down on single pillow, no LL swelling , recently had a pet at home 6 month ago and noti
ced that symptoms were getting worse ,no heart burn or acid brush , cough is dry most of the
time sometimes associated with white phlegm, no haemoptysis , recieved some ABx 6 month
ago for single episode of chest infection , no skin rash no joint pain , , no chest pain , no fe
ver , but 6 month ago had one episode of fever ,no history of atopy or eczema , smoker 10
cigarette /day , better to stop smoking as it can worsen ur condition will refer to smoking cess
ation clinic , no recent travel , pmhx not significant, FHx mother had heart problem , drugs usi
ng blue inhalers occasionally, working at office , affecting my work and can't go for exercise e
arly morning, no hx of exposure to any irritants at work , drink alcohol occasionally,
*concern :

Is it a heart problem ?

U look quite concerned about heart problem may i know why ?

*Diagnosis :

COPD

As patient is having Chest tightness smoker for prolonged time. She is having progressive SOB
, age of the patient

*DD:

Adult onset asthma

Copd

GERD

*Investigation :

CBC ESR CRP LFT alfha 1 anty

Initial inves :PFT CXR bed side spirometry PEFR

*management :

Non pharm

Education

PT

OT

Social support

Smoking cessation
Avoid triggering factors

LTOT

Pharma

Low dose Bd

How to differentiate between asthma and COPD :

by PFT PEFR improved by more than 20 % this goes with asthma

St4)COPD breathless on mild excersie,chronic smoker talk to him about smoking cessation, an
d LTOT

______________________

*Ask about onset of symptoms

*Check understanding

*smoking history

*daily activity affection

*explain nature of disease and its close relation to smoking ,

*is it serious? If u follow some rules u will feel better

*will i recover from my illness ? It will not be completely recoverable, if u stopped smoking and
took med regularly u will be ok

*chest physiotherapy

*with home u are living ? Are they helping u ?

*do u need any other support from social worker ?

*role of social worker

*u have to stop smoking to prevent further progression but damage already happened will not
be reserved

*LTOT will improve difficulty breathing but u have to stop smoking first

*explain LTOT oxygen cylinder for 15 hours /day

*if u stopped smoking will do some inves

*flying : need to evaluate u , paO2 should be maintained more than 90

*smoking cessation centre,

*smoking side effects ,

*concent for LTOT

Ethical issue

Autonomy

Beneficence

Non maleficence

Conset

*indication of LTOT

*Safety precautions u will take at home : well ventilated room , O2 concentration machine safer
no smoking while using LTOT , no cleaning detergent or oil emollient while using LTOT fire alar
ms ensure they are working

Station 2

35y male was treated for anxiety n panic attacks for few years by diazepam. Recently, presented
with palpitation and accidentally is found to have glycosuria n high blood pressure. Plz see an
d advise

______________________________

5 years anxious, can't sleep well , psychiatrist diagnosed my condition as anxiety disorder and
put me on ttt diazepam and was ok , stopped medx bcz it's not working like b4 , went back t
o GP and did some inves found that i have high BP and glucose in urine ,

Anxiety comes in attacks , heart racing during this attacks, sweating , no hand shaking during t
his attack , headache occasionally, no wt change , good apetite, no lose motion , no tummy p
ain , no constipation, no fever no fatigue , father died from Cancer , no polyuria and ploydepsi
a, no history of dizziness or syncope , no history of heart problem , social history to explore
more about stressful factors
_________________________

*cause of glycosuria?

I think he wants to hear that during anxiety attack glycosuria could be found secondary to high
catechlamine but not because of pheo

*what type of cancer u assume that father died from ?

*DD:

Anxiety disorder (reassure him most probably bcz u r not compliant to diazepam ) , pheochro
mocytoma, thyrotoxicosis, valvular heart disease (MVP)😃

*diagnosis :

MVP

*Inves

*TTT

Station 2 : history taking

U are meeting daughter of 71 ys old man with lethargy amd confusion and admitted today to
hospital and ct brain : brain atrophy

Labs : Na 155 , k : N , creat 1.7 urea : 120

take history from daughter and answer her concerns

_________________________________

He was severely tired and confused since yesterday , first time to happen , before that he was
mentally ok , depression for the last 10 years , not suffering from any medical condition , on lit
hium, for 2 years , no headache, no dizziness, not aware of ppl and place , no jerky movem
ent, no speech problem no weakness , no chest pain , no SOB , no cough , no fever , bowel
work ok , no tummy pain , no change in water work , no rashes, no joiny pain , apetite good
,no wt loss no lumps or pumps , non significant pmhx , family history non significant, no tra
vels recently, non smoker , 20 units of alcohol /week , didn't drink alcohol since yesterday , he
had GE 4 days before confusion, lithium toxicity symptoms : specifically about polyuria and plo
ydepsia for neprhogenic DI and volume , ask about tremors , ask about thyroid gland symptom
s hypothyroidism

*concern:

Will recover ?

Yes will rehydrate him and check his drug level

*DD:

lithium toxicity, Nephrogenic DI , infection mainly meningitis and SDH.

*Why NA is high ?

Dehydration due to GE , nephrogenic DI

*TTT:

Stop lithium , thiazides , hydration , NAHCO3 , dialysis if not responding

*social care services as patient is living alone

St4) 66 years lady brought to hospital in confused state and was admitted as acute kidney injur
y and UTI. she was brought by her EX-HUSBAND who claimed that he is the only care taker an
d there is none else to take care for her.

Now the patient's son who apparently lives away has come to hospital and he is annoyed why
he was not informed (as being Next of kin and why his father (who left them when they neede
d him the most) is around his mother. He said that he is Next of kin and he should be the on
e deciding about his mother health and whatever to be done to her will be with his approval.
He did not have LPA/advance directives.

Examiner asked : what are the legal rights of Next of kin.

In the situation when it is not clear who is next of kin then from where can we get information
about next of kin.

_______________________________

*Check previous hospital file usually next of kin is registered and contact her GP to know next
of health.

*Legal right : take decision on behalf of the patient

*if he suspect that father is responsible for her bad health what to do?

Her condition can be explained by pug in water work and ur father is not responsible of her c
urrent disease.

*ethical ;

Beneficence and nonmal justice

*Legal issues :

Advanced directive and LPA should be clarified , local GP should be contacted to get informati
on about next of kin
*who's going to take care of her when she go back home?

After improvement : we will judge about her capacity again if she is found to be competent so
she will be the one who decide about herself

*am very sorry that we couldn't contact u bcz we don't have any previous idea about this issue
,we relied on information from the available person she was in critical condition and not able t
o communicate.

*did she nominated ur father in any paper ?

*legally divorced partner no more next of kin

*her condition can be explained by pug in water work will ttt her and she likely to imrpove will
involve my consultant an will tell u regarding every update arrange other meeting with u take
hospital legal advice and then can solve the matter of next of kin

*apply court of protection to take decision on behalf of her

*we appreciate that ur father bought her into hospital

*don't confront with the surrogate Be diplomatic .

St 4 scenario : Mr jack 55 years old came to the emergency 4 days ago after episode of vomit
ing and heamatemisis . He had been managed and today he is in stable condition and had hi
s breakfast. The medical team had done for him endoscopy and they highly suspicious that it's
gastric cancer and waiting for biopsy result . The medical team also request for Mr.jack CT scan
chest and abdomen for staging of cancer. Your task. Explain to Mr.jack endoscopy finding and
the explain the need of CT abdomen and chest for staging. Highly suspected cancer stomach b
y endoscopy after haematemisis Need to do CT chest and abdomen for staging. Task explain e
ndoscopy result and the need to do CT Chest and abdomen .

________________________________
Not 100% cancer , uncertain diagnosis ,

*Explain need of endoscopy

*Furthet CT before results of endoscopy are out as complimentary to diagnosis will add further i
nformation we are not sure that's cancer , pros cons if positive and negative.

*both of them will help us to reach diagnosis may CT show something else.

this case came before for candidate who got 16 &answered that by doing this scan we safe tim
e for treatment to start as soon as possible bcoz the lesion showing high susceptibility to be ca
ncer ,that's Y doctors request it to be done

If asked why u want to do CT scan before knowing biopsy results?

I really appreciate your concern but the team thinks that its in your best interest. I can give yo
u some time to think over and can help you with some web addresses as well, will arrange an
other meeting today evening 😃.

1.difficulty in walking

________________________
Started by Numbness in legs , progressive, both legs , which part ? Below kness , any similar
problem in arms ? Yes sometimes but no weakness , no visual problem , no headache, this is fi
rst time , no skin rashes , no smoking no alchol , any chronic illnesses lik Dm no , any medx n
o , no fhx , exm power reflex normal, fine touch and temperature are there but vibration and
joint position lost , romberg sign positive, examine the back , hands, cerbellar symptoms , fun
dus normal , diet strict vegetarian , job , surgery, TB medx exposure ،metformin

DD

Vit b12

Pernicious anaemia, heavy metals

All causes of p.neuropathy

St5)40 yrs old male presented with sudden loss of vision in right eye one week back.he went to
opthalmologist for check up and found to have central retinal artery obstruction.opthalmologist
refer to you for evaluation and answer patient concern if any. You are working as med reg in
out patient medical clinic.

______________________

Sle , vasculitis, DM HTN , headache , fhx of clots ,

Ex pulse heart digital ulceration fundoscopy

Vision will be back ?

Unfortunately it doesn't have very good outcome

DD AF
Referral tp cardio and DVLA

Causes?

Embolic hypercoagu atherosclerosis vasculitis

St2)30 years old male with dark urine

Vitals are normal

Take history and focused examination and manage pt concetn

__________________

Dark urine for 4 months

Color ? Dsrk red or dark urine ? Timing ? Frequency ? First episode , almost daily , no swelli
ng in body parts , no blood just dark urine , no joint pain no rashes , relation to excersie, tu
mmy pain centre in attacks , any bleeding, any fever any cough , no change in water work , n
o wt loss , no recurrent infections, no infection in private area , no fhx , PMHx stroke 6 month
back , drug : blood thinning medication, any regular checking to INR , last INR , any other me
dx ,

Exam

pulse pallor bp moth , kidnyes bladder palpation ,

Concern : is it CA ? Renal cardiac neurological referral

Do i need some blood transfusion?

I will look for blood test for HB level then i will be in a better place to answer ur q

DD
paroxysmal natural h

Bleeding due to overuse

Vasculitis

Inves

Cbc inr anca crp esr LDH reticulocytosis haptoglobin

24 urine analysis

24 urine albumin

Creatinine ratio

Kidney abdomen us

Flow cytomerty ab against cd55 cd59

Ttt of PNH

Eculizumab

st5)25 years old male presented with back pain and difficulty in walking from 1 year

______________________________

One year back , no radiation, both knees , fingers of hands , feet pain , no rashes , no chang
es in bowel habits , no Fhx , no trauma , achilis pain , no pain on moving neck , no chest or
heart racing , tenderness in back , long fingers tall man ,

DD

Marfan with ankylosing

Ocular iridondensis respiration for apical fibrosos cardio block AR bounding collapsing pulse bac
k and neck signs of marfan
St 5 ; You are doctor in AMU. Please see Ms Smith who has presented with headache since m
orning

____________________________

Neck stiffness, any contact with sick patient , pmhx of migraine but this headache is different,
no PKD fh , APLS and OCP ,

Sah , CVT , GCA , pain reaches severity in one hour

Vital signs , eyes examination;, kerning sign , rashes no , abdomen for PKD , power ,

Sensitivity of CT brain ?more than 94

LP

Admission

What xanthochromia

st5)35 ys of age. He has presented with joint pains

_____________________________

Lt knee lt ankle , 4 wks back , no fever no hand pain , through out the day , morning stiffness
, no rashes , soreness in private area , travel history

DD seronegative enteropathic, reactive , behcet

U/s joint , tap if fluid , ESR CRP

WBC

St5)Fatigue 55 female

________

Disturbed sleep , no pmhx , no medx , no surgical,episodic headache generalised, no wt chang

e , hot intolerance, heart racing , depressed, dx :menopause DD thyroid anxiety , menapause
, pheochromocytoma

________________________________

Ca in diet if not sufficient add ca and vit D

Excersie, counselling

St5)35 yr old man presents with fatigue cr increased ,two plus protein and one plus for bloo d

Dx

Wegner DD pulmonary renal syndrw

40 y.o Known case of PMR p/w blurring of vision

_____________________________

A day back developed sudden loss of vision on the right side , last for 2_3 mins , no hx of si
milar episodes , no eye pain , no gritty eye sensation, no change in night vision, no change i
n color vision , bo double vision, headache at the end of the day , generalised headache, relie
ved after cup of coffee, no limb weakness , no speech disturbance , diabetic for last 10 years
HTN , BP controlled, blood sugar 1.8 fasting , affection of daily activities , ask how much PMR
is controlled are u taking steroids, went to any dr recently ?

Stop Driving and inform DVLA

___________________________

*Diagnosis

TIA

*Ex

Acuity : ok

Eye movement : ok

Field : ok

Fundoscopy : normal

Pulse :

Carotid:
Heart auscultation:

*Concern :

Will come back again ?

Yes am afraid that might occur again

*DD

Amourosis fugax

Temporal arteritis

*Do u think it's related to GCA?

Not likely as this patient is not having headache or scalp tenderness but still one of the possibil
ities ??

*Inves :

Routine inves , Vasculitis work up , ECHO , carotid doppler , MRI brain , 24 holter

25years old femal c/o skin redness

Skin redness for that last 4.mont , painful, sometimes itchy , happened 3 months ago lasted fo
r 2days and resolved by itself , after 1 month of this attack happened again lasted for 2 days
and resolved again , last 2 weeks started to have blistering skin lesion on forearms but at the
moment i don't have redness like that i had before , no oral cavity affection, no private area l
esions, blisters are not painful, easy rupture, taking doxycyclin for 6 months for acne , relation
to sun exposure, impact on job , no join pain , no hair fall , no change in bowel work , sex
ual history , no fever no cough, developed rash after eating fish (misleading) , mother had brea
t ca and she has skin lesions as well but not sure if they are

______________________________

*Concern :
Am working as a model and this skin rashes affecting my job alot is it treatable or not ?

Most probably related to medx stop it now and will involve dermatologist

*diagnosis :

Drug induced lupus

*DD:

pct

Pemphigoid

Drug induced

*inves:

Specific test if drug induced :

Antihistone AB , ANA , dsdna , eosinophilia

30 yr old man present with pain in knee joint

_______________________________
Got pain in right knee for 1 week , severe pain , started suddnely, associated with swelling , n
o other joint pain , no back pain no neck pain , fever for last 3 days , hx of trauma to rt knee
, inury was very mild , any redness not sure , not happened before , brother has same proble
m , no history of bleeding problem , sometimes i have gum bleeding , not having any medical
health problem , taking aspirin , family hx , driver and can't drive now bcz of pain , sexual hist
ory , bowel habits, urinary changes , social history , travel history , mouth sores , rash , any pr
oblem with big toe .

_________________

*Diagnosis:

Haemoarthrosis

*DD:

Haemoarthrosis

Septic arthritis

Gouty arthi

Inflammatory arthritis

*Ex :

Eye anaemia

ask for vital chart

Skin for any bleeding manifestation

Knee examination : red hot effusion evident by patellar tap (shouldn't be done in pain)

Check other knee joint

*concern :

Am going to be disabled?

Most of patient with this condition have a normal healthy life

* joint scan routine inves , aspiration contraindicated in case of haemoarthrosis ????, refer to he
alth care worker , avoid any kind of trauma , stop aspirin refer to cardiology , antibiotics,

St4)30 years old female diagnosed with RA .

She was planned to be started on methotrexate

The patient is relactant to start the treatment

Please see this patient and discuss with her the need to start the methotrexate, safety profile

______________________________

I don know why they referred me to u ? They gave me a strong medx for pain but right now
i don't have any pain as it is well controlled on paracetamol so i don't know the reason for pr
escribing this medx

*check how much she knows abt her condition

*explain condition in details. Your Condition is due to disturbance in your defensive system, chro
nic and multisystemic disease can affect many organs in ur body. We don't know the reason of
this condition as there are multiple factors contribute to it .It's a long standing disease unfortun
ately it's a progressive disease in some cases it can cause disability. there are studies saying tha
t this medx can stop progression of the disease which if not controlled with this drug unfortun
ately can end up with disability.
*dr am happy with my medx at the moment i've read alot abt and am aware of all side effects
that can happen that's why i don't want to be started on this medxany medx has its own side
effects but in ur case beneifts outweigh risks it was prescribed by consultant in the best interes
t of ur case and the sooner u start the drug the better outcome ,

*am planning to be pregnant soon i read that this medx is harmful for baby and can affect hi
m that's why i don't want to start on this med

Every single medx has some side effects will refer u to obs and joint dr whenever u r planning
to get pregnant u should stop it for 3 month will refer u to mdt

*my aunt has RA arthritis and she is on methotrexate

*explore side effects of methotrexate

*what kind of precautions that i need to follow ?

Once a week injection will be prescribed with folic acid injections to protext ur bone marrow ,
this medication can affect wbc , before we start it we need to have a baseline of ur blood cells
level , if u developed any sore throat or infection u have to come to the emergency departme
nt and tell them about ur conditions and ttt u r taking , LFT need to be monitored and will do
some blood test to know the baseline before starting this medx

*Social history affection of job and life , occupational health care worker referral if job affected

*we can arrange another meeting with ur future husband we can discuss more about methotrex
ate

*F.history
*Ethical issue

Autonomy

Beneficence

Non maleficence explaib the side effects and what to do if developed one of the side effects
St4)Marathon runner dehydrated, he is taking frequent NSAID , p/w AKI talk to him about dial
ysis he has high K

______________________________

*How do u feel now?

*Do u want anyone to attend this meeting with u

*How much u know about ur condition?

They brought me here after falling down in marathon race , I recieved ttt and now feeling well
i want to go back home dr .

*unfortunately ur kidneys now are not functioning because of multiple factors in terms of dehyd
ration, medication u are taking and running also injured ur kidney

*Try to convice him on dialysis

We have to shift to another type of ttt will refer u to kidney dr , they may need to filter ur bl
ood through a device connected to ur tummy to work like a kidney , talk to the patient in de
tails about side effects of dialysis

*No i want to go home

Why u want to go home ?

My wife and kids are alone now am the one who is driving them to school .

We can arrange another meeting with ur wife and will involve our consultant and kidney dr as
well. Dicuss complications that may happen if dialysis not done.
*Social history

*If i agreed on recieving dailysis what u will do ?

Will call kdiney dr to come now to answer all questions that u may yave and start ttt as soon
as possible

*stop NSAID now and can affect ur kindey in future , ACEI should be changed by GP

*For how long i will be on dialysis ?

This to be decided by kidney dr according to the underlying cause of ur condition , will keep c
hecking ur blood if found to be fine may will remove .

*What's ur diagnosis

AKI due to Rhambom dehydr NSAID ACEI

*Inves

Renal biopsy

*Complication of haemodialysis

Dialysis disequilibrium syndr drowsiness after first dialysis

*Any benefit from giving

Bicarbonate ? there is a debate whether to give or not.

*reasons for starting dialysis in this patient ?

Hyperkalaemia, k can block heart and may kill him

*What about aluminium toxicity ?

(i missed this point)

40 y.o female p/w wt gain

______________________________

Intentional or not what about ur diet All around my body , no rash , fatigue , no proximal myo
pathy, hit her car don't why this happened, snoring at night , HTN recently , no change in
bowel work , no surgeries , no facial features change , not taking medx ,
BMI BP

Signs of cushing

Check for P.myopathy

Cardiac exam

*Concern:

Wt gain could be related to geneta wt gain or gland problem osa fat dep bloc of air way that'
s why cause snorin5

Dx :

OSA leading to fatigue

*DD;

Narcolepsy

*Inves:

Basic , TFT

Epworth scale polysomnogr

Pitur fasting blood glu

Mri brain

BI PAP wt reduction stop driving o2 sat HR EEG microphonography

*cause of OSA in this patient

Simple obesity
Station 4 ) (summariesed by ocolleague)

Mis aisha c/o recurrent pain headache and fatique for many years

Her last presentation is headache for which the consultant treating her

Come to the decision all her investigation including ct scan were normal .

Your role to explain to her the consultant decision and answer any other concerns.

________________________________

Case presented with headache

For many years

Did for her all investigation and it came normal

Aftr introduction

Try to ask what her expectation

She may say

May be i have serious condition

Appreciate her concern

Reassure her by

Break the good news she have no any serious cause for her headache as all test come normal
and no need for further tests.

She may get angry

Again show empathy and sympathy

Admit that she is suffring

And we are here to help her

Then ask about social history and stressess in her life in general :

If said yes then deal with her as a case of conversion disorder .

if no then take breif analgesic history and then followed by appropriate managmen .

If no stress and no overuse of analgesics

Then reassure the patient that we need to follow you regualrly and try different kinds of manag
ment

In pain clinic

And tell het in breif about when to come again at once if she developed alarm symptoms .

Then ask about other consern

And summarize the case for her

And check understanding .

Dont mention psychatric refferal

St4 ) nice summary done by dr m.khalifa

You are medical doctor in AMAU. A pt. presented with Lt sided weakness. CT was reported as
normal. MRI>> normal. Plz speak to Pt and address concerns.

from start: Angry pt. wants to speak to neurologist. insisting to speak to neuroloogist. expresses
that she is upset. ??arrange for neurologist??. Lt sided weakness CT scans done >> Normal. Pt
concerned that this might be a stroke. MRI done also>> Pt asks what is an MRI. and angry wh
y not do an MRI straight away. MRI >> Normal. Pt still concerned why still having the sympto
ms?. exploring social Hx reveals that Pt mother is suffering from mobility problems and pt is tak
ing care of his mother with an overwhelming stress and pressure on pt life. tough working hour
s also. tell pt that he has coversion disorder and explain that to him. Concern: will I be OK? A
m I mad? Some para-medical staff membder is saying that I am making this up, this is really a
nnoying me. up untill the end the pt. is insisting to see a neurologist.

Examiner Q?

how do u think this conversation go?

What principles invoved? Autonomy. Justice.

also: unprofessionalism from paramedical staff member spoke about this pt. need to arrange a
meeting with Pt. and staff member and nursing manager
Why not did the MRI first? Although MRI is superior imaging modality, CT is easy to do and ca
n be done very quickly and less expensive.

Would you send this Pt. to neurology? Ideally no>>>> principle involved here is justice. also au
tonomy>> need to involve neurologist by sending a letter to him but not commiting to time fr
ame.

N.B> Pt is clearly having bad home situation... needs O.T. to sort managing home problems.

Tell her first i have good newws for u all ur image are normal she will ask u immediately u
dont belive me doctor

Tell he no i believe u have condition called conversion ur brain will act abnormally expressing p
ain or weakness due to stress from out side ur are not lying and will take time and resolve

"The good news here is that ct and mri scans of ur brain are ok... which means that u r not s
uffering from any strokes...

From wut u r telling me... it seems that u are having tremendous stresses in ur life... in such ca
se, sometimes stress can be reflected on the body as physical ways like weakness, headache an
d others, and it is not serious"

Justice: each and all pt need to have equal chances to access NHS resources

In this case: unnecessary refferal to neurology will mean that another genuine pt will have to w
ait longer

st5) Joint pain + SoB

__________

Rashes in legs painful

Gritty eyes

Constipation >> hypercalcaemi

dx Sarcoidosis

___________________________

St5)Knee replacement (O.arthritis) and visual problem (field defect)

_____________________________

Acromegaly .

______________________________

St4)Iv drug abuser hep C homeless

Involve inpatient psychiatry team

Involve social worker

Further assess the HCV status by investigation

Send the patient for detox

Tell the patien about "needle exchange program"

Talk about partner, sexual health

Arrange follow up with liver doctor

WE USUALLY DONOT DISCHARGE UNLESS INPATIENT PSYCHIATRY TEAM HAS SEEN

(IVDU) in communication

*HCV , HBV HIV serology

*Send the patient for detoxification. *Tell the patien about "needle exchange program"

*Talk about partner, sexual health.

*Methadone used to prevent withdrawal symptoms of herion but not supposed to be enough t
o give the positive effect and euphoria of herion ,to be reduced gradually after administration.

*Cognitive-behavioral therapy have been shown to effectively treat heroin addiction, designed t
o help modify the patient’s expectations and behaviors related to drug use and to increase skills
in coping with various life stressors.

(Needle and syringe programmes) are a type of harm reduction initiative that provide clean nee
dles and syringes to people who inject drugs to reduce transmission of HIV and other blood bo
rne viruses . (WHO) recommends providing 200 sterile needles and syringes per drug injector p
er year, in order to effectively tackle HIV transmission via this route.

Many programmes supply other equipment to prepare and consume drugs such as filters, mixin
g containers and sterile water. The majority are run by drug services or pharmacies .

Many also work to reduce other harms associated with injecting drug use by providing:

advice on safer injecting practices

advice on minimising the harm done by drugs

advice on how to avoid and manage an overdose

information on the safe handling and disposal of injecting equipment

referrals to HIV testing and treatment services

help to stop injecting drugs, including access to drug treatment (such as opioid substitution ther
apy) and encouragement to switch to safer drug taking practices

other health and welfare services (including condom provision)

St5)Sudden loss of vision

_______________________

10 mins ..last night also ... completely recovered, Dm HTN , no tender scalp ,

Pulse , carotid , neurology , heart ,

Fundscopy

Amourosis fugax

St4 (25 year old female comes to you worried that she may be rejected by her fiance. She is
going to get married soon as her father has died of ESRD secondary to ADPKD. Kindly address
her concerns

______________________________
It's a matter of my future i luv this guys so much am worried that he might leave me

We can detect this disease early and therefore ttt any side effects will monitor ur blood pressur
e will stop progression of this sacs

Do u think for sure i will have this disease ?

We need to do us genetic test will refer to genetic dr to do some test to know whether u hav
e the affected gene or not.

*I read in the internet that every member in the family will have this disease and end up with
dialysis

Am worried

Do u have any change in urine color no , any recurrent flank pain no , no i don have an y sy
mptoms, any headache no , am just worried that boyfriend will leave me

Advise u to tell him after confirmation, if u hide this and he discovered it later he will leave u
,

If he loves u so much he will support u

What u gonna do

Will do us blood test to check kidney function then will refer u to genetic dr ,

50% of family members will be affected

Should i tell?

I will encourage u to dicuss this thing with fiance we can arrange other meeting with him.

Ethical issues :

Autonomy

Confidentiality

Why she's worried,

If her bf discovered will leave her

Any confidentiality?

She should tell him by herself

(another summary 4 this cas)

*Confirm her id

lm sorry about her father can u tell me more about what u know

Worried about her life shedoesn't t want to end like father in misearble way in dialysis

*After empathy ask her again what she was so far knows about her father condition she tell he
have multiple sacs in kidney

*explain that dis called APKD It affects the kidney with many sacs And running in families and h
ave differnt way in ending

She is worried about telling fiance ??? ask about symptoms of flank pain red urine headche she
denied and ask also about family member for screening

We should ask about family planning if she is planning to get pregnant she has to f/u withwo
man dr and renal dr through Multidisplinary team
Assure her this disease affects family member by 50% we will send her for us and kidney docto
r to run some blood test and also there is genetic doctor will help us

And offer to talk with her fiance and help her to talk with him

Disease severity varies among PKD families so not everyone will end up on ESRD.

2. There is no proven role of any drug to stop the progression of PKD but if examiner ask tell
him that heard about tolvapten ( V2 receptor antagonist) but not sure cuz it's still need to prov
e it's significance

3: chorionic villous sampling has very limited use in certain countries and only used in families
with severe disease in family members

And the best way to monitor is US .. genetic testing has no role in disease progression
St 4 )mock from past exam : Mr smith admitted to hospital with pneumonia, his condition is no
t improving. Received antibiotics and developed diarrhea. Clostridium Difficle has been confirmed
. Pt is isolated in sideroom.

He is not for palliative treatment. Talk to his son who is concerned about father condition.

_________________________

*son was angry for not changing bed lining thinks it's the cause of his father infection tell him
that u will talk to nurse encharge but this is not the cause, his condition due to AB

*explain condition ur father had severe infection of lungs and we gave him medicines to treat t
his infection which kills most of the bugs and causing eradication of tummy flora leading to the
se sym

*Ask if he saw any something odd to figure out any error

*Why my father is not improving?

response to treatment is different from one pt to another so some time it's difficult to know wh
en he will improve we started him on treatment and will follow him up and see how he will re
spond if no response will shift to another types of med ,Also there other condition affect resp
onse to treatment ask about other diseases how was his health before he got infection

*will follow ur father condition bcz it's critical condition , may need to do imaging to his tum
my

Is he dying? He is in critical case

*Beneficence to give Ab

*Precautions, barrier nursing and side room

The initial step in the treatment of Clostridium difficile infection (CDI) is cessation of the inciting
antibiotic as soon as possible. Infection control practices must be implemented, including contact
precautions and hand hygiene. Hand hygiene with soap and water may be more effective than
alcohol-based hand sanitizers in removing C. difficile spores, since C. difficile spores are resistant t
o killing by alcohol. Therefore, use of soap and water is favored over alcohol-based hand sanitiz
ation in the setting of a CDI outbreak, although thus far no studies have demonstrated superiori
ty of soap and water in non-outbreak settings. (See 'General management principles'above.)

St4) (summarised by dr omar)

cenario of possible lung cancer and consent for bronchoscopy:

First step the beginning, confirm yourself and your role and confirm pt identity. Ask pt do you
want any one to join this meeting. Then 3 checks (how do you feel now? How much you know
about your condition? What do you expect from this meeting? ).
Second step:

Background (I understand you have been troubled with cough. .......and we did for you. .....and y
ou received ...... {just read what written in the scenario}).and we did scan to your chest, tummy.
.....and the result with me now and it's not as we hope (silence for few seconds) then break the
news (it shows possibility of lung cancer){just say what's written in scenario could be, highly po
ssibility, high probability. ....} and then the GOLDEN SILENCE FOR AROUND 30 SECONDS.

Show empathy (I highly appreciate your feeling. I'm really sorry for this bad news) sympathy (I
want you to know you are not alone and all of us here to give you the proper management y
ou need and till now this is not 100% a cancer THAT IS WHY my consultant decided to do ano
ther test called bronchoscopy. Did you ever heard about it? Do you want me to explain for you
? Are you ok Mr. ..?

Third step:

Importance of procedure. Reassure (it will be done by well experience doctor who did hundreds
time this test

Then explain before, during, after procedure.

Then tell like any procedure it has a bad effect as well like pain, bug infection, bleeding, perfor
ation (injury to nearby structures) but if we compared the benefits with the bad effects we will f
ind the benefits more.

Then pt will concern here about pain bug infection perforation. ....reply accordingly and reassure
him.

Fourth step: if you are agree I will inform the chest doctor to sign you a consent for the proce
dure, is that ok?

Fifth step:

C/3S (concern+social+summary and recap+support)

Do you have any more concern?

In social ask about important points according to the procedure and pathology but in general:

Job, smoking, alcohol, driving, impact of symptoms on job and daily activities, HOBBIES. DON'T
FORGET TO ASK THE PATIENT AFTER EVERY STEP ARE YOU FOLLOWING ME? DO YOU WANT
ME TO TELL YOU MORE?
YOU CAN USE THIS APPROACH FOR ALL PROCEDURES IN PACES.

St4) Unawareness of hypoglycemia :

*explain seriousness of this condition : sz coma death

*ask about causes:

strict control of blood sugar.

autonomic neuropathy.

alcohol.

renal failure and hepatic failure.

exercise.

Drugs BB anxiety medc

*ask abt insulin dose , compliance , ask about injection sites (dystrophy)

*ask abt symptoms of hypoglycemia

*ask about HA1Cd

Management: dietitian referral , adjust insulin dose , admission ,diabet nurse

St 4 mock from diet 2 : Mr Williamson is 75 yr old diabeticcontrolled by oral meds, admitted
with ischemic CVA admitted in general medical ward as the stroke ward was full. He developed
bed sores in both ankles on day 6. Nurse sent a swab which shows MRSA. No systemic or loca
l features of infection. Talk to his daughter Ms Mary, explain to her condition of her father & a
nswer any concerns

_______________________________

*Infrom about development of bed sores and explain causes of that , MRSA colonisation, explai
n what's MRSA ,

*Incident report

*Involve skin wound care team and infectiom control team

*Precautions (frequent hand washing , wearing gloves) ; dressing

*No isolation unless there are nearby patients with opened wounds and catheters
*regarding ttt will take opinion of infection disease control team and mirobology whether to rec
eive antibiotic or not ,

(points added by oncolleague 😃)

1. here were no places in stroke unit.

2. Was followed and taked after by stroke unit team.

3. We are sorry for these bed sores and usually we take measures as frequent change of postu
re and air mattress to prevent it but actually stroke and diabetic pts are liable to

4.mrsa is a type of bug that may be present on our skin without causing any problem.

5. If she mentioned anything about nursing not washing their hands apologize and said this will
be reported and investigated.

6.we will contact a team involved in management of bugs about management of bed sores wh
ich may need only some local cream and frequent dressing.

7.isolation

Visitors should wear aprons and gloves

Hand wash before and after visit.

(another summary done by dr aylin)

MRSA

Intro
Agenda

Check identity

Check understanding

How is father's condition?

How he was previously?

Previous life style?

Dm,htn,ihd,previous stroke .?

Good thing your father is recovering

Leg blister

Incidence report form

Risk management team

Roots cause analysis?

Meeting nurse doctor adminstrator?

Give u number and proceeding will be informed.

Why in side room ?

Spread infction..

Barrier protection.

Hand washing

Isolation

Contact tracing .

Management ?

Antibiotics

Blood culture

What concern. ?

Complain pals .

Can I bring my children?

No children can meet

Follow up soon

Give num .complain updates will be given to us.

Iv antibiotics .Mrsa septecemia

Vancomycin,merepnem.

30 years old male with abdominal pain.

Vitals are normal

Take a focused hx and examination and answer pt concerns

________________________________

Upper part , 2 months back , increasing, burning pain , increased after eating , no swelling, n
o dysphagia, vomited once , food containing, no blood ,no bowel changes , appetite ni chan
ge , no skin rashes no joint pain , no alcohol smoking , hx og back pain , on NSAID for 6.mo
nths , no surgeries, no fhx

, Concern;: what's going on with me ?

Pain killer causing damage in the lining of tummy causing this symptoms, stop medx at this m
oment prescribe other medx for back pain , we may need to proceed for camera test ,

*Exclude cancer by asking about red flag signs

Melena wt loss , dysphagia

* what med will give ?PPI

*exclude hypercalcaemia

other dd
*galltones

St4) (summarised by dr sanjay)

Pt k/c RA on metho developed UTI , GPpreprescribTMX now pt came with pancyto

___________________________

Introduce

Check identity

Ask how's patient feeling now

Ask any fever,joint pain ,cough

Break the news (as you came to hospital we did your blood test which shows your having cond
ition called pancytopenia its reduced number blood cells in your body.which makes you pron to
catch infection.cause of this is because of the drug you take which is methotraxate which we u
se to control of your RA on top of this recent episode of uti in which ur gp treated with TMX
this antibiotic which usually given for uti can increase the toxicity of the methotraxate so we bel
ieve this is the trigger for ur condition.
Give time to express patient may b patients will angry you keep silent and listen.patient will ask
is it the mistake of gp?

Giving TMX with methotraxate is mistake but I don't know the circumstances in which it was giv
en to you I will try to contact gp and get the documents after that only I can comment on thi
s.

Patient will ask I want to complain then tell yes its your right to complain I will guide you rega
rding this but before that I want to b sure that your condition don't get worst so my 1st priorit
y to handle current situation.then explain what you are going to do...we will stop your meds rig
ht now and I will refer you to joint doctor who is expert in dealing with such condition and he
will advice what alternative medication we can start..also you need to stay away from any perso
n who got infection also sometimes you will get abnormal bleeding in that case you have to vi
sit hospital.tell her this condition is reversible once we stop the culprit your count will come bac
k ...if patient ask how long it will take then tell you can not tell exact time some times weeks o
r months...but we keep you under monitoring and access the progress if its necessary then we
can give you some stimulator to increase blood count.

Check the understanding recall offer leaflets give your phone number and close consultation

St4 ) VV attack by dr sanjay

*Fainting or syncope is temporary loss of conciousness because of reduced blood supply to brai
n .its for a short period and after that a person can gain full

conciousness .It has many causes and in your case its over stimulation of one of our cable due
to coughing , sneezing or severe stress

*What is the cause?

Causes are different usually long time standing in hot climate,anxiety,stress,dehydration,pain,seein

g blood are few causes of them.

*Advice about vasovagal drink lots of fluids,avoid standing fr long periods,always stand in steps i
f v severe we can give compression stockings or med,pls correct me if am wrong?

*What can b done to avoid it?

Avoid standing for long stress dehydration.. If u feel dizzy or lightheadedness then lie down and
elevate ur leg also u can clench ur hands repetedly to improve blood supply to ur brain.

*What precaus. Has to b taken

Avoid triggers, keep your self hydrated avoid alcohol and smoking. As soon as you feel symtom
ps lie down to avoid any injury keep yourself away from heights, fire and hot source equipment
. Tell your family members and friends about the condition and measures to b taken when you
have such episodes

*Can i drive?

As we did all investigations which are normal so no need to inform dvla. U can just take preca
utions while driving and as soon as you feel symptoms take car on side and elevate ur legs to
avoid any accidents

Ask concern give leaflet and phone number

St4)summarisedby dr sanjay )

councelling about LTOT in cOPD

_____________________

Introduce

Check identity

Ask patient what he knows about his condition

Tell him that the breathlessness he is having is because of condition called copd

Tell as he is not responding well to inhalaers consultant advised to offer him LTOT.tell what is L
TOT.its small o2 cylinders through which he has to breath for 15_18hours daily.ask about smokin
g tell him smoking is contraindicated in case of ltot and he has to stop smoking.tell that smoki
ng has negative impact as copd is progressive and if he don't stop his condition may get worst
.tell also O2 is highly imflamable and smoking near cylinder can cause fire.

Tell about all precaution like do not let anyone smoke near you don't not keep cylinders near
heat sources fire alarm should b on n working.

Patient may ask will b cured -tell its progressive disease n damage can not be revesered only
we can control further damage and treat symptoms

Ask patients job and family and financial condition offer social and occupational support if requi
re

Refer him to chest phy. For further assessment summaries the information .give information leaf
let n ur phone number.
St5 )Opd asked 2 c mr william 60 yo p/w artharlgia and worsening of renal functions bp 154 _9
4

___________________________

Bk pain 6 m , increasing, lower part increases by move, stiffness? Don't know , no wt loss, no
bowel or water work problem, no fever , HTN on ramipril concor , Ca carbonate, asj abt skin r
ash, eye problems , Muscle problems ; mouth ulcers ,

*Ex:

Ankylosing
Examiner asked the candidate to examine Abdomen infra umbilical scar

*Concern why renal functions are deteriorating ?

Amylidosis 2ry to ankylosing

Examiner asked did u find anything that suggests amylidosis?

*DD of deteriorated RF

ramipril ask any recent change in the dose , nephritis due to analgesia , HTN

St5)40 female c/o recurrent vacant episodes , for last 6 months

After every 2_3 weak episodes followed by confusion no loss of control over water work ,loss
consciousness for 2_3 mins headache but not bothering her alot 1year bk had bleeding in brai
n ,

*Dx :

Epilepsy , scar epilepsy had hx of brain hge

*Ex:

Visual exam acuity field movement fundoscopy

I would like to do full neurologist and cardiac

RAPD ????

*Inves

EEG repeat CT scan any new pathology

*If more time was given what are things u will ask ?
Physical activity driving job

St2)Joint pain Last 6 months on paracetamol no much help , workimg as a secretary in a comp
any ,only lymphopenia in inves

_______________________

Affects all the joint , more in the hand , very painful , morning stiffness more than hour , no s
kin rash , no mouth sores no sores in private area , no Change in color on exposure to cold ,
no clot hx , married , no kids , hx of 2 micarrige, initial month of pregnancy, 6 months back
i had chest pain and dr told me it's a muscle pain , no hx of OCP , no numbness or tingling,
pmhx thyroid disease on thyroxin, on OCP , my mother had RA ,

can I have the same problem ?

SlE evidenced by miscarriages and abnormality in inves we should put RA also in our mind , ye
s can affects prenancy MDT , med to control ur pain , occupational health worker , with manag
ement wil improve ,

Dx :

SLE , APL

RA but lymphopenia against

*Inves:

ESR CRP ANA Adsa APL screen LFT RFT , hand XRAY , TFT

*Single test to r/o any other comp?

Urine dipstick
St4)88 y.o with AD refusing to eat became bed bound agitated NG tub was pulling out by her
many times , daughter read about PEG tube , peg is not an option as prognosis is not good ,
talk to her regarding PEG tube and answer her concerns

________________________

*confrim identity

*NOK.

*what do u know abt mother condition?

She's forgetting alot , she started to refuse eating completely, her condition deteriorated, refus
e to eat any thing

*Explain AD is a progressing disease , she will become agitated ur mother is in the late stage o
f the diseae , very advanced no ttt for her , will help her regarding eating or infection but the
re's no ttt for her brain disease ,

Daughter will tell that one of her relatives had stroke and PEG inserted to him and became ok
,

*Explain cons that PEG tube needs endoscopy to be inserted through the skin of the patient , n
o benefit from this tube it's an operation and ur mother not fit.

*ask about LPA AD

*Raise the issue of end of life care ,

*Ethics

Justice

Beneficence

Non maleficence

Did u convince thr pt no putting peg tube ? Yes risk more than benefits

Palliative ttt ,

St4) 75 yr old Mrs. Reynold was admitted with severe pneumonia,5 days back. she also has HT
N, controlled DM & osteoarthritis. Now she is improved & occuptnl & physiotherapy team exami
ned her & told her cured. she also wants to go home today & your team is going to discharg
e her. but her daughter Mrs. Reeze found this out & she thinks its too early and she is quite
angry. Now talk to her & explain current situation. Assume that she has her mothers permission.

___________________________

*check identity , permission, understanding .

*am afraid if she went home she may fall at any time,she is tired.
she is tried bcz just recovered from infection, it will take time she will be recovered .

*with whom she is living ?

Alone , am visiting her every 2-3 days .

*Anyone else to look after her at home?

No

*Daily activities before admission

She can cook , she can manage herself , but now she is tired and she has severe OA i can't le
ave my job and family and stay with her

*What is your mom willing what's her wish ?

*Someone told me it might take long for her to recover so why you are going to discharge he
r today ?

I apologise if someone gave you wrong information , but peresntly from chest xray it showed r
ecovered from infection doesn't have any fever that's why , but it usually takes 2 _3 weeks to r
eturn back to her natural condition . Medical team examined her and gave her proper manage
ment and now she has recovered , we have discussed her condition medically she is ready to b
e discharged, OT assesed her for any fall risk at home and decided that she can go back hom
e , we talked to your mum and she is agreed about the plan.

*she might get another infection if we kept her in the hospital , beside that we can't keep her
against her wishes .

*is she living upstairs?

Yes
*we can solve this problem by addressing some modifications at home by OT and social worker
, MDT for prevention of fall.

*what they will do dr ?

Can provide some safety measures, alarm bell for any emergency help , if no one around , ca
rpet cutlery,

*can u move her to nursing home ?

This thing we should discuss with ur mother, we have to respecther wishes we can send her ag
ainst her wish , if she agreed on that will call nursing home team to asses her first.

Viva questions :

*Ethical issues:

Autonomy has the right to take her decision

Beneficence : if D/c good 4 her ,

Non maleficence keeping her at hospital will expose her to infection

Justic no medical indications to keep her in the hospital

*Criteria of competence :

Understand retain and take decision and communicate .

*Agneda :

Angry relative

Social things because no one to take care of the patient.

1) st 4 : You are CMT in medical ward. Theme : talking to angry son. Mr John is 82 yr k/c of
dementia & a resident of nursing home. He was admitted in medical ward 2 days back with c
hest infection. Yesterday night he became confused & was wandering around. He was given inj
lorazepam to calm down. HE went into respirTory arrest. He was resucitated, given inj flumazen
il. He has been stabilized & now in ITU with intubation done. Your task to speak to son about
condition of father & address his concern

___________________________

*flumazenil was given in the best interest of the patient as he was drowsy and confused so flu
mazenil given to calm him down and to protect him from falls and injuries, and was not given
to make our duty easy , it's a safe medication and rare to cause side effect but unfortunately it
happened in ur father's case , we ttt him immediately by giving medication reverse the action
of this drug and aslo by intubating him , regarding recovery he may recover and may not but
will do our best and keep him under observation, if son expressed any objection to any certain
kind of ttt ask about LPA and AD

PMR communication
*Check understanding , expectations

*Explain condition : inflammation of blood conduits supplying muscles leading to stiffness special
ly in the morning; explain associated symp like depression artharlgia night sweats

*explain complications : GCA and tell the pt if u noticed any visual change headache u have to
seek medical advise .

*the only effective ttt is steroids , explain benefits and side effects which can be prevented by v
itD ca PPI regular f/u and checking of BP sugar , precautions avoid contacts with sick pple , bu
t steroids will help ur symptoms and improve ur daily performance decrease progression of the
disease.

*prognosis : varies from one person to person some patients respond very well to steroids so
me may have relapse after tapering steroids.

*social history job smoking alcohol

*ask about affection of dialy activities.

*managment MDT rheumatology physiotherapist , social worker , o.h.c.w ,

*summary leaflets etc

St4)Talk to daughter mrs Smith of mr Jim tanner 76 year old frail man with underlying COPD a
nd osteoporosis who presented with marked weight loss ,scan showed suspicious lesion in liver ,
biopsy results are back showing secondary adenocarcinoma with unknown primary

Pt wants to know what’s going on

Task

BBN and management

Talk to her about telling mr tanner the dx

______________________________

*introduce.

*confirm identity.

*permission

*check understanding.

*he is loosing alot of wt depressed bcz of death of my mother bcz of CA went to GP sent us
to hospital for some inves and took snip

*explain condition : k/c of COPD fragile bones , scan done has showed lesions in his liver and
snip was taken, results are with me now

*any expectations, fears , what might be going on with him?

*Do u want to know everything about your father's condition.

*I'm afraid I'm not having good news forbyou today results are not as we hope , showed that t
here's nasty growth in liver we don't know where is the primary growth ,

*Are u sure about the results ?

Unfortunately yes .

*Any possibility of error ?

We usually check the results before releasing them.

*Do u want to continue this discussion?

Yes go on

*empathy and sympathy.

*Unknown source , TTT in the form of symptomatic ttt ,will be managed through MDT tumor dr
, palliative care team , psychiatrist , macmillan nurse wil look after him

*Is it curable?

We don't know whe is the source am afraid to tell u no ,Will refer him to Palliative team to ke
ep him comfortable manage any symptoms he may develop.

Palliative will give feeding and nutrition al support and relieve any pain he may experience.

*I don't want to tell him

Why

He is already depressed because of mother death .

From our experience it is better to let him know what's going on with him , as he may need
f/u in the future also he has the right to share in the management plan , we will support him
and will never leave him alone , will ask him how much infrom he wants to know , knowing t
hat there's something serious is going on with him can be a relief , I have been infromed that
he wants to know.

*What benefits will you get if you infromed him ?

His right to know what's going on with him to share in his future management plan as he is c
ompetent and can take his own decisions, and we Will be there to support him , will never le
ave him alone

*LPA ?

No

I really appreciate your feelings I know u want the best for your father , I can't hide from him
as it's my duty to inform him about everything.

*Concern ?

Yes unable to tolerant such news

Am sorry this is his right to know

*Financially supported?

No problem.

*Summary

Viva quest:

*Why do you think he needs to know what's going on with him ?

This is his right to know to share in mana plan , we may need to take his consent if invasive
inves needed.
*In what case u can hide from pt ?

If there is no capacity.

*If unable to convice her what will u do ?

Will involve my consultant.

*What do u know about duty of candour?

Duty to be honest and clear to the pt and relatives .

St4)80 year old mr wilkinson admitted in chest ward with severe pneumonia.he has severe deme
ntia as well. Pt is vitally stable and improving and currently treated with iv antibiotics. Pt son
mr sam wants to talk to dr and wants to know about his father and discusss some concerns an
d about alternate medicine .

_____________________________

*introduce.

*check identity.

*NOK.

*check understanding. How much you know about your father's condition?

He came with Chest infection ,am shocked that AB was given through viens straight away ,

So why no one told me regarding his condition?

Ok really sorry for the inconvenience , but let me ask you how you have been infromed that ur
father was transferred to our hospital ? i recieved a call from ER , exactly u recieved a call fro
m ER that's why u r here
We r very busy lots of pt , sometimes lack of communication happens , but you have the righ
t to be infromed , that's why you recieved a call from ER.

*why i wasn't informed from the beginning that AB would be given to him ?

*Do u live with him ? How was ur father b4 ? He was fine .

Yes u have the right to be involved , we tried to contact u at that time but we couldn't reach
u , so AB was given as a life saving ttt u have the right to he involved that's why u r here a
nd now I'm discussing with you about the AB .

*why you are afraid of that AB ?

He shouldn't be taken AB straight away , u should try ulternative medicine before starting him
on AB.

*What kind of ulternative med u mean ?

Ginger herbals

*your father doesn't have simple cough or flu that can be ttt by AB , he has severe chest infec
tion, if not ttt with AB he might die we don't have other option. Ur father came in critical con
dition and he was not competent so AB was given in his best interest . Every patient with infec
tion should be TTT with AB this is the polici and practice of our hops and AB was given in his
best interest , that's why he's doing well.

*ask about LPA .

_________

*3 concerns:

First concern why i have not been infromed regarding my father's condition?

Second concern why he was not given ulternative med?

3rd concern why i have not been Involved ?

*If he has LPA what u will do ?

LPA doesn't change our management options , won't stop AB even if he has LPA ,

If he insists to do so i will involve my consultant and legal team.

Points added by dr mostafa 😃

*Why I am not informed?*

Ok really sorry for the inconvenience , but let me ask you how you have been infromed that ur
father was transferred to our hospital ? i recieved a call from ER , exactly u recieved a call fro
m ER that's why you are here today ,

We are very busy lots of pt , sometimes lack of communication happens , but you have the ri
ght to be infromed , that's why you recieved a call from ER.

*Why I am not involved* ?

- You are the next of keen? LPA? Any advance directive?

- You have the *right* to be involved. But when your father brought to ER he was really unwell
and our concerns at that time was to rescue him and save his life. However, in some situation
s, especially the *critical* medical conditions, we may respond to emergencies without family inv
olvement, and the *decision* will be taken *medically* by the medical team.
Diet 3 mock : st 2 - you r CMT in medical outpt. GP letter Plz see Mrs lorraine, 45 ys. She pr
esents e recurrent falls. She is a known hypertensive diabetc. Vitals pulse 88/min, Bp 95/60 , R/
R 16, temp 36.7 deg.

_______________________________

Last 2 months i had 3 attacks of fall , not associated with LOC , felt light headed before fa llin
g down , no awarness of heart beat , last episode occurred when I got up to make a cup of t
ea ,another one 2 months back got up from chair , Hypertensive for the last 3 years , controll
ed , On BB and ramipril, alpha blocker , diabetic for last 5 years on metformin , GP satisfied,
no attacks of hypoglycemia , no symptoms of micro or macro complications, no hx of heart at
tacks , has heart rythem problem , 3 years back , on med , thigh and shoulders weakness , fati
gue , no skin rash , should aches and pain , no fever , use his arm to get up from sitting posi
tion, no tummy pain , no change in bowel habits, no breathing diff , PMHx hypothyroidism
on thyroxin , no wt change , no FhX , not smoking not drinking alcohol, on statin , on diureti
cs, and bisphosphonate had menopause 2 years back was given by GP, vit D and ca , Ibuprof
en, difficulties in carrying out daily activities,

*Concern :

Am afraid that if am alone i would fall again ..

We need to examine you and run some more inves , OT to asses home situation , and social s
ervices help

MDT cardio , dietitian, gland specialists , diabetic nurse

I advice you to get up slowely , if u felt dizzy lay down immediately

Most likely related to your med we have to refer u to cardiologist, to have a look at your med
to make some adjustments. Ask about melena as a complication of Ibuprofen .
______________________________

*Possible cause :

Drug induced postural hypotension.

Addison (PGS)

Autnomic neuropathy

Proximal myop

Anaemia pt is on Ibuprofen

*Inves :

CBC (look for anaemia as pt on Ibuprofen), short syn test , BP sitting and standing , HBA1C, uri
ne analysis, autoimmune profile, inflammatory marker , CK level (pt on statin)

*Management :

Pt education councelling, social worker and OT advice and asses home situation, get up slowl
y, if dizziness she should settle and lay down ,

Refer to cardio to stop ramipril or adjust the dose , and other med like bB statin , referral to f
all clinic.

Compression stockings , increase salt intake and good hydration, mineralocorticoids.

St4)53 years old mr.smith presented to hospital with chest pain and sob,after a long haul flight
from Australia.He was investigated and was diagnosed with pulmonary embolism.

He was started on lmw heparin initially,and will be switched to oral warfarin,as decided by your
consultant.
Your task.

To explain diagnosis of pe to mr.Smith and to deal with his concerns.

______________________________

*introduce, check identity.

*do you want anyone to attend our meeting today.

*check understanding.

*any residual chest pain or SOB ?

*do you know why these investigations requested for you ?

*What's your expectations?

Don't know , can u tell me what's going on with me?

*Inves showed that you have condition called PE , It's life threatening condition, caused by clot
formation in blood conduit in your lung ,in the presence of recent hx of long flight makes you
susceptible to develop such condition , any history of blood clot before ? FHX ? no , surgery i
n the last 3 months ? Hx of medical illness ? No

Main cause in your case is recent history of long flight , leaded to stagnation of blood in chan
nels supplying legs and lungs ,it can cause heart failure, severe SOB if not ttt well , you alread
y recieved proper management in the form of blood thinning med, which called heparin , our c
onsultant wants to start you on other type of blood thinning called warfrin ,

It has some side effects like bleeding, but we can prevent such compilation by regular checking
of your blood thinning value to keep it within 2_3 in coag clinic , and you should avoid using
any med without informing your blood physician , alsp some types of foods can alter the effica
cy of warfrin will refer you to a dietitian to give you list of types of foods that you should avoi
d.

*Can it cause bleeding in brain ?

As i infromed you , warfrin can increase risk of bleeding in any organ , but regular checking o
f INR till we reach to the target level reduces this risk .
*Will i take it for whole life ?

Only for 3 months, after that will give u regular F/U.

*Can i develop it again?

Difficult ques to answer , i can't expect whether it may happen again in the future or not.

*Concern:

I need to go back to Australia to attend my daughter's wedding after 3 weeks ?

I appreciate your concern, unfortunately in such condition patient should avoid travelling for 4 w
eeks to prevent this condition from happening again , before any flight visit your GP to give yo
u some instructions and precautions to prevent such condition from happening again.

*Can i play golf ? Yes it's safe to play golf, but hockey or any other heavy excersie should be
practiced after 4 weeks .

*There are Some new drugs with few side effects why not to give me
St5)33 years old mrs.collins presented to the department of emergency with incrrasing shortness
of breath.you are spr in er.your consultant wants you to evaluate the patient.

____________________________

sob started 1 month back , went to GP gave me some tablets (AB) no improvement , develop
ed gradually over one month , increasing , mostly related to exercise, no chest pain , wake up
at night searching for fresh air , no leg swelling, no racing of heart beats , dry cough , smoke
r 5 cigarettes/day, no joint pain , no skin rash , no PMHx , no Fhx , first time to have such co
ndition, alcohol 14 units/week , not on med , ask about allergies , occupation for asthma , ask
about pregnancy history , time of last delivery .

*Examination :

Check Vital chart

Heart exam normal no murmers.

JVP norma.

LL no edema.

Bilateral basal crepita.

*Concern :

What's going on with me?

*DD:

peripartum CM (PND , exertional dysnea)

Interstitial lung disease

*Inves :

CBC to r/o anemia, CXR , ECG , ECHO ,

*Types of CM you know ?

Dilated CM

Restrictive CM

Peripartum CM 5 months after labour, should ask about the age of last child who is 5 months
now.

Mr smith is a known case ofankylosing spondylitis, renal biopsy showed deposits of amyloid AA
ptn , plasma creatinine is normal , explain the diagnosis and further management plan.
_______________________________________________________

Some points added from mayo clinic

*You have condition called amylidosis it occurs when a substance called amyloid builds up in yo
ur organs due to long standing inflammation , amyloid is an abnormal protein produced in you
r bone marrow and can be deposited in any tissue or organ like heart kidney liver spleen nervo
us system and digestive tract , unfortunately this amyloid protein affected your kidney's filtering
system which became more leaky , causing ptn to leak from your blood into your urine , the
kidneys ability to remove waste product from body is lowered which may eventually lead to kdi
ney failure, and you may need to be on haemodialysis to clear your blood from toxins.

*Managment : nothing to be done further , will give you some med to decrease excretion of th
is ptn.

*I read on internet about amylidosis which can deposit in heart is that correct ?

No , It never deposits in the heart , there is another type of amylidosis called AL that has mor
e tendency to deposit in your heart , but in your case it's very less likely to happen .

*Is serious condition?

sometimes people could die from that , but at the moment your kidney function is good , will
give you potent med , to decrease any further progression ,
St5)30 yrs old mr.frampton,presented with a h/o sever headahe in the er,for about 3 hours.

Fir ur evaluation n management.

________________________________

Worst headache, started last night all over my head , very severe couldn't look at the birght lig
ht , pain score 7/10 , no visual problem first time to have such headache, there is neck pain ,
neck stiffness , no rashes no fever , vomited once , no recent illnesses, no weakness , no high
BP , fhx aunt was diagnosed with kdiney problem and now she's on dialysis, no hx of blood dis
eases , smoker 1 pack/day , alcohol

Exm:

Vital chart normal.

Visual exam

Acuity ok

Field ok

Fundoscopy no need

Reflex ok

Motor exm normal no weakness

Kernig sign
Concern :

What's going on with me?

Mostly there's bleeding in your brain , it's one of the possibilities ,sometimes could be very mild
bleeding that's why you are stable now , we need to do CT and LP ,it's a serious condition th
at's why we need to admit you , will do , for how long i will be admitted? We don't know t
he diagnosis yet it's so early to answer this question.

*DD:

Meningitis

IC bleeding

CVT as pt is on OCP

*imagine :

CT ,MRI , then LP after r/o increase ICP ,

1st4 scenario: 35 yr old mrs kiran was admitted into A&E department with 2 episodes of seizure
s which subsided after admission. CT & MRI done & showed suspicious primary brain tumour in
the frontal lobe. Neurology consultant wants to confirm it by brain biopsy, which would be do
ne by neurosurgery dept & she will be transferred to neurosurgey dept. now break her the bad
news & convince her to give informed consent for brain biopsy.

__________________________

*introduce

*permission, anyone to join the meeting .

*check understanding

*dr told me i had some fits at home and hospital but am quite fine now. *Anyone spoke to yo
u about possibilities ?
No am waiting for the results of inves , what's going on with me dr ?

*how are you feeling at the moment?

*warning shot , unfortunately scans are showing growth in you brain ,

*How come I was totally fine are you sure ?

Yeh we have double checked it before telling you .

*Are you ok if i describe it further ?

Yes please

*We discussed this results with the brain drs they want to do other confirmatory tets , they wo
uld like to do surgrey to take sinp from your brain ,

*But you said it's already confirmed why you want to proceed for further investigation?

sometimes for ttt purposea we need to know more about type of tumor, this procedure will be
done by brain drs , to take piece from this growth and this will help in deciding ttt ,

*why you can't start ttt without doing such procedure?

It's big decision to start ttt at this point , usually patients with results like this do further inves t
o confrim the type some ttt better for some types of tumores than the others .

Possible to do it right away today ? I really like to do it today as soon as possible.

But for this purpose we have to shift you to other ward neurosurgey ward, they might need to
do some more tests to check your fitness for that procedure it may take sometime.

Give me sometime to speak to them again will try my best to arrange it as soon as possible .

Explain her reason why she is in a hurry.

*Can you tell me.more about side effects and complication.

Am not expert in that field will arrange meeting for you with a brain dr to speak to you regard
ing advantages and side effects.

Will give you some witten information about this procedure .

Do i have hope , may i get cured ?

early to talk about it will keep you updated at every point, after results are back we will talk to
you again ,

*Can you tell me is it curable?

These conditions are very variable unpredictable we cannot predict how it will behave very early
to talk about it

Will speak to brain dr team , will try to shift you as soon as we can , and they will update you
about procedure,

*Any family member around ? No , my husband is away from the country will be coming tmw
, i have little son am the only carer

Who is looking at your son at the moment ?

My sister has come to look after him but she's living far away that's why i want to it as fast as
possible to go back home it's very difficult for me to stay at the hospital.

*Will give yoy some paper bcz we need your permission to do this procedure it might contain
a little bit more infrom about procedure ,

Driving , ulternative inves maybe the wanted to know about pET scan, CSF Ab and tumor mark
er ?? alcohol and smoking , impact on occupation.

___________

Viva quest:

*what things you need to explain for a patient p/w fits ?

We need to explain about driving , activities can indanger the patient

*ulternatives investigations to biopsy.

*did you ask why she is in a hurry ?

St5)53 years old ms angela morris, presented with complaints of easy fatiguability and sob for a
bout 6 months.her bloods showed:

Hb 9

Mcv 109 fl

You are junior doctor in medical department.

For ur kind review.

________________________

Started 6 months ago , some problem in my neck ? , fatigue all the time , neck lump , increasi
ng in size , started 5-6 months back , cold intolerance, constipation, put on some wt , mood is
ok , menstruation stopped 4 years ago , was vegetarian but recently started to eat meat , drin
king alcohol occasionally, no joint pain , working as accountant , no skin lesions

*Examination :

pulse 55

Bp normal

Pallor

diffuse goiter

Ankle reflex

Spleen
*Concern:

What's going on with me ?

Underactivity of neck gland , will do blood test and images to confirm our dx ,

How could it affect her blood count?

Can be part of AI disease Pernicious anaemia , could be due to other causes she is vegetarian.
Hypothyroidism

*Inves:

TFT T3 t4 neck US, IF ab , parietal cells ab

St2 )GP letter Mr.John is a 27yrars old man,who presented to me about 5 days ago,with sore t
hroat n fever.He was prescribed tab augmentin n tab paracetamol.

Today,he presented to me again with c/o yellow discoloration of his eyes n skin.

I found him to be mildly jaundiced.

Thank you for seeing him.

___________________________

Problems in my eyes and skin , one friend told me my eyes were a bit yellowish , started for t
he last 2 days , 2 years b4 had similar situation settled by itself after 3-4 days , fever and sore
throat GP gave me AB ,jaundice progressing , no tummy pain , no fever currently, no change
in urine color , no bowel problems , no itching , PMHX nil , no surgeries in the past , no hx
of blood transfusion , medications on augmentin stopped 2 days before , and paracetamol, no
HTN or dm , FHX adopted, no wt changes , no tummy distension, sleep pattern ok , no trem
ors , no lumps or pumps , smoker , alcohol occasionally , not on daily basis, student, has one
partner , travel hx nil , diet : ask about fava beans , no hx of sharing needles ,

*Concern :

what's going on with me? Is it serious?

Some possibilities could be related to recent med , infection, i need to examine you , some in
ves blood test , asses liver condition, u need to moderate alcohol consumption if possible,

Is it related to alcohol?

Alcohol could be harmful to ur liver so better to moderate your alcohol intake.

*DD:

G6PD

Gilbert

DRUG induced augmentin cause acute and obtructive jaundice.

Infectious

Alcoholic hepatitis

Want to exclude wilson disease

*INVES :

LFT , Haemolytic screen LDH serum bilirubin haptoglobin retics , G6PD enzyme assay , blood
film for heinz bodies , ESR , CBC UE, U/S abdomen , metabolic screen , Hept B C serology ,
AI screening

*Is it obtructive or non obstructive jaundice?

Non obstructive no urine stool color change no itching.

*Needs admission , avoid triggers ( antimalarial, ciprofloxacin , drugs contain sulfa

5)Mr.Smith is a 56 years old man,working as an accountant in a local law firm.Recently,he has b
een complaining of bumping into different things,n into the working table at office.

For ur review.

Bp 100/60 Pulse 94/min

Spo2 96

____________________________

Started 2 months before , became more severe, left or rt side ? no difference , no blurring of
vision , affects his job working as accountant, no headache, no eye pain , no weakness , fatig
ue for about 6 months , no ms stiffness, pmhx nil , no DM no HTN no high cholesterol, no
chest pain , no swallowing difficulties , no mouth sores, no joint pain , not on med , fhx nil ,
not diagnosed with gland problem before , wt loss 3 kg in 6-7 months , driving history.

*concern : What's going on with me? Could it be cancer bcz am smoking heavily?

I have to do few tests , blood tests , brain sacns, might be small stroke , small tumor inside
brain , nasty growth or pituitary growth , will refer you to eye specialist,

*Exm:

Pulse regular

No Carotid bruit

No Murmers

Pupils ok

Visual acuity ok

V.field inferior quadrants both sides affected

Accommodation ok

Fundoscopy normal

*DD:

Craniopharyngioma bcz of inferior quandrantanopia

Pituitary tumor

Stroke
*Inves:

Brain MRI , including pituitary fossa , and to exclude obstructive hydrocephalus , blood sugar L
ipids , ECG ECHO , hormonal assay for hypoadrenalism (wt loss)

NB :

Bitemporal hemianopia :

Upper quadrant defect : pituitary tumor

Lower quadrant defect : Craniopharyngioma

St5)Mr.Walker is a 58 years old man,who presented with the c/o putting on some weight for qu
ite some time.

For ur kind assessment.

Vitals...Normal

_________________________

lost my wife one year bk , during this year was depressed and put on wt , 15 KG in the last 1
year ,around face and tummy , no skin changes , no change in hand size , no acne , no hirsu
tism, no change of bowel habits , no change in diet , snoring occasionally , doesn't feel sleepy
at day time , alcohol drinking heavily ask about CAGE at least one question , no SOB , no lum
ps or pums , no neck swelling, No high BP or sugar , k/c/o bronchial ashtma taking inhalers
for 10 years , 2 months before was started on another inhaler steroids plus salbutamole , 2puff
in the morning and night , no oral thrush

*Exam :

No mouth ulcers

No wheezy chest

Bp ok

Tummy distension no stria

Rounded face

No proximal myop

*concern : What's going on with me? What u will do for me ?

Maybe you have gained this wt bcz of depression, i need to refer u to psychiatrist to evaluate
you more , dietitian , exercise program, chest dr

*DD:

Simple obesity

Pseudo cushing (depression and acohol ) no stria no proximal myopathy in Pseudo cushing.

Steriods induced less likely , as introduced recently .

Depression causes wt gain .

*inves:

24 urinary cortisol

Low dose Dexamethaso suppression test.

St5 ) Mr.dennis bingley is a 25 years old student,who is studying at the local university.He is us
ually fit and regularly goes to gym.

Today after returning from his usual gym,he fell down at home,when he tried to stand up from
a chair.

U r sho in emergency.

Please evaluate him.

All vitals normal

__________________________
I Went to gym today , I was watching TV and wanted to stand up then felt down , First time t
o happen , no specific symptoms before falling , any weakness ? Yes after falling down couldn't
stand up needed help from cousin, no UL weakness , no wt changes , no headache no visual
changes , no lumps or pumps , no change in bowel habits , PMHX nil , no fhx of any signific
ant illness , not on any med , smoker not drinking alcohol , no recent fever or illness , ask abo
ut thyrotoxic symp , ask about bk trauma , bk pain, sphincter problems and diplopia for MG ,

*What happened to me ? It's not a serious condition , resolves spontaneously , will do some in
ves to exclude other illnesses, it can happen again , you should avoid triggers. Supervised excer
sie.

*Ex :

both legs

Power reduced

Hypotonia

Reflexes decreased

Sensations normal

thyroid exm

pulse for thyrotoxicosis.

*DD

Hypokalemic periodic paralysis

Hyperkalaemic , Normokalemic

Thyrotoxic periodic paralysis

GbS no features of previous illness

MGravis

*What other types of Periodic paralysis?

Hyperkalaemia and hypokalemic

Normokalemic responds to NA .

thyrotoxic periodic paralysis

*Inves :
K LEVEL EMG , muscle biopsy , UE , TFT , spinal MRI , NCS .

*Management :PE , Councelling on triggers, Replacement of K , acetazolamide ,

St5)Mr. Steven waugh is a 48 years old man,who was diagnosed with dm2 about 7 years ago.h
e was also diagnosed with htn 5 years ago.

He is now feeling tired more often,and also complains of morning headaches.

His vitals

Bp 150/90

Pulse 85/min

Spo2 96%

Afebrile

Please explore further his complaints

_________________________

overweight person 100 KG , k/C/O DM , HTN , my wife said that I'm snoring at night , get mo
re fatigued recently , Early morning headache, feeling not fresh at the morning , no symp of I
CP , wt increased last few years , no cold intolerance, no change in ring size , no heart racing
, on metformin, aspirin , 7.5 last HBA1C , BP controlled , I do regular eye check up renal funct
ions ok , fhx mother had thyroid problem and DM , ask about alcohol intake , smoking history

Driving should be stopped , refer to DVLA , and sleep clinic once we have the test results will
be giving you some ttt , will do some blood tests .

*concern :

Do you think my snoring is normal because of my wt ?

You should Lose wt ,will refer you to dietitian, advise you to do regular exercise, moderate ur
alcohol intake , smoking cessation clinic , will do blood tests .

will you admit me ? You can go home but u shouldn't drive will call someone to drive you ho
me .

*Dx :
OSA .

*DD:

OSA secondary to metabolic synd

*Ex :

Thyroid ,R/o acromegaly , Adenoid polyps or tonsils if time allows , Collar size ,P2 sounds.

*Modifiable risk factors :

Control wt , diet , excersie, DM and HTN , control underlying disease.

*Where you will do it ?

Sleep clinic, pulse oxy can done at home , Epworth sleeping scale .

*any test you know to determine whether his snoring is normal or not ? Polysomnography

*Management :

Councelling about alcohol and sedatives if any.

TTT underlying disease.CPAP and mandibular devices.

__________________________________________________________________________________

St5 )Mr,smith is a 42 years old man,who is known to ve hypertension for 7yratd,and he is takin
g candesartan 16 mg od for that.He started to complain of headaches and dizziness,for a perio
d of 6 months.Please evaluate the patient.

His vitals Bp 130/77 Pulse 84/min Afrbrile Spo2 97%

___________________________
Headche 2-3 months , feeling fatigued all the time, , pressure in front of my head constant pa
in ll the time , dizziness , BP controlled , no recent change in the dose , no other med ,no PM
H , no FHX , smoker 2 packs /day , alcohol occasionally, no stressful factors , working as gas c
ar mechanic, ask about arrythmias convulsions for CO poisoning.

*Ex:

Bp standing sitting.

Skin color.

Papilledema and retinal hgs for (CO poisoning)

*DD:

Chronic Co poisoning.

Chronic fatigue synd , depression, meningitis ,

*Inves:

carboxyhemoglobin levels :

10-30 % symptomatic

More than 30 % indicates severe toxicity

*management :

100% O2 , avoid triggers

st2) Gp letter , Thank you doctor for seeing mrs.Ann. She is a 27 years old lady,who is new to
my practice.She shifted in the city recently to continur her law degree in the local university.She
presented to me about 1week before with fever,sore throat and cough and fatigue.i suspected h
er to ve urti n prescribed her amoxicillin.

Today,she presented to me again with fever,and a skin rash.her vitals are :

Bp 95/55 pulse 108/min

Temp 37.8c

I suspect she might ve developed allergic reaction to penicillin.

_______________________________

Fever 1 wk b4 had throat infection Gp gave me some med , but 2 days before developed rash
in my legs and full body , i feel sick , high fever around 38 , no diurinal variation, night sweati
ng , no cough , no chest pain , no sob , racing of heart beats only with fever , mouth sores ,
had 2 attacks of vomiting, no tunmy pain , no lose motions , no change in water work , bliste
rs all over body , generalised body aches , no extra marital relationships , no recent surgeries,
smoking alcohol occasionally, pmhx epelipsy on phenytoin for 3 years , 2 wks back some new
med added after one attack of sz ,

*Dx:

Steven Johnson (Lamotrig penicillin and phenytoin)

*inves :

Basic Esr crp CXR, C/s from bullae

RFT for dehydration.

*Management :

ICU admission, review drugs by neuro, IVF , pain killer , steroids ,

*NB :

Drugs cause Stevens Johnson :

Penicillin

Sulphonamide

Carbamazepine
Allopurinol

NSAIDs

OCP

St5Ms.kate is a 33 years old woman,who presented with complaints of difficulty eating,and she h
as lost about 8kg weight in the last 3 months.

She is stable vitally.

U r sho in medical ward.

Ur consultatnt wants u to evaluate her.

_________________________

Difficulty in swallowing, for both solids and liquids , increasing, severe now , presents all the tim
e , apetite preserved, no neck swelling, no hypo or hyperthyroid symp , no skin tightness, no
bowel changes , no dropping in eyelids, no speech prolems , no drugs , not smoking not drin
king alcohol , no tummy pain , no difficulty in breathing.

*Ex:

Eyes pallor ,Thyroid

*Concern :

What's happening with me ?

Could it be problem in the nerves responsible for swallowing, or growth in ur gullet , we need
to do images , Camera test

Could it be ca ? In your age it's very unlikely, but will do inves to exclude it .

*DD:
Achalasia.

Malignancy ?

*inves:

Basic , inflammatory markers,

Barium swallow (contraindicated in pregnancy) , manometry excessive LOS tone doesn't relax on
swallowing , CXR wide mediastinum and fluid level

*TTT of achalasia :

Intra sphincteric injection of botulinum toxin ,

Heller cardiomyotomy

Balloon dilatation

Station 2: 35 years old lady referred to you who presented to her gp with feeling of abnormal
heart beat since few months, examination and 12 lead ECG is normal, kindly facilitate

_______________________________

abnormal beats for 6 months , it was happening around 1_2 /wk , but now it becomes more fr
equent , intermittent , neither fast nor slow , feel it like missed beats , everything make it wors
e so no specific aggravating factors , no LOC , no dizziness, no chest pain , no SOB on lyin
g flat , no LL swelling, no cough, no preference to specific weather , no wt change , not hype
rtensive not diabetic , no hx of heart attack or heart problem , no hx of lung problem , no s
weating , no weakness , father died of heart attack in his 60 (mother also???) , no hx of gland
problem , not on any med , smoking more than 4 packs /day, alcohol more than 1 bottle /d
ay ask about CAGE , her job is affected , there is hx of recreational drugs last dose was 10 yea
rs back ,

Was on lithium for bipolar but stopped 5 years back . Ask about mood .

*Concern:
*Is it heart attack ?

We need to examine you, admit you and do further tests and images to answer ur question ,

*Will I die like my father ?

*Can I do my job?

Advise u to take a rest till we know what's going on with you .

Stop driving till we get final dx.

*DD:

Anxiety excess caffeine alcohol anaemia

Structural MVP

*Inves :

CBC TFT, drug level (lithium) ,

ECG during episode to detect any ectopics ,

24 holter , ECHO , U&E K mg Ca ,

*Management :

life style mod , smoking cessation clinic , alcohol rehab ,

MDT cardio and psychiatrist , if these measures are not effective we can provide some tablets t
o control rythem , depending on the cause

St5)plz see this 54 yrs old male Mr Patrick.. sudden onset of Shortness of breath for 1 day and
chest tightness.

Please see and advice

O2 sat: 90% on Room Air

PR: 94/min

BP: 126/80

Temp: 37. Also raised tropinin at 81 (normal less than 34)

_____________________________

sudden chest tightness when i was climbing stairs, lasted for only couple of minutes, , at the ce
nter of the chest , sharp pain while breathing in , 7/10 , happened yesterday and this morning,
not referred to any other site , breathing in makes it very bad , associated with SOB , no cou
gh , PMHX HTN on amlodipine 5mg , no leg swelling, no hx of recent travels , no hx of hops
ital admission, working as taxi driver , was smoking for 5-6 years but stopped, no hx of blood
clots , no recent hx of no sore throat no fever , fhx not aware of that.

*EX:

Pulse normal

Chest normal

S1 s2

No bibasal crp

No PulmHTN

No LL edema no calf swelling

*Concern :

My dr told me I have high troponin what'sthe cause of that ?

We need to do Blood test , tracing of heart , chest imaging , on the background of high trop
i need to r/o heart attack , clots in lung

*DD :

PE

Acute coronary synd but there is no other risk factors , pain not radiated

Acute pulmo HTN

*Inves:

ECG looking for ST elevation tachy s1q3t3 , CXR , D dimer, ECHO , RFT , f/u troponin Levels ,
CTPA , ABG

*DD of raised trp ?

Acute coronary synd ,PE , myocarditis, renal failure , sepsis ,

St5)You are the Medical SHO in AMAU... GP LETTER:

Dear colleague

Ms. Ali is a 38yrs old female who presented with a lump in her neck.. plz see and advice

Vitals:

O2 sat: 99%

PR: 78/min

BP: 118/84

Temp: 36.6

______________________________

Noticed it 3-4 months ago , not increasing , not painful , on the left side of the neck , no swa
llowing problems , no hx of fever , no cold or hot intolerance, no change in water wark , no c
hange in bowel movement, no skin rash , no eye pain or redness, no change in wt , no sweati
ng , PMHX irregular beats for couple of years , on warfrin and bisoprolol no SOB no chest pai
n fhx nil , not smoking not drinking alcohol , working as Secretary not affecting her work.

*Ex:

Fairly firm cystic mass , moves with swallowing , No Neck scar , No tenderness , No tremors

No murmers , No gland bruit , Pulse irregular irregular , No Chemosis opthalmoplegia led lag

LL for Myxedema
*Concern :

*What I have ?

The lump is likely to be coming from a gland situated in front of ur neck called thyroid gland,
secreting excess hormone causing this abnormal beats , will do blood tests , scans , may we n
eed to take snip to be checked under microscopy , will refer you to gland specialists

*Can it be cancer?

Couldn't find any evidence suggesting malignancy, i need to do more inves may we need to t
ake snip from ur gland for further examination .

*DD:

Toxic adenoma

Dominant nodule in multi nodular goiter

Malignancy

*INVES:

TST , ab screen , Us neck , FNA if needed (to R/O Ca)

St4) 75 dementia , severe chest infection, admitted to hosp , confused pulling out his cannula,
wandering around , so was given small dose of lorazepam , but he developed resp Arrest , re
suscitated, talk to son explain

answer concerns :

______________________________

NOK

Understanding, he doesn't know what's going on with father Explain condition when he came t
o hospital , was agitated pulling out his cannula, dr decided to give him medication to calm hi
m down , unfortunately he reacted badly to it , any med has bad and good effects , ur father
developed this bad effect,

why you gave him this med , your father was in danger bcz he was pulling out his cannula ,
may harm himself and others , med was given in the best interest of gim to calm him down ,
why u didn't call me and tell me about that ?
If my father developed another agitation are u going to give same med again ? No as he react
ed badly to this med will give him another type of med if developed any , can u garantee th
at this problem won't happen again ? no but will try to avoid that med.

*Concern:

Worry about the management plan ?

What about his health in the past ?

Memory problem , but able to move , no illnesses

With whom he is living?

Advice regarding home condition, keep a close eye on him ,keep him away from fire , bracelet

*Viva ques:

U didn't say sorry ?

Do u think u should be sorry ?

Yes bcz his father developed this side effect

*Managment :

Stabilisation, will involve consultant , no u have to involve another one , she said neurological d
r examiner agreed , another candidate mentioned we can give haloperidol

*Did u ask his son what he is doing for living?

U have to ask about financial issues.

*Focus on social hx more, involve social worker , son's financial issues , carers

*If father wanted to leave hospital? Wha this called in communication? Called DOLS (deprivati
on of liberty and safeguard )

St2)Ms.Marium 25 yrs c/o Lt side weakness and on

 OCP and BP 149/90

You are medical doctor.

__________________________

Numbness left side of body , can't move lt side ,lasts for 3 hours , first time to happen , affect
s UL and LL , resolved now , rt sided headache b4 the attack , no speech or swallowing proble
m ,past hx of migraine, but the recent headache is different , no pmhx , no dm or HTn , me
d OCP for 1 year , father stroke at the age of ? , mother is diabetic, no sibling , not smoking
not drinking alcohol , no recreational drugs , teacher , peroid regular , no skin rash ،no limb w
eakness, no facial assym, , cholesterol not checked before , no joint pain , no tummy pain ,
no fever , no loss wt no loss apetite, not driving , ask about headache in details (to exclude
migraine) compressing headache , hx of visit to hair dresser (carotid artery disec) ask about nec
k pain, similar case came one year before there was neck pain and weakness developed after vi
siting hair dresser ,

*Concerns :

*Do i have stroke like my father ? Will u admit me ? Can it happen again ?

Yes it can happen again if u didn't recieve ttt , ministroke one of the possibilities, will admit y
ou , stop OCP at the moment ,

*DD:

TIA as symp resolved now

Stroke ask about all risk factors : vasculitis, thrombophilia, paradoxical embo ,

Hemiplegic migraine

Carotid artery disec

*Is it TIA or stroke ? Examiner was not happy for mentioning HTN in ABCD score

*Inves:
Admission as ABCD more than 4 (examiner was not happy about that )

CBC , blood sugar , lipid profile ,head , ESR , CRP , autoAB , ECG for AF , ECHO paradoxical e
bmbolism , carotid doppler

St4 82 yrs old male known case of DM &diagnosed with ILD for last 2 yrs during which he has
many admission to the hospital &one admission to the ICU ,he tried with him many medicatio
ns but unfortunately failed to control his symptoms &also steroid tried but lead to deterioration
of his diabetes that's Why it was stopped the chest doctors decided palliative treatment for him
bcoz of poor prognosis for him .your task to talk to his son about his father condition &palliati
ve care for him

____________________________

*summary by dr mustafa*

- Explain the disease: inflammation result in lung scaring.

-curablity:

not curable and steroid cause high suger, the only option we have oxygen therapy.

- prognosis:

variable, differ from one to another but overall- progressive disease and will get worse with tim
e. Your father now has advance disease.

- death:
Unpredictable because of the disease variability but definitely the disease will shorten your father
live. However, we speak about months rather than years.

- explain the ttt:

. MDT composed mainly of chest Dr, palliative team, chest nurse, social, ... etc.

. Mainly palliative, their job to (.......) Explain palliative in detail bcoz written in scenario it is the
main ttt.

. Oxygen therapy:

(15 hrs a day, it should be away of fire, close the valve if there is fire, don't smoke near
it, refill setting, social workers can help to provide oxygen concentrator (especially in UK exam c
enters), specialised nurse will explain more about the way of use)

. In case he developed infection he would receive ttt and antibiotics.

. Follow up.

-Social HX:

. With whom he live?

. If alone, did you think before about nursing home? What do you know about it? I think it is t
ime to think about it.

- advance directive; power of aut.; pt wishes.

- Other Concerns?

Transplantation:

What do you know about it?

It is a major operation and your father may die during the operation; not fit because of the co
-morbidity; difficult in your father condition; recurrence possibility in new lung; outwight the ben
efits and the drawback;.....etc.

- Closure :

Smoking, alcohol,

Summary and check understand,

Offer leaflets & videos, involve consultant and GP

(another summary 😃😃)

st4)Pumon fibrosis end stage resp failure,referred to Palliative ttt

Explain father's condition to the son and answer his concerns :

____________________________

*Understanding , NoK

*ask about carers Quality of life

*BBN Chest physicians decided to refer him to Palliative team , ttt symptoms only , if developed
sob will give him med to make his breathing better

*LPA , AD

*ask about DNR

*explain clearly that this disease will shorten his life , Could be days weeks or hardly could be
months

*discuss advanced care planning.

*Viva Q:

Why it's imp to give time period?

To be prepared for amy financial discussions with the father

Why do you think that GP should be infromed ?

Station 2: 48 years old lady c/o tiredness. HB is 9.5 g/dL , MCV is 78 . Take history and answe
r her concerns.

______________________________

Tirdeness for the last 6 months!, no diurinal variation, presents all the time , asked about all s
ymp of anaemia dizziness sob palpitation on exertion, angiodysplasia , menst , wt loss 5 kg ov
er the last 7 months , apetite is ok not changed , no hx bleeding , no changes of bowel habits
, no lumps or pumps no nt fever , has knee pain for few months , no stiffness no other joint
pain no skin rash , , drugs hx was on NSAID not taking PPI has tummy pain , not smoker , p
eroids are normal , candidate missed to ask mouth sores which , lose motion , relation to pasta
to r/o or to confirm celiac diease.

*Concern :

Why am having low blood counts?

There are many reasons , could be related to ur med which can cause sores in ur bowel and b
lood loss will do camer test ,and stop ur med

*Could it be cancer ?

Its one of the possibilities in a view of wt loss will do camera test through mouth and back pa
ssage.

*DD

Celiac

Durg induced gastritis

Malignancy

Dietary patient easts little meat .

*Inves :

Cbc , LFT CRP ESR iron profile stool occult blood , upper GIT endo, colonsocopy to rule out co
lon ca ,
*Do u think u answered her coner properly?

*How do u dx celiac ?

Biopsy ab

* What's the effect of NSAID on bowel?

Microscopic colitis, what else ?

Maybe examiner wanted to hear Villious atrophy

got 16

Most porpable dx is celiac disease in this cas

Station 5: BCC1: 24 years old female c/o fluttering sensation in the chest for the last 6 months .
TFT normal. All vital signs are normal written in the scenario.

_______________________________

Fast heart beats , lasts for few seconds then disapper , started 6 months ago comes during re
st , no SOB no fainting attacks , becomes more frequent , no sympt of hyperthyro , doing ver
y stressful job , caffaien drinks more than 5 cups/day , no over counter med , smoking alcohol
nil , no fhx of heart problems , asked about pregnancy pills menses , drug list salbutamole and
citalopram , Anxiety for many years , salbutamole using it 4 times /day

*Concern :

It Could be due to ur med stress , we need to do elect tracing

Advice about caffeine stress , will refer u to GP may need to add another type of inhaler to de
crease the frequency of using this inhaler ,

*Ex:

Hands for tremors pulse sweating all were normal.

No Pallor
Cvs normal

*viva:

What are ur findings

Did u hear any murmer

No

*DD :

Paroxysmal arrythmia

Anxiety

Drug induced salbutamol , citalopram causing long QT synd

MVP

*Inves:

CBC , resting ECG if normal will do holter monitor for 7 days , echo to rule out structural heart
disease

Station 4: 72 years old demented male was admitted to the hospital with pneumonia, started o
n iv antibiotics. Task: talk to his son who is angry because he was not informed or consented b
efore starting the antibiotics. Also requesting to start alternative medications like herbal and garli
c.

_______________________________

*Understanding.

*Living in nursing home , very angry son as the medical team didn't tell him before starting A
B
Sorry for what happened to ur father i know u care about him , explained that pneumonia wou
ld be fatal if not ttt properly

*Why you started him on AB? I know this medicine can cause Cl dif , some can cause bad effe
cts starting ab is the best option again spoke about pneumonia

*in our practice we are not starting our patients on these types of med which are not tried bef
ore what if he had side effects under close observation will be moniterd and ttt effectively if a
ny side effects happened , benefits are greater than bad outcomes ,

* there are many researches about ulternatives like garlic why you don't try these ulternative he
rbal med ?

*we don how harmful they could be because they are not tried before , ab was tried hundred
of times on many patients and their effects are well known and they are treating pneumonia,

*they are natural med not chemical how can ghey be harmfuk , just reas not tried before on p
atients , don know to cause harm because we don't know about their effects , *did u see him
recently? Yes i think he is better , it's good news this proves that he responding to our med ,

conditons before admission , u said he is living in nursing home , yes bcz am living far from hi
m , asked about condition there whether they are taking care of him , he doesn't have other c
oncerns , summary checked undersat,

*Do u think u convinced him ?

I think yeh bcz he doesn't have any other concern.

What principles u depended upon on explaining the situation?

Beneficence by starting him on AB

Non mal by not giving herbal which is not tried before

Dealing with Incompetemt pt

*Do u think son has right to refuse ttr ?

I think yeh if he has LPA and if patient has Ad

Wht if he has AD and refused to be ttt?

Do u think AB are one of the types of invasive ttt ?