Scenarios Part 1 For PLAB 2

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INDEX
S.NO TOPIC PAGE NO.
1 Alcoholic hepatitis 2 – 5
2 Antenatal assessment 5 – 9
3 Nosebleed Apixaban 9 – 11
4 Depression-CBT failed 11 – 14
5 Cystic fibrosis-prenatal counseling 15 – 17
6 Child with tantrums 18 – 20
7 Patient with lymphadenopathy-STI 21 – 23
8 Elderly woman-Medication review 23 – 25
9
Feeling unwell-on oxybutynin
25 – 28
10 Post Herpetic Neuralgia 28 – 30
11 Premature ovarian insufficiency 31 – 34
12 Subcutaneous injection teaching 34 – 35
13
Seborrheic keratosis
36 – 38
14 Urticaria 39 – 40
15 Optic neuritis (multiple sclerosis) 40 – 42
16 Urine dipstick – teaching 42 – 45
17 Erectile dysfunction 46 – 48
18 Bacterial vaginosis 48 – 51
19 Premenstrual syndrome 51 – 53
20 Non accidental injury (sexual harassment) 53 – 54
21 Teenager confused about sexual orientation 55 – 60
22 Epipen Use - Teaching 60 – 65
23 Meningitis prophylaxis – Talk to Father 65 - 68

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Alcoholic hepatitis
You are FY2 in GP clinic. A man aged,40 came for the blood reports. Explain
results to him and discuss further management.
Bilirubin-Normal ALT-
Normal
AST-63(Raised)
History
Dr:Hello,I understand you are here for your blood tests. Before we discuss that, can
I ask why did you in the first place?
Pt:Just for my regular blood checkup. Dr:Alright,do you any symptoms at the
moment? Pt:No
Dr:Any tummy pains? Pt:No
Dr:Any fever? Pt:No
Dr:Any yellowish discoloration of body
Pt:No
Dr:Any vomiting or diarrhea(Hepatitis A)? Pt:No
Dr:Any color change of stools or urine?(Obstructive jaundice)
Pt:No
Dr:Any weight loss or lumps and bumps in body?(Malignancy)
Pt:No
Dr:Any blood transfusions ,tattoos?(Hepatitis B) Pt:No
Dr:Have you ever been diagnosed with any STI?(Hepatitis B,C)
Pt:No
Dr:Ask sexual history from the patient Dr:Do you have any
health problems? Pt:No
Dr:Are you using any medication? Pt:No
Dr:Any allergies? Pt:No
Dr:Anyone in the family with liver problems? Pt:No
Dr:Do you smoke? Pt:No
Dr:By any chance do you use recreational drugs? Pt:No
Dr:Do you drink alcohol?
Published by dr-notes.com

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Pt:Yes,half glass of wine daily from last 20 years (Do CAGE for alcohol
consumption)
Examination
I would like to check your vitals i.e. your BP,pulse,temperature and respiratory rate.
Also I will do general examination of you including your tummy examination in
particular to liver and spleen.
Management
Explain results.
Dr:From what you have told me and from your blood results, we think that you are
having a condition called alcoholic hepatitis unfortunately. It means that your liver has
been affected by your excess alcoholintake.
Pt:What can you do now?
Dr:We will do further tests like GGT and Ultrasound scan of your tummy.
Pt:Ok
Dr:We will refer you to specialist doctor called gastroenterologist who will talk to you in
detail. Is that ok?
Pt:Ok
Dr:We would advise you to stop drinking as well. What do you think?
Pt:I love alcohol, I can’t stop
Dr:(Convince the patient on alcohol cessation and offer replacement and support)
Dr:We will arrange your follow up in 2 weeks. In the meantime, if you feel any tummy
pains, any yellow discoloration of your body, bleeding from anywhere in your body,
please let us know.
Reference information:
Symptoms of alcohol-related liver disease (ARLD)
ARLD does not usually cause any symptoms until the liver has been severely
damaged.

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When this happens, symptoms can include:
• feelingsick
• weightloss
• loss of appetite
• yellowing of the eyes and skin(jaundice)
• swelling in the ankles andtummy
• confusion ordrowsiness
• vomiting blood or passing blood in yourstools
This means ARLD is frequently diagnosed during tests for other conditions, or at a
stage of advanced liver damage.
Treating alcohol-related liver disease (ARLD)
There's currently no specific medical treatment for ARLD. The main treatment is to
stop drinking, preferably for the rest of your life.
This reduces the risk of further damage to liver and gives it the best chance of
recovering.
If a person is dependent on alcohol, stopping drinking can be very difficult.
But support, advice and medical treatment may be available through local alcohol
supportservices.
• spread your drinking over 3 days or more if you drink as much as 14 units
aweek
A unit of alcohol is equal to about half a pint of normal- strength lager or a pub measure
(25ml) of spirits.
A liver transplantmay be required in severe cases where the liver has stopped
functioning and does not improve when you stop drinking alcohol.
You'll only be considered for a liver transplant if you have developed complications
of cirrhosisdespite having stopped drinking.
All liver transplant units require a person to not drink alcohol while awaiting the
transplant, and for the rest of their life.
Complications
Life-threatening complications of ARLD include:
• internal (variceal)bleeding
• build-up of toxins in the brain(encephalopathy)

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• fluid accumulation in the abdomen (ascites) with associated kidneyfailure
• livercancer
• increased vulnerability toinfection
Preventing alcohol-related liver disease (ARLD)
The most effective way to prevent ARLD is to stop drinking alcohol or stick to the
recommended limits:
• men and women are advised not to regularly drink more than 14 units aweek.
Antenatal assessment
You are FY2 in Antenatal clinic. A 32 year old lady is coming for her antenatal
assessment. She is 14 weeks pregnant. Talk to her and address her concerns.
Her lab results are:
Blood group:O Rheseus type:RH -ve Rubella:Non
immune
All other blood tests like LFT’s ,RFT’s and U and E’s normal.
USG:Singelton fetus
History
Dr:Hello,my name is dr XYZ.I am one of the junior doctors in antenatal
clinic. How can I help you?
Pt:I am here for my regular checkup.
Dr:Alright,I understand that we did some blood tests last time you visited us. I have
the results with me.Before that may I ask a few questions from you?
Pt:Ok
Dr:I understand that you are 14 weeks pregnant so how is your pregnancy so far?
Pt:Fine doc Dr:Any
vomiting? Pt:No
Dr:Any bleeding through vagina? Pt:No
Dr:Any tummy pains? Pt:No
Dr:Is this your first pregnancy? Pt:Yes
Dr:Any miscarriages before? Pt:No

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Dr:Any fever,rash(Rubella) Pt:No
Dr:Do you have any health problems like increase blood pressure, blood sugar or
clots in lungs or legs?
Pt:No
Dr:Any allergies?
Pt:No
Dr:Are you sexually active? Pt:Yes
Dr:Are you in a stable relationship? Pt:No
Dr:How many partners do you have in last 6 months? Pt:2,3
Dr:Do you practice safe sex? Pt:No
Dr:Do you know the biological father of the baby? Pt:No
Dr:Have you ever been diagnosed with any STI? Pt:No
Dr:What you do for your living? Pt:Nothing
Dr:Do you smoke?
Pt:Yes
Dr:Ask how much a day?From how long? Dr:Do you consume
alcohol?
Pt:Yes
Dr:Ask how much a day?From how long?
Dr:By any chance do you use any recreational drugs? Pt:Yes
Dr:What do you use?
Pt:Heroin
Dr:How much a day?From how long?Do CAGE.Ask about needle exchange.
Examination
Now I would like to check your vitals i.e. your BP,pulse, temperature and respiratory
rate. Also general examination of your whole body. Is it ok?
Pt:Ok
Discuss test results
Dr: Everything is normal.However,your blood group is O-ve,it means that we have to be
a bit careful if baby is O+ve.For that, I will discuss with my seniors and we will discuss
regarding this in next visit ok?
Pt:Ok

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Dr:Also ,your results are showing that you are not immune to rubella infection.
Did you have this infection earlier in your life?
Pt:No
Dr:For this,we will recommend you to avoid close contacts with people who
have symptoms like fever,sorethroat or rash on body.Is it ok?
Pt:Ok
Dr:Fortunately,you have a single, healthy pregnancy as well.
Pt:Ok
Management:
• Advice her on smokingcessation
o Offer support via replacement therapy, support groups and
smoking cessation clinic.
• Advice her on alcoholcessation.
o Offer support via replacement medicines, CBT,support groups and
alcohol cessation clinic.
o Tell her that smoking and alcohol both can badly affect the
development ofbaby.
• As she is a heroin abuser,advice her to stop using it as it can also
affect herbaby.
o Offer support via CBT and Narcotic anonymous supportgroup.
• Advice her on safesex.
Dr:We will also do your blood tests regarding any sexual transmitted
infections(HIV, Syphilis).Is it ok?
Pt:Ok
Dr:We will arrange your next follow up in a month. In the meantime, if you feel
unwell in anyway like fever
,tummy pains or bleeding through vagina, please let us know.
Rubella
What are signs and symptoms of rubella?
About half of people with rubella have signs and symptoms, and half don’t. Rubella is
usually mild with flu-like symptoms followed by a rash. The rash often lasts about 3

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days. Flu-like symptoms include:
• Low-grade fever
• Headache
• Runny nose
• Red eyes
• Swollen glands
• Muscle or joint pain What causes rubella?
Rubella is caused by a virus (a tiny organism that can make you sick). It’s very
contagious and is spread through the air from an infected person’s cough or sneeze.
What problems can rubella cause during pregnancy?
Rubella can be a serious threat to your pregnancy, especially during the first and
second trimesters.
Having rubella during pregnancy increases the risk of:
• Congenital rubella syndrome (CRS) – This is a condition that happens when a
mother passes rubella to her baby during pregnancy. It may cause a baby to be born
with one or more birth defects,
including heart problems, microcephaly, vision problems, hearing problems,
intellectual disability, bone problems, growth problems, and liver and spleen damage.
• Miscarriage – This is when a baby dies in the womb before 20 weeks of
pregnancy.
• Stillbirth – This is when a baby dies in the womb after 20 weeks of pregnancy.
• Premature birth – This is birth that happens too early, before 37 weeks of
pregnancy.
Can you pass rubella to your baby during pregnancy?
Yes. The best way to protect your baby is to make sure you’re immune to rubella.
Immune means being protected from an infection. If you're immune to an infection, it
means you can't get the infection.
Most likely you’re immune to rubella because you were vaccinated as a child or you
had the illness during childhood. A blood test can tell whether or not you’re immune to
rubella. If you’re thinking about getting pregnant and aren’t sure if you’re immune, talk
to your health care provider about getting a blood test.
If you’re not immune to rubella, here’s what you can do to help protect your baby:
Before pregnancy. Get the m easles, m umps and
rubella (MMR) vaccine. Wait 1 month before trying to get pregnant after getting the
shot.
During pregnancy. You can be tested at a prenatal
visit to make sure you’re immune to rubella. If you’re not immune, the MMR vaccine
isn’t recommended during pregnancy. But there are things you can do to help
prevent getting infected with rubella:
• Stay away from anyone who has the infection.
After pregnancy. Get the MMR vaccination after you give birth. Being protected from
the infection means you can’t pass it to your baby before she gets her own MMR
vaccination at about 12 months. It also prevents you from passing rubella to your baby
during a future pregnancy.
What are the chances of passing rubella to your baby during pregnancy?

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You’re more likely to pass rubella to your baby the earlier you become infected during
pregnancy. For example:
• If you get rubella in the first 12 weeks of pregnancy, your baby has about an 8 to
9 in 10 chance (85 percent) of getting infected.
• If you get rubella at 13 to 16 weeks of pregnancy, your baby has about a 1 in 2
chance (50 percent) of being infected.
• If you get rubella at the end or your second trimester or later, your baby has about
a 1 in 4 chance (25 percent) of getting infected.
If you have rubella during pregnancy, your baby’s provider carefully monitors your
baby after birth to catch any problems early.
Nosebleed Apixaban
You are FY2 in General practice. James Carter, aged 25, has had a nosebleed. He
is on Apixaban. Talk to him and address his concerns.
History:
Dr:Hello,my name is dr XYZ,I am one of the junior doctors in GP clinic. How can I help you?
Pt:Doc,I had bleeding through my nose 2 hours ago. Dr:I am sorry about that. How are you now?
Pt:I am fine now.
Dr:How much did you bleed? Pt:Around 1/4th of a glass.
Dr:For how long did you bleed? Pt:Around 10 minutes
Dr:What were you doing when it started?
Pt:I pricked my nose then bleeding started
Dr:What did you do to stop it?
Pt:Nothing ,I just put a towel on my nose
Dr:Is it the first time it happened?
Pt: Yes
Dr:Bleeding from anywhere else in the body? Pt:No
Dr:Any bleeding disorders? Pt:No
Dr:Any fever/ infections?(Blood malignancies) Pt:No
Dr:Any weight loss or lumps or bumps in body? Pt:No
Dr:Any tiredness?(ITP) Pt:No
Dr:Any headaches? Pt:No
Dr:Do you have any health problems? Pt:I have clot in my leg from last 3 years.
Dr:Sorry for that. What are you taking for it? Pt:I am taking apixaban

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Dr:From how long? Pt:Last 3 years
Dr:Are you taking it as prescribed?
Pt:Yes
Dr:Are you going for your regular blood check up? Pt:Yes
Dr:Are you taking any other medicine(blood thinner)? Pt:No
Dr:What you do for living? Pt:I am a student.
Examination
I would like to check your vitals now i.e. your blood pressure, temperature ,pulse and respiratory
rate.
I would also check your nose ,mouth and glands in your body.
Diagnosis
Dr:From what we have discussed we suspect that you had this nosebleed because you pricked your
nose unfortunately.
So, we would advice you not to prick your nose when you are on Apixaban. Is that ok?
Pt:Ok doc
Pt: What do I do when I get bleeding?
Dr: You should:
- sit or stand upright (don't lie down)
- pinch your nose just above your nostrils for 10 to 15 minutes
- lean forward and breathe through your mouth
- place an icepack (or a bag of frozen peas wrapped in a tea towel) at the top of your nose.
When a nosebleed stops:
After a nosebleed, for 24 hours try not to:
- blow your nose
- pick your nose
- drink hot drinks or alcohol
- do any heavy lifting or strenuous exercise
- pick any scabs
Go to the A&E:
- your nosebleed lasts longer than 10 to 15 minutes
- the bleeding seems excessive
- you’re swallowing a large amount of blood that makes you vomit
- the bleeding started after a blow to your head
- you’re feeling weak or dizzy

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- you’re having difficulty breathing.
Hospital Treatment
If doctors can see where the blood is coming from, they may seal it by pressing a stick with a
chemical on it to stop the bleeding. If this isn't possible, doctors might pack your nose with sponges
to stop the bleeding. You may need to stay in hospital for a day or two.
Dr:We will also do some blood tests to check you are not anaemic and everything is fine with your
liver and kidneys. Also we will check your INR levels as well.
Pt:Ok doc
Dr:Any other concerns? Pt:No
Dr:We will arrange your follow up in a month. In the meantime, if you have excessive bleeding or
headache, please let us know. Thank you
Depression-CBT failed
You are FY2 in GP clinic. Steven Douglas, aged 35 has been divorced from his
wife and is in depression. He saw the psychiatrist , was given CBT treatment but
he is not improving on CBT. Talk to the patient and address his concerns.
History
Dr:Hello,how can I help you?
Pt:I am not getting well, I am still depressed Dr:I am sorry, we will try to help you Dr:From how
long you have depression?
Pt:Last 2 months
Dr:Why were you diagnosed with depression? Pt:I got a divorce from my wife 2 months ago
Dr:I am sorry about that, is there anything other than CBT you are taking?
Pt:No
Dr:How many sessions have you taken for CBT? Pt:6 sessions
Dr:Are you taking them regularly? Pt:Yes
Dr:Are you diagnosed with depression for the first time in life?
Pt:Yes
Dr:How is your mood now? Pt:Low
Dr:Can you score for me on the scale of 1 to 10? Pt:Around 2 to 3
Dr:Are you having any thoughts of harming yourself or others
Pt:No

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Dr:Do you have family,friends? Pt:Yes, but I don’t meet them. Dr:Why?
Pt:I don’t feel like meeting anyone. I have lost interest in everything.
Dr:What is in your life that is particularly worrying you? Pt:I don’t know may be my divorce
Dr:Do you have any idea how can you come out of this worry?
Pt:I don’t know doc
Dr:Do you have any other stress in your life? Pt:No
Dr:How is you sleep?
Pt:I am getting up early in the morning now a days. Dr:What you do for living?
Pt:I am a plumber
Dr: Do [FAMISHT],ask about smoking, alcohol(drinking heavily)
Examination
I would like to check your vitals i.e. your BP,pulse,temperature and respiratory rate. Also general
examination of your body.
Management
Dr:From what we have discussed, we can see that CBT is not working on you so what we can do is
,we can refer you to specialist doctor,psychiatrist.What do you think about it?
Pt:Ok what he will do then?
Dr:May be he will start you on Anti depressants. Pt:Does antidepressant have side effects?
Dr:Yes ,it has some side effects but they improve with time like nausea,headaches,dry mouth.
Pt:Will I get addicted to them?
Dr:No,we will taper the dose of medicine so that you don’t have any addiction.
Pt:For how long I have to take this? Dr:For minimum 6 months
Pt:Does it cause loss of libido?
Dr:Some antidepressants like SSRI’s can cause reduce libido, we can take care of this side effect by
giving you some other antidepressant like TCA(Amitriptyline) which doesn’t cause reduce libido.
Pt:Ok Dr:
1. Advice patient on cutting down on alcohol ,offer him all replacement and support options.
2. Tell the patient about Sleep hygiene as his sleep is affected.
Dr:We will do all blood tests as well to make sure everything is fine with you. Also we will arrange
a follow up in 2 weeks.in the meantime if you feel that you are having thoughts of harming yourself
or others, please contact us.

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Moderate to severe depression
If you have moderate to severe depression, the following treatments may be recommended.
Antidepressants:
Antidepressants are medicines that treat
the symptoms of depression. There are many different types of antidepressant.
Combination therapy:
A GP may recommend that you take a course
of antidepressants plus talking therapy, particularly if your depression is quite severe.
A combination of an antidepressant and CBT usually works better than having just one of these
treatments.
Mental health teams:
If you have severe depression, you may be referred to a mental health team made up of
psychologists, psychiatrist and occupational therapists.
Antidepressants:
Antidepressants are medicines that treat
the symptoms of depression. There are many different types available. Most people with moderate
or severe depression benefit from antidepressants, but not everybody does.
You may respond to 1 antidepressant but not to another, and you may need to try 2 or more
treatments before you find one that works for you.
The different types of antidepressant work about as well as each other. But side effects vary
between different treatments and people.
When you start taking antidepressants, you should see a GP or specialist nurse every week or 2 for
at least 4 weeks to assess how well they're working.
If they're working, you'll need to continue taking them at the same dose for at least 4 to 6 months
after your symptoms have eased.
If you have had episodes of depression in the past, you may need to continue to take
antidepressants for up to 5 years or more.
Antidepressants are not addictive, but you may get some withdrawal symptoms if you stop taking
them suddenly or you miss a dose.
Selective serotonin reuptake inhibitors (SSRIs):
If a GP thinks you'd benefit from taking an antidepressant, you'll usually be prescribed a modern
type called a selective serotonin reuptake inhibitor
(SSRI).

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Examples of commonly used SSRI antidepressants
are p aroxetine (Seroxat), f luoxetine
( Prozac) and c italopram (Cipramil).
They help increase the level of a natural chemical in your brain called serotonin, which is thought
to be a "good mood" chemical.
SSRIs work just as well as older antidepressants and have fewer side effects, although they can
cause nausea, headaches, a dry mouth and problems having sex. But these side effects usually
improve over time.
Some SSRIs are not suitable for children and young people under 18 years of age. Research shows
that the risk of self-harm and suicidal behaviour may increase if they're taken by under-18s.
Fluoxetine is the only SSRI that can be prescribed for under-18s and, even then, only when a
specialist has given the go-ahead.
Tricyclic antidepressants (TCAs):
Tricyclic antidepressants (TCAs) are a group of antidepressants used to treat moderate to severe
depression.
TCAs, including imipramine (Imipramil) and amitriptyline, have been around for longer than
SSRIs.
They work by raising the levels of the chemicals serotonin and noradrenaline in your brain. These
both help lift your mood.
They're generally quite safe, but it's a bad idea to smoke cannabis if you're taking TCAs because it
can cause your heart to beat rapidly.
Side effects of TCAs vary from person to person but may include a dry mouth, blurred vision,
constipation, problems passing urine, sweating, feeling lightheaded and excessive drowsiness.
The side effects usually ease within 10 days as your body gets used to the medicine.
Venlafaxine and duloxetine are known as serotonin- noradrenaline reuptake inhibitors (SNRIs).
Like TCAs, they change the levels of serotonin and noradrenaline in your brain.
Studies have shown that an SNRI can be more effective than an SSRI, but they're not routinely
prescribed because they can lead to a rise in blood pressure.
Withdrawal symptoms:
Antidepressants are not addictive in the same way that illegal drugs and cigarettes are, but you may
have some withdrawal symptoms when you stop taking them.
These include:
• an upset stomach
• flu-like symptoms
• anxiety
vivid dreams at night

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• sensations in the body that feel like electric shocks
In most cases, these are quite mild and last no longer than 1 or 2 weeks, but occasionally they can
be quite severe.
They seem to be most likely to occur with paroxetine (Seroxat) and venlafaxine (Efexor).
Withdrawal symptoms occur very soon after stopping the tablets so are easy to distinguish from
symptoms of depression relapse, which tend to occur after a few weeks.
Other treatments:
Mindfulness
Mindfulness involves paying closer attention to the present moment, and focusing on your
thoughts, feelings, bodily sensations and the world around you to improve your mental wellbeing.
The aim is to develop a better understanding of your mind and body, and learn how to live with
more appreciation and less anxiety.
Mindfulness is recommended by NICE as a way of preventing depression in people who have had 3
or more bouts of depression in the past.
Brain stimulation
Brain stimulation is sometimes used to treat severe depression that has not responded to other
treatments.
Electromagnetic currents can be used to stimulate certain areas of the brain to try to improve
the symptoms of depression.
There are a number of different types of brain stimulation that can be used to treat depression,
including transcranial direct current stimulation (tDCS), repetitive transcranial magnetic
stimulation (rTMS) and electroconvulsive therapy (ECT).
Electroconvulsive therapy (ECT):
Electroconvulsive therapy (ECT) is a more invasive type of brain stimulation that's sometimes
recommended for severe depression if all other treatment options have failed, or when the situation
is thought to be life threatening.
During ECT, a carefully calculated electric current is passed to the brain through electrodes placed
on the head.
The current stimulates the brain and triggers a seizure (fit), which helps relieve the symptoms of
depression.

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Cystic fibrosis-prenatal counseling
You are FY2 in General practice. A 28 year old lady is coming with some
concerns.Talk to her and address concerns.
Dr:Hello my name is dr XYZ.I am one of the juniors doctors in general practice.
How can I help you?
Pt:I am planning to get pregnant and I am afraid that my baby will get cystic fibrosis.
Dr:Why do you think like this? Pt:My brother has cystic fibrosis. Dr:I am sorry to hear about him.
Dr:Are you planning for your first pregnancy? Pt:Yes
Dr:Do you have any symptoms of CF? Pt:No
Dr:Any recurrent chest infections?(Ask CF symptoms in her)
Pt:No
Dr: Any shortness of breath?
Pt:No
Dr:Any bowel problems? Pt:No
Dr:What about your partner? (Ask same symptoms of CF in partner and partner’s family)
Pt:He is healthy Dr:That’s good
Dr:What are you expecting from us today?
Pt:I want to know that what are my chances to have normal baby?
Dr:Sure,I will draw a diagram to show you.Is that ok? Pt:Ok
Dr:This diagram implies to the scenario, in which you and your partner both are carriers of CF i.e.
you are absolutely healthy but you are carrying one affected gene.Am I clear?
Pt:Yes doc
Rr x Rr
RR Rr Rr rr
Where:
R=Normal gene
R=Affected gene
RR=Normal
Rr=Carrier
rr=Affected(Cystic fibrosis) So,
I. 25%(1 in 4) chances of Normal child.

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II. 25%(1 in 4) chances of affected CF child. III. 50%(1 in 2) chances of carriers Dr:Is
everything clear?
Pt:Yes doc
Dr:We will refer you and your husband to genetic clinic for genetic assessment.Is that ok?
Pt:Sure
Dr:Any other concerns? Pt:What is CF?
Dr:It is an inherited condition that causes sticky mucus build up in lungs and digestive tract. This
causes lung infections and problems with digesting food.
Pt:Is there any treatment for it?
Dr:There is no definite cure for this condition unfortunately but a range of treatments can help
control symptoms and complications.
Pt:Like what doc? Dr:Alright,I will explain you:
• Lung problems:
o Antibiotics to treat chest infections
o Medicines to make the mucus in lungs thin eg hypertonic saline.
o Bronchodilators to widen the airways
o Routine jabs
• Exercise also helps in clearing up the mucus.
• Specific breathing techniques like postural drainage also helps.
• Good high caloric diet including vitamin and mineral supplements is important for CF
patients as mucus makes it difficult to digest food.
• Last resort is lung transplant. Pt:Ok doc any complications of CF? Dr:Complications are:
o Weak and brittle bones (Osteoporosis)
o Diabetes
o Sinus infections/Nasal polyps
o Liver problems
o Fertility problems
But don’t worry all these complications can be managed.
Pt: During pregnancy, can we know how baby is?
Dr:Yes,we have some procedures like amniocentesis or chorionic villous sampling in which they
take some fluid from the baby to check the genetic makeup.
Pt:Ok doc and after the delivery, can we check that whether my baby is having CF?
Dr:Yes,we do heel prick test at birth to check this. If CF is confirmed then we can do further
confirmatory tests as well like sweat test.

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Pt:Ok doc
Dr:Any other concerns? Pt:No doc ,thank you
Child with tantrums
You are FY2 in General practice. A 30 year old mother wants to talk to you
regarding her 3 year old child. Talk to her and address her concerns.
History
Dr:Hello,my name is dr XYZ,I am one of the junior doctors in GP clinic. How can I help
you?
Pt:My child is showing a bit strange behavior now a days.
Dr:Please explain it
Pt:He gets out of the bed when I put him to sleep and then he comes out and plays with
toys.
Dr:I see,is there anything else that you would like to tell about his behavior?
Pt:He also throws the plates when he is given food Dr:From how long he is showing such
behaviour ?
Pt:2 to 3 months
Dr:How many times he shows such behaviour in a day? Pt:3 to 4 times
Dr:Any fits in a day?
Pt:No Dr:Alright,anything else? Pt:Like what?
Dr:Is he able to walk,speak,laugh and cry? Pt:Yes
Dr:Does he have any repetitive behaviour ?(Autism) Pt:No
Dr:Does he have friends? Pt:Yes
Dr:Does he play with different toys? Pt:Yes
Dr:Does he cuddle you back? Pt:Yes
Dr:Any fever? Pt:No
Dr:Does he have any health problems? Pt:No
Dr:Is he on any medication? Pt:No
Dr:Who takes care of the child mostly?
Pt:Grandmother
Dr:How is he with grandmother? Pt:They get along very well Dr:Do you spend time with
him? Pt:Not much
Dr:May I know why?
Pt:I am searching jobs now a days Dr:How is everything financially? Pt:It is fine
Dr:Does he go to Nursery? Pt:Yes,he enjoys there
Examination
Ideally, I would like to examine him.(Patient is not with mother)
Diagnosis

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Dr:From what we have discussed, we think that your son is absolutely fine. This a normal
behaviour usually shown by the children in this age to gain more attention and care from
their loved ones.
Pt:Ok doc so what are you going to do ?
Dr:We can give you some suggestions for how to cope with your son.
• Spend more time with child, show him that you love him.
• Involve him in every activity which you are doing.
• Decorate the kitchen plates which he likes and all family should eat together at a
time.
• At night time, read him stories, kiss him, If he is coming out, again put him to
sleep.
• Don’t get angry on him.
Dr:We will arrange a follow up in a month time. If in the meantime, he develops any fever,
fits or if his behaviour is getting worse ,please let us know.
There are lots of possible reasons for difficult behaviour in toddlers and young children.
Often it's just because they're tired, hungry, overexcited, frustrated or bored.
How to handle difficult behaviour
If problem behaviour is causing you or your child distress, or upsetting the rest of the
family, it's important to deal with it.
Do what feels right
What you do has to be right for your child, yourself and the family. If you do something
you do not believe in or that you do not feel is right, it probably will not work.
Children notice when you do not mean what you're saying.
Do not give up
Once you've decided to do something, continue to do it. Solutions take time to work. Get
support from your partner, a friend, another parent or your health visitor. It's good to have
someone to talk to about what you're doing.
Be consistent
Children need consistency. If you react to your child's behaviour in one way one day and a
different way the next, it's confusing for them. It's also important that everyone close to
your child deals with their behaviour in the same way.
Try not to overreact
This can be difficult. When your child does something annoying time after time, your
anger and frustration can build up.
It's impossible not to show your irritation sometimes, but try to stay calm. Move on to
other things you can both enjoy or feel good about as soon as possible.
Find other ways to cope with your frustration, like talking to other parents.
Talk to your child
Children do not have to be able to talk to understand. It can help if they understand
why you want them to do something. For example, explain why you want them to
hold your hand while crossing the road.

20
Once your child can talk, encourage them to explain why they're angry or upset. This
will help them feel less frustrated.
Be positive about the good things :When a child's behaviour is difficult, the things they
do well can be overlooked. Tell your child when you're pleased about something they've
done. You can let your child know when you're pleased by giving them attention, a hug
or a smile.
Offer rewards : You can help your child by rewarding them for good behaviour. For
example, praise them or give them their favourite food for tea.
If your child behaves well, tell them how pleased you are. Be specific. Say something
like, "Well done for putting your toys back in the box when I asked you to."
Do not give your child a reward before they've done what they were asked to do.
That's a bribe, not a reward.
Avoid smacking : Smacking may stop a child doing what they're doing at that moment,
but it does not have a lasting positive effect.
Children learn by example so, if you hit your child, you're telling them that hitting is
OK. Children who are treated aggressively by their parents are more likely to be
aggressive themselves. It's better to set a good example instead.
Things that can affect your child's behaviour
Life changes – any change in a child's life can be difficult for them. This could
be the birth of a new baby, moving house, a change of childminder, starting
playgroup or something muchsmaller.
You're having a difficult time – children are quick to notice if you're feeling
upset or there are problems in the family. They may behave badly when you feel
least able to cope. If you're having problems do not blame yourself, but do not
blame your child either if they react with difficult behaviour.
How you've handled difficult behaviour before – sometimes your child may
react in a particular way because of how you've handled a problem in the past.
For example, if you've given your child sweets to keep them quiet at the shops,
they may expect sweets every time you gothere.
Needing attention – your child might see a tantrum as a way of getting
attention, even if it's bad attention. They may wake up at night because they
want a cuddle or some company. Try to give them more attention when they're
behaving well and less when they're beingdifficult.
Extra help with difficult behaviour
Do not feel you have to cope alone. If you're struggling with your child's behaviour:
talk to your health visitor – they will be happy to support you and suggest some
new strategies to try
visit the Family Lives website for parenting advice and support.

21
Patient with lymphadenopathy-STI
You are FY2 in General practice. A 23 year old male is coming with some
complaints. Address them and discuss further management.
History
Dr:Hello,my name id dr XYZ.I am one of the junior doctors in GP clinic. How
can I help you?
Pt:I felt some swellings/lumps in my groin area.
Dr:I am sorry to hear about that. Please tell me more about it.
Pt:Like what doc?
Dr:From how long are you having these swellings? Pt:From last 2 weeks
Dr:How many swellings are there in groin area? Pt:Around 2 to 3
Dr:Swellings on any other part of the body? Pt:No
Dr:Do you any idea how did it happened? Pt:No
Dr:Are these swellings painful or itchy? Pt:No
Dr:Any discharge through penis? Pt:No
Dr:Any burning sensation while passing urine? Pt:No
Dr:Any fever? Pt:No
Dr:Any rashes over the body? Pt:No
Dr:Any weight loss? Pt:No
Dr:Is it the first time it is happening to you? Pt:Yes
Dr:Do you have any health problems? Pt:No
Take sexual history:
Dr:Do you have stable partner? Pt:No
Dr:Do you practice safe sex?
Pt:Sometimes
Dr:What is your sexual preference? Pt:I am bisexual
Dr:What route of sex do you prefer? Pt:Mostly anal

22
Dr:Is any of your partners having similar symptoms? Pt:I don’t know
Dr:Have you ever been diagnosed with STI? Pt:No
Dr:Did you travel anywhere recently? Pt:Yes,I travelled to
Thailand Dr:When did youtravel?
Pt:3 weeks ago
Dr:What did you do there?
Pt:I had sex with my partner Dr:Was it
protected?
Pt:No
Dr:What you do for living? Pt:I am a
student
Dr:Do you have tattoos? Pt:No
Dr:Do you drink alcohol? Pt:
Occasionally
Examination
I would like to check your vitals i.e. your blood pressure,pulse, temperature and
respiratory rate.Also,general examination of your whole body.
(Examiner will give findings)
Findings:Generalized lymphadenopathy in whole body including axilla,groin andneck.
Tell the findings to thepatient.
Diagnosis
Dr:From what we have discussed and assessed, we think that you may be having
a condition called sexually transmitted infection unfortunately. I am afraid that it
could be something like HIV.
Pt:Are you sure?
Dr:We are not sure at the moment, we will some of your blood tests for
HIV,Gonorrhea,syphilis and then we can say anything for sure.
Pt:How did I get it?
Dr:Unfortunately,you may have gotten this from one of your partners.
Pt:What can you do now?

23
Dr:We will do some blood tests and also discuss with seniors.
Pt:Ok
Dr:Any concerns? Pt:No
Dr:I would advice you to avoid/practice safe sex until everything is sure about your
condition. Is that ok?
Pt:Ok
Dr:We will arrange a follow up in 2 weeks time,In the meantime, if you feel any
fever,discharge through penis,weight loss or increased lumps, please let us
know.Thankyou
Reference information
D/D’s of lymphadenopathy plus sexual history +ve.
• HIV seroconversion illness(Acutepresentation)
o Fever
o Sore throat
o Diarrhea
o Weightloss
o Rashes
o Lymphadenopathy
• Other STI’s like Chlamydia ,Gonorrhea,Syphilis
o Discharge throughpenis/vagina
o Burning in genitaltract.
o Penileulcer
Elderly woman-Medication review
You are FY2 in General practice.
An elderly woman is coming for follow-up of her test results. Discuss test results
with her, review her medications and discuss further management.
Test results:
TSH low,T3,T4 high. Blood
pressure:160/95
Cholesterol in normal range Her meds:
Levothyroxine 125 microgram/litre once daily. Statin 20mg once daily.

24
Amlodipine 5mg once daily.
History
Dr:Hello,my name is dr XYZ.I am one of the junior doctor .I understand that you are here
for your follow up.
Pt:Yes doc.
Dr:Alright,I have test results with me.Before explaining your results, is it ok if I can
discuss somethings with you to have a better understanding of your health?
Pt:Ok doc
Dr:Why did you come in the first place to GP clinic? Pt:For regular checkup
Dr:Okay,how is your health overall? Pt:I am fine doc
Dr:Any visual disturbances?(Hyperthyroidism symptoms)
Pt:No
Dr:Any chest pain? Pt:No
Dr:Any change in bowel habit? Pt:No
Dr:Any heat intolerance? Pt:No
Dr:Any tummy pains(hypertension symptoms) Pt:No
Dr:Do you have any health problems? Pt:I have hypothyroidism.
Dr:From how long? Pt:From last 10 years
Dr:So how are you managing it?
Pt:I am taking levothyroxine 125microgram/litre daily. Dr: Are you taking it as prescribed?
Pt:Yes
Dr:Any other health problems?
Pt:I have hypertension and high cholesterol Dr:Are you taking medicines for them?
Pt:I am taking statin 20mg daily but not taking blood pressure med.
Dr:May I know why?
Pt:I have run out the medication. Dr:From how long you are out of it? Pt:From last 3
months.
Dr: Any other medication? Pt:No
Dr:With whom do you live?
Pt:With my daughter Dr:Do you smoke or drink? Pt:No
Examination
Dr:Ok now, I would like to check your vitals i.e. your blood pressure, pulse, respiratory
rate and temperature. Also your thyroid gland and general examination of your body.is it
ok?
Pt:Ok
Discuss results
Dr:From your results, we can see that unfortunately your thyroid is working more than
normal. Also your blood pressure is quite high. Your cholesterol levels are gladly normal.
Pt:So what are you going to do for me?
Dr:As your thyroid is working more, we have to reduce its dose to 100
microgram/litre.What do you think?

25
Pt:(patient will become angry at this point and doesn’t want this change in dose.) No doc,I
am feeling better. I don’t want this change in my dose.
Dr:I can understand that but its important to reduce the med dose because extra thyroid
hormones can do harm to your body I am afraid.
Pt:How by just looking at my blood results,you can say that you want to reduce the dose?
Dr:These results are showing that thyroid levels are more in your blood than normal that’s
why we are concerned.
Pt:(patient will keep complaining )
Dr:Keep convincing her and involve seniors
Dr:Also,we can see that your blood pressure is high. And you have runout of the med.
Pt:Yes doc,I think that blood pressure is short term and it will go away .
Dr:I am sorry but blood pressure is long term condition and if you will not take your med
then it can cause serious side effects.
Pt:I will think about it
Dr:We will also refer you to a specialist doctor(endocrinologist).is it ok?
Pt:ok
Dr: We will arrange your follow up in a month. In the meantime,if you feel blurry
vision,chest pain,change in bowel habit or headaches please let us know.
Feeling unwell-on oxybutynin
You are FY2 in General practice. A 50 year old lady is coming with some
concerns. Talk to her and address her concerns.
History
Dr:Hello my name is Dr XYZ,I am one of the junior doctors in GP clinic.
How can I help you?
Pt:Doc,I am feeling confused now a days. Dr:Please elaborate it
Pt:I am forgetting things, I forgot that I had to go to lunch at 2pm today and then
my daughter reminded me.
Dr:From how long are you feeling like this? Pt:From last 2 weeks.
Dr:Were you completely fine before it? Pt:Yes
Dr:Any other symptoms at all? Pt:Like what?
Dr:Any fever?(Any infection)
Pt:No
Dr:Any cough or shortness of breath?(Pneumonia) Pt:No
Dr:Any rashes over the body?(Meningitis) Pt:No

26
Dr:Any change in bowel habit?(Gastroenteritis) Pt:No
Dr:Any burning while passing urine?(UTI) Pt:No
Dr:What else are you forgetting?
Pt:I am losing track of time and forgetting my daily routine chores.
Dr:Sorry to hear about that
Dr:Any concentration problems?(Dementia) Pt:Yes, mild
Dr:Any planning problem? Pt:No
Dr:Do you have any health problems? Pt:I have urinary
incontinence.
Dr:What are you taking for it?
Pt:Oxybutynin
Dr:From how long? Pt:From
last 3 weeks
Dr:Do you feel that you have started feeling like this after taking oxybutynin?
Pt:May be doc
Dr:Are you using any other medication? Pt:No
Dr:Any one in family with memory problems? Pt:No
Dr:What you do for living? Pt:I am a
teacher
Dr:Is it affecting your teaching? Pt:Yes doc
Dr:Don’t worry we will try to help you as much as we can.
Pt:Ok doc
Dr:With whom do you live? Pt: My
husband
Examination
I would like to check your vitals now i.e. your blood pressure,pulse,temperature and
respiratory rate, also general physical examination of your body. Is that ok?
I would also like to do Mini mental state examination of you which involve checking
cognitive function of your mind.(Examiner will give you normal MMSE score=26)
Diagnosis
Fortunately, your cognitive function is intact. From what we have assessed, we
think that you may be having this confusion as a side effect of oxybutynin

27
unfortunately.
(Check the BNF)
Dr:So now, we will refer you to your specialist doctor, Urologist so that he will take
care of this side effect and may be switch you to some other med for incontinence.
Pt:Ok doc
Dr:We will also take your blood to check for anaemia, any infection and whether
your kidneys and liver are fine.
Pt:Ok
Dr:We will also arrange your follow up in 2 weeks. In this time if you feel any fever
,cough, burning sensation while passing urine or if your forgetfulness is getting worse
,please let us know. Thank you
How to tell if someone is confused If a person is
confused, they may:
• not be able to think or speak clearly orquickly
• not know where they are (feeldisorientated)
• struggle to pay attention or rememberthings
• see or hear things that aren't there(hallucinations)
Try asking the person their name, their age and today's date. If they seem unsure or can't
answer you, they probably need medical help.
Do
• stay with the person – tell them who you are and where they are, and keep
reassuringthem
• use simple words and shortsentences
• make a note of any medicines they're taking, if possible
Don’t
• do not ask lots of questions while they're feeling confused
• do not stop the person moving around – unless they're indanger
Causes of suddenconfusion
Some of the most common causes of sudden confusion include:

28
• an infection – urinary tract infections (UTIs)are a common cause in elderly
people or people with dementia
• as
trokeorT
IA ("mini-stroke")
• a low blood sugar level in people with diabetes– read about treating low
bloodsugar
• a headinjury
• some types of prescriptionmedicine
• a
lcohol poisoningora
lcoholwithdrawal
• taking illegaldrugs
• carbon monoxide poisoning– especially if other people you live with
becomeunwell
• a severe asthma attack– or other problems with the lungs orheart
Post Herpetic Neuralgia
You are FY2 in GP. Benjamin White, aged 72, has come for consultation. He was
diagnosed with Shingles 2 months back and was given Acyclovir. He saw his GP
1 month back for the pain on the right side of his chest and was given
Paracetamol and Codeine. Talk to him and address his concerns.
History
Dr: How can I help you? Pt: I am still
in pain.
Dr: Is the pain still in the same place? Pt: Yes, it’s on the
right side.
Dr: Is it always there? Pt: Yes
Dr: Can you score the pain?
Pt: 3/4 normally but during night the bedsheets touch the area and I get unbearable
sharp pain.
Dr: How has it impacted you?
Pt: It is hindering my daily life, as I am taking care of my wife who is on wheelchair and
has RA.

29
Dr: How are you feeling? Pt: I feel tired
all thetime.
Dr: Do you have rash on your body? Pt: No, they are gone.
Dr: Did you have similar condition in the past?
Pt: Yes, I had it 6 months back and was given antibiotics.
Dr: Have you been diagnosed with any medical condition in the past?
Pt: No
Dr: Are you taking any medications including OTC or supplements?
Pt:No
Dr: Any allergies from any food or medications? Pt:No
Dr: Any previous hospital stays or surgeries? Pt:No
Dr: Has anyone in the family been diagnosed with any medical condition?
Pt: No
Dr: Do you smoke?
Pt:No
Dr: Do you drink Alcohol? Pt:No
Dr: Tell me about your diet? Pt: Healthy
Dr: Are you physically active? Pt: I try to be
Dr: Do you get any help looking after your wife? Pt: Yes, Nurse comes twice
a week.
(Ask about Sleep, depression, rule out Cancer (As age is
72) and other causes of Tiredness)
Examination
I would like to check your vitals i.e. your BP,pulse,temperature and respiratory rate.
Also rash on your body.
Diagnosis
Dr:From what we have assessed think that you are having this pain due to a condition
called post herpetic neuralgia. It is lasting nerve pain in an area previously affected by
shingles.
Pt:What can you do for me?

30
Management
• To help reduce the pain and irritation of post- herpetic neuralgia wear
comfortable clothing and use cold packs – some people find cooling the
affected area with an ice packhelps.
• We can give you Lidocaine plasters and Capsaicin cream (Capsaicin is the
substance that makes chilli peppers hot. It's thought to work for nerve pain by
stopping the nerves sending pain messages to the brain).
• Antidepressants: Amitriptyline and duloxetine are the two main antidepressants
prescribed for post- herpeticneuralgia.
• Anticonvulsants: Gabapentin and pregabalin are the two main anticonvulsants
prescribed for post- herpeticneuralgia.
• We can also prescribe Tramadol or Morphine if symptoms are notrelieved.
• Living with post-herpetic neuralgia can be very difficult because it can affect
your ability to carry out simple daily activities, such as dressing and bathing.
Support the patient and talk about support groups andwebsites.
Patient Concerns:
Pt: How to get rid of this Pain? Pt: How to
managetiredness?
Pt: Can you give something else other thantablets?
Investigations and follow up
We will do some blood tests do check whether you are anaemic and everything is fine
with your liver and kidneys and also your inflammatory markers like ESR and CRP.
We will arrange a follow up in a month time.in the meantime if you feel more
pain, any fever ,rash or weight loss please let us know. Thank you
Premature Ovarian Insufficiency
You are FY2 in OBG.Sana,aged 26 presented with amenorrhea. She had blood tests
done. Results are as follows:
FSH and LH high Estrogen

31
low
Diagnosis of premature ovarian insufficiency was made. Talk to her, explain the
results and address her concerns.
History
Dr:Hello,how can I help you? Pt:I am not having periods Dr:From how long?
Pt:From last 2 years
Dr:Sorry to hear about that. Do you have complete cessation of periods from last 2 years?
Pt:Yes
Dr:Did you do anything for it ? Pt:No
Dr:How were your periods before 2 years? Pt:They were regular
Dr:Do you have any health problems?(Immune problems ,tuberculosis or any infection)
Pt:No
Dr:Do you have hot flushes? Pt:Yes/No
Dr:Do you have night sweats,vaginal dryness,reduce libido,problems with
concentration?(Symptoms of POF)
Pt:Yes/No
Dr:Did you had any fractures?(Osteoporosis, complication of POF)
Pt:No
Dr:Any chest pain, SOB?(Cardiovascular complication of POF)
Pt:No
Dr:Any fever? Pt:No
Dr:Have you gone through surgery of ovaries or womb?
Pt:No
Dr:How is your mood? Pt:It is low
Dr:How is your sleep? Pt:Fine
Dr:Any one in family with premature ovarian failure? Pt:I don’t know
Dr:Do you use any contraception? Pt:No
Dr:Do you have any kids?
Pt:No,I am planning for pregnancy Dr:With whom do you live ?
Pt:My partner Dr:Do you smoke? Pt:No
Dr:Do you drink alcohol? Pt:Occasionally
Examination
I would like to check your vitals i.e. your BP,pulse,temperature and respiratory rate. Also
general examination of your whole body. Is it ok?
Pt:Ok
Dr:Explain the results.
Dr:From what we have discussed and from your blood results it shows that you are having
a condition called premature ovarian failure unfortunately. It means that your ovaries have
stopped working and that’s why you are not getting periods.
Pt:Doc,I want to have children?
Dr:I understand that but with this condition it can be a bit difficult to have children
naturally,I am sorry.
However, we have a lot of methods by which you can have children like;
o IVF
o Donated eggs from other woman or using your eggs if you had stored

32
o Surrogacy
o Adoption
Pt:Ok,what treatment can I have?
Dr:Treatment:
COCP or HRT unless contraindicated in breast cancer Lifestyle changes like
diet,sleep,exercise
Counselling and Support groups
Dr:We will arrange your follow up in a month.in the meantime if you feel any chest pain,
SOB or you feel unwell in anyway, please let us know. Thank you
Early menopause
Early menopause happens when a woman's periods stop before the age of 45. It can happen
naturally, or as a side effect of some treatments.
For most women, the menopause starts between the ages of 45 and 55.
Causes of early menopause The ovaries stop working
Early menopause can happen naturally if a woman's ovaries stop making normal levels of
certain hormones, particularly the hormone oestrogen.
This is sometimes called premature ovarian failure, or primary ovarian insufficiency.
The cause of premature ovarian failure is often unknown, but in some women it may be
caused by:
• chromosome abnormalities – such as in women with Turner syndrome
• an autoimmune disease – where the immune system starts attacking body tissues
• certain infections, such
as t uberculosis, very rare malaria and mumps – but this is
Premature ovarian failure can sometimes run in families. This might be the case if any of
your relatives went through the menopause at a very young age (20s or early 30s).
Cancer treatments
R adiotherapy and c hemotherapy can cause premature
ovarian failure. This may be permanent or temporary.
Surgery to remove the ovaries
Surgically removing both ovaries will also bring on premature or early menopause.
For example, the ovaries may need to be removed during a hysterectomy (an operation to
remove the womb).
Symptoms of early menopause
The main symptom of early menopause is periods becoming infrequent or stopping
altogether without any other reason (such as pregnancy).
Some women may also get other typical menopausal symptoms, including:
• hot flushes
• night sweats
• vaginal dryness and discomfort during sex
• difficulty sleeping

33
• low mood or a nxiety
• reduced sex drive (libido)
• problems with memory and con
Women who go through early menopause also have an
increased risk of o steoporosis and c ardiovascular
disease because of their lowered oestrogen hormone levels.
Treatments for early menopause
The main treatment for early menopause is either
the combined contraceptive pill or HRT to make up for your missing hormones.
A GP will probably recommend that you take this treatment long term, beyond the
"normal" age of natural menopause (around 52 on average), to give you lasting
protection.
If you have had certain types of cancer, such as certain types of breast cancer, you may
not be able to have hormonal treatment.
Getting support
Going through the menopause early can be very difficult and upsetting.
Permanent early menopause will affect your ability to have children naturally. This can
be very distressing to women of all ages.
You may still be able to have children by using IVFand donated eggs from another
woman, or using your own eggs if you had some stored. Surrogacy and adoption may
also be options for you.
Counsellingand support groups may be helpful. Here are some you may want
to try:
• The Daisy Network– a support group for women with premature
ovarianfailure
• healthtalk.org– provides information about early menopause, including women
talking about their ownexperiences
• Fertility friends– a support network for people with fertilityproblems
• Human Fertilisation and EmbryologyAuthority
(HFEA)– provides information on all types of fertility treatment
• Adoption UK– a charity for people who are adoptingchildren
• Surrogacy UK– a charity that supports both surrogates and parents
through theprocess

34
Subcutaneous injection teaching
You are FY2 in skills lab.Lorrie 3rd
year medical student is here.Teach him how to
administer subcutaneous injection. Don’t ask him to perform theprocedure.
Teaching:
A subcutaneous injection is given into the subcutaneous fat under the skin. The skin is
made up of different layers. Underneath the epidermis and dermis, which contain sweat
glands and hair follicles, is a layer of fat. This is the area into which subcutaneous
injections are given.
Getting ready to give the subcutaneous injection
You will need
• Yellow/sharps bin
• Cleaning wipe
• Medicine bottle
• Syringe package
• Cotton wool or gauze
• Site rotation chart
What to do
1. Wash your hands
2. Wipe the top of the medicine bottle with the cleaning wipe and leave to dry
3. Choose the injection site for this dose
4. Open the syringe package and put on a clean surface
5. Insert the needle into the top of the bottle at an angle of 90°
6. Pull back the plunger and draw up slightly more than the prescribed dosage
7. Remove the needle from the bottle
Note: If you are using an auto injector or pen device, load it according to the instructions in
the package and how you have been taught.
Giving the subcutaneous injection
What to do
8. Holding the needle upwards, tap the syringe gently to move any air bubbles towards
the needle
9. Push the plunger gently to remove the air bubble and squirt a small amount of the
medicine into the air
10. Lift the skin in the chosen injection area between your thumb and index finger
11. Holding the needle at a 90° or 45° angle ,insert the needle into the skin fold
12. Continue to hold the skin and push the syringe plunger to inject the medicine while
counting to 10 slowly. Do not aspirate or rub the skin afterwards.
13. Remove the needle from the skin and let go of the skin fold
14. Put a piece of cotton wool or gauze over the injection site for a few seconds
15. Throw the syringe away in a ‘sharps’ bin.
16. Mark the injection site on your site rotation chart
17. Please document the details of procedure and medication administered.
Sites of subcutaneous injection

35
o Abdomen-2 inches away from umbilicus
o Upper outer aspect of arm
o Upper outer aspect of upper thigh
o Upper buttock
o Do not use the site which is inflamed, scarred or bruised.
o If multiple injections needed, use different sites for each injection.
Post injection care
It is normal for the injection site to be sore for one or two days. Advise that if they
experience worsening pain after 48 hours, they should seek medical help.
Some rare complications of subcutaneous injection are hematoma formation, persistent
nodules, local irritation and rarely anaphylaxis
3a. Lift the skin between thumb and 3b: Incorrect technique
two fingers with one hand, pulling
the skin and fat away from the
underlying muscle
Seborrheic keratosis
You are FY2 in GP.Nancy James, aged 70 emailed you a picture of skin lesion. Talk
to her and address concerns.
History

36
Dr: Hello,how can I help you?
Pt:I noticed the lesion on my breast Dr:Tell me more about it
Pt:Like what?
Dr:When did you notice it? Pt: 2 months ago
Dr:Is it the first time you have such type of lesion? Pt:Yes
Dr:Is it painful,itchy? Pt:No
Dr:Is it bleeding? Pt:No
Dr:What about the site,size,shape and color?
Pt:Right,outer quadrant of breast,greyish in color,irregular in shape
Dr:Is it growing? Pt:Yes
Dr:Any lumps in breast other than this? Pt:No
Dr:Any discharge through nipples? Pt:No
Dr:Any pain in breasts or fever? Pt:No
Dr:Lesion anywhere else on the body? Pt:No
Dr:Any weight loss? Pt:No
Dr:Any lumps or bumps in body? Pt:No
Dr:Do you go out in sun more often? Pt:No I don’t
Dr:Any tanning beds? Pt:No
Dr:Any one in the family with skin cancer? Pt:Yes,my dad has
Dr:Sorry for that, what you do for living? Pt:I am retired
Dr:With whom do you live? Pt:My wife
Examination
I would like to check to your vitals i.e. your BP,pulse,temperature and respiratory rate. I
would also like to examine your breasts for lesion(Picture is in the cubicle)
Diagnosis
Dr:From what we have discussed ,we think that you have a condition called seborrheic
keratosis.It is non cancerous growths of outer layer of skin.
Pt:Is it cancer?
Dr:No it is non cancerous growth, don’t worry Pt:What can you do for me?
Dr:Treatment options are:
Cryosurgery
Liquid nitrogen, a very cold liquid gas, is applied to the growth with a cotton swab or spray
gun to “freeze” it. A blister may form under the growth which dries into a scab-like crust.
The keratosis usually falls off within a few weeks. Occasionally, there will be a small dark
or light spot that usually fades over time.
Curettage
The keratosis is scraped from the skin. An injection or spray is first used to anaesthetise
(numb) the area before the growth is removed (curetted). No stitches are necessary, and the
minimal bleeding can be controlled by simply applying pressure or the application of a
blood-clotting chemical.

37
Electro surgery
The growth is anaesthetised (numbed) and an electric current is used to burn the growth,
which is then scraped off.
Pt:Ok doc,any other precautions ?
Dr: If you have this keratoses it's important to avoid any further sun damage. This will stop
you getting more skin patches and will lower your chance of getting skin cancer.
Do
• use sunscreen with a sun protection factor (SPF) of at least 30 before going out into
the sun and reapply regularly
• wear a hat and clothing that fully covers your legs and arms when you're out in the
sunlight
Don’t
• do not use sunlamps or sunbeds as these can also cause skin damage
• do not go into the sun between 11am and 3pm – this is when the sun is at its
strongest.
Dr:We will also arrange your referral to skin specialist so that he can also assess you. Is
that ok?
Pt:Ok doc
Dr:We will book your follow up appointment in a month.in the meantime if you feel that
your lesion is growing ,changing its color, any bleeding from it or any weight loss, please
let us know. Thank you
Seborrhoeic keratoses are often confused with warts or moles, but they are quite different.
Seborrhoeic keratoses are non-cancerous growths of the outer layer of skin. There may be
just one growth or many which occur in clusters. They are usually brown, but can vary in
colour from light tan to black and range in size from a fraction of an inch in diameter to
larger than a £2 coin. A main feature of Seborrhoeic
keratoses is their waxy, “pasted-on” or “stuck-on” appearance. They sometimes look like a
dab of warm brown candle wax that has dropped onto the skin or like barnacles attached to
the skin.
Causes of Seborrhoeic Keratoses:
The exact cause of seborrheic keratoses is unknown; however, they seem to run in families.
They are not caused by sunlight and can be found on both sun- exposed and non-exposed
areas. Seborrhoeic keratoses are more common and numerous with advancing age.
Although seborrheic keratoses may first appear in one spot and seem to spread to another,
they are not contagious.
Development of Seborrhoeic Keratoses:
Anyone may develop seborrhoeic keratoses. Some people develop many over time, while
others develop only a few. As people age, they may simply develop more.
Facts about Seborrhoeic keratoses:
Seborrhoeic keratoses are most often located on the chest or back, although they also can
be found on the scalp, face, neck, or almost anywhere on the body. The growths usually
begin one at a time as small, rough,
itchy bumps which eventually thicken and develop a warty surface.
Seborrhoeic keratoses are benign (non-cancerous) and are NOT serious and are not
generally treated by a dermatologist in secondary care, you can speak with your GP who

38
can offer you the treatment. Removal may be recommended if they become large, irritated,
itch, or bleed easily.
Treatments
Creams, ointments, or other medication can neither cure nor prevent seborrheic keratoses.
Most often seborrhoeic keratoses are removed by cryosurgery, curettage, or electro
surgery.
Cryosurgery
Liquid nitrogen, a very cold liquid gas, is applied to the growth with a cotton swab or spray
gun to “freeze” it. A blister may form under the growth which dries into a scab-like crust.
The keratosis usually falls off within a few weeks. Occasionally, there will be a small dark
or light spot that usually fades over time.
Curettage
The keratosis is scraped from the skin. An injection or spray is first used to anaesthetise
(numb) the area before the growth is removed (curetted). No stitches
are necessary, and the minimal bleeding can be controlled by simply applying pressure or
the application of a blood-clotting chemical.
Electro surgery
The growth is anaesthetised (numbed) and an electric current is used to burn the growth,
which is then scraped off.
If you have this keratoses it's important to avoid any further sun damage. This will stop you
getting more skin patches and will lower your chance of getting skin cancer.
Do
• use sunscreen with a sun protection factor (SPF) of at least 30 before going out into
the sun and reapply regularly
• wear a hat and clothing that fully covers your legs and arms when you're out in the
sunlight
Don’t
• do not use sunlamps or sunbeds as these can also cause skin damage
• do not go into the sun between 11am and 3pm – this is when the sun is at its
strongest.
Urticaria
You are an FY2 in GP. Mother of 5-year-old Daniel has got some concerns. Talk to
her and address her concerns.
History
Dr: Hello my name is Dr XYZ,I am one of the junior doctors in GP clinic. How can I help
you?
Pt: My son has rash on his whole body

39
Dr:I am sorry to hear about that. Please tell me more about it.
Pt:It has happened 2-3 times. Once, after shower and this time he was playing in the
garden.
Dr:For how long it stays?
Pt:Disappears after few minutes to hours. Dr:Is it ichy?
Pt:Yes
Dr:Any one in family with similar symptoms? Pt:No
Dr: Is it painful?
Pt:No
Dr:Is it bleeding? Pt:No
Dr:Any fever? Pt:No
Dr:Any shortness of breath(Anaphylaxis)? Pt:No
Dr:Any wheeze? Pt:No
Dr:Any swelling of face? Pt:No
Dr:Any dizziness? Pt:No
Dr:Does he have any health problems any asthma or allergy?
Pt:No
Dr:Is he using any medication? Pt:No
Dr:Any allergies to food or medicine? Pt:No
Dr:Family history of asthma or allergy? Pt:No
Dr:How was his birth? Pt:Fine
Dr:How is his development overall? Pt:It is normal
Dr:Is he up to date with his jabs? Pt:Yes
Examination
Image was given when asked to examine. (Lateral view of head with rash all over face).
Diagnosis
Dr:From what we have assessed we think that he got this rash due to a condition called
urticaria.It is allergic rash that develops on exposure to some allergen.
Pt:Is it contagious? Dr:No it is not contagious
Pt:Can my child go to his school? Dr:Absolutely once he feels better Pt:So what can you
do for him?
Management
In many cases, treatment isn't needed for urticaria, because the rash often gets better within
a few days.
If the itchiness is causing discomfort, antihistamines can help.
A short course of steroid tablets (oral corticosteroids) may occasionally be needed for more
severe cases of urticaria.
For persistent urticaria, refer to a skin specialist (dermatologist). Treatment usually
involves
medication to relieve the symptoms, while identifying and avoiding potential triggers.
Certain triggers for Urticaria:
• drinking alcohol or caffeine
• emotional stress
• warm temperature Causes of Urticaria:
• an allergic reaction – such as a food allergy or a reaction to an insect bite or sting
• cold or heat exposure
• infection – such as a cold

40
• certain medications – such as non-steroidal anti- inflammatory drugs (NSAIDs)or
antibiotics.
Dr:We will arrange a follow up In a month .in the meantime if he feels any shortness of
breath, fever or if the rash is spreading, please let us know. Thank you.
Optic neuritis (multiple sclerosis)
You are FY2 in GP.A middle aged lady wants to see you. Talk to her, address her
concerns and discuss further management.
History
Pt:I have pain in my eye from yesterday
Dr:Sorry to hear about that, please tell me more about it
Pt:I cant differentiate between colors as well Dr:From how long?
Pt:From yesterday
Dr:How is your right eye? Any symptoms? Pt:No
Dr:Are you experiencing it for the first time?
Pt:it happened 3 months ago as well but it resolved on it is own after a week
Dr:Ask all eye symptoms like vision, discharge, colored haloes,redness,floaters,pressure in
eyes
Pt:(In this case everything is negative)
Dr:Ask all symptoms of MS
• fatigue
• difficulty walking
• vision problems, such as blurred vision
• problems controlling the bladder
• numbness or tingling in different parts of the body
• muscle stiffness and spasms
• problems with balance and co-ordination
• problems with thinking, learning and planning dr:Do you have any other health
problems?
Pt:No
Dr:Are you using any medicine? Pt:No
Dr:Any one in your family with MS? Pt:My mom has
Dr:Sorry for that
Dr:What you do for living? Pt:Homemaker
Examination
I would like to check your vitals i.e. your bp,pulse,temperature and respiratory rate. Also I
would like to examine your eye(Do eye examination)
Examiner may give you findings i.e. decreased visual acuity and blurred optic disc.

41
Management
Dr:From what you have told me and from what we have assessed we think that you are
having a condition called optic neuritis unfortunately. It means that by mistakenly your
immune system is attacking nerve of your eye
Pt:what can you do now?
Dr:We will refer you to eye specialist urgently so that he can further assess and manage
you
Pt:Do I have MS like my mother?
Dr:I am afraid it is related to multiple sclerosis but we need to do more tests to confirm
your condition
Pt:Ok
Dr:We will also do your blood tests to make sure everything is fine with your liver,
kidneys, and we will also check inflammatory markers like ESR,CRP.
Pt:Ok
Dr:We will arrange a follow up in a month.(Safety net regarding MS symptoms including
eye problems mentioned above)
Multiple sclerosis (MS) is a condition that can affect the brain and spinal cord, causing a
wide range of potential symptoms, including problems with vision, arm or leg movement,
sensation or balance.
It's a lifelong condition that can sometimes cause serious disability, although it can
occasionally be mild.
It's most commonly diagnosed in people in their 20s and 30s, although it can develop at
any age. It's about 2 to 3 times more common in women than men.
Treatments for multiple sclerosis (MS)
There's currently no cure for MS, but a number of treatments can help control the
condition.
The treatment you need will depend on the specific symptoms and difficulties you have.
It may include:
• treating relapses with short courses of steroid
medicine to speed up recovery
• specific treatments for individual MS symptoms
• treatment to reduce the number of relapses using medicines called disease-
modifying therapies
Disease-modifying therapies may also help to slow or reduce the overall worsening of
disability in people with a type of MS called relapsing remitting MS, and in those with a
type called secondary progressive MS who have relapses.
Unfortunately, there's currently no treatment that can slow the progress of a type of MS
called primary progressive MS, or secondary progressive MS in the absence of relapses.
Living with multiple sclerosis (MS)
If you have been diagnosed with MS, it's important to take care of your general health.
Charities and support groups for multiple sclerosis (MS)
There are 2 main MS charities in the UK:
• MS Society
• MS Trust
These organisations offer useful advice, publications, news items about ongoing research,
blogs and chatrooms.

42
They can be very useful if you, or someone you know, has just been diagnosed with MS.
There's also the shift.ms website, an online community for younger people affected by MS.
Social care and support guide
If you:
• need help with day-to-day living because of illness or disability
• care for someone regularly because they're ill, elderly or disabled, including family
members
Urine dipstick – teaching
Question: You are an FY2 in theNephrology Department
Abby Gale is a student nurse. This is her first day in the Nephrology department. She
wants to learn how to perform a urine dipstick test.
(On the table there is a sample of urine, a box of urine dipsticks and a stop watch)
Hello.My name is ……… I am one of the junior doctors here in the Nephrology
Department.
I am Abby.
Hello, Abby. Nice to meet you. I understand it is your first day in the nephrology
department. How are finding it?
Good. Thank you.
I understand that you wanted to learn about the urine dipstick test.
That’s right. I want to know how to perform the test.
What do you know so far about testing urine?
I don’t know anything about it.
That’s fine. Let’s sit down and start by discussing by some general principles. Is that okay?
All right.
Well, whenever we perform a test it’s important not only to look at the sample but the
patient as a whole. You would ideally want to know something about the patient’s history-
like what the patient came in with. So what could symptoms could the patient have come in
with for us to want to perform a urine dipstick?
I don’t know.
Well, it might be that they have pain or burning sensation while passing urine. They might
have noticed a change in the appearance of the urine. Or they may have come in with

43
tummy pain that we suspect may be caused by some problem in the urinary system. Does
that make sense?
Yes
Normally urine is 95% water and 5% other chemical substances. Due to different
pathologies there might be some abnormal substances found in the urine or the normal
substances may increase in amount. Can you name something common that if we find in
urine indicates pathology?
Blood?
Yes, that’s right. Very good. Similarly we might find excess proteins or glucose.
If we find substances such as nitrites or leukocytes, it indicates an infection in the urinary
tract.
Abnormal constituents of urine:
▪ Ketones
▪ Blood
▪ Bilirubin (urobilinogen)
▪ Glucose
▪ Protein
▪ Nitrates
▪ Leukocytes
▪ Drugs
A urine dipstick test is the quickest way to test urine. It involves dipping a specially treated
paper strip into a sample of urine
Urine dipstick test consists of a reagent strip, which is literally dipped into the urine sample
triggering a series of color changes along its length, which correspond to the presence, and
concentrations of specific molecules. So we detect the presence as well to some extent the
quantity of these substances in the urine. Different substances give clues as to the
pathology.
Do you have any questions so far?
When do we see blood in the urine?
That’s a very good question-
Blood is seen in urine during menstruation, in kidney disorders such as glomerulonephritis
when the kidney’s filter system is damaged, stones or tumors in the urinary tract as well
urinary tract infections. It’s also important to find out if the patient takes any blood thinners
or has any blood disorders. Does that answer your question?
Yes.

44
• Glucose - is found when its concentration in plasma exceed the renal threshold may
indicate diabetes
• Bilirubin/urobilinogen – indicates excess in the plasma. Commonest cause of
positive results is liver cell injury e.g. hepatitis, paracetamol overdose, late-stage
cirrhosis.
• Ketones – due to excessive breakdown of body fat. Common in fasting, may
indicate low carbohydrate diet, vomiting & fever, present in starvation
• Protein – excess albumen in the urine is unusually due increased permeability in the
glomeruli. Positive results in acute and chronic kidney disease, pre-eclampsia.
• Nitrite – UTI – most of the organisms that infect the urinary tract contains an
enzyme that convers nitrate (normally found in urine) to nitrite, which is not found
in urine in the absence of infection.
• Leucocytes – leucocytes enter inflamed tissue from the blood and are shed into the
urine. UTI is commonest cause of positive results.
Also measured by the Dipstick test is-
• Specific gravity – a measure of solute concentration. High values can be found in
dehydration. Low values found in high fluid intake. Diabetes insipidus; chronic
renal failure; hypercalcaemia; hypokalaemia.
• pH – high values - commonest cause of high vales is stale urine; large intake of
antacids;UTI with ammonia forming organisms. Low values – acidosis (diabetic &
lactic); starvation; potassium depletion. )
To start with we must collect the sample-we should instruct the patient on how to collect a
mid-stream sample in a sterile container. The sample should be labeled with the patient’s
name and hospital ID.
Collect al the materials needed-
Reagent/test strips – in-date and stored correctly
Stop-watch
Urine sample in suitable container
Gloves
Paper Towels
Apron
Access to hand washing and drying
A clinical waste bin
Before you start -wear gloves and apron and confirm Sample details- patient name, hospital
number and date of birth
First is gross inspection this includes the color of urine and its turbidity some might also
include odor.
Normally urine is straw coloured.
Colour: The colour and clarity of the urine has significant implications and should always
be noted. The colour of normal urine varies with its concentration, from deep yellow to

45
almost clear. In disease, the colour may be abnormal due to excretion of the endogenous
pigments as well as drugs and their metabolites.
The color which would concerns someone the most is red as it is most often result of
bleeding somewhere in the GU tract. The source of bleeding can be the kidneys, the ureters
the bladder or the urethra. Sometimes the blood is minimal and no colour change is noticed
but the strip is able to detect small amounts hemoglobin.
Clarity/turbidity
Cloudy urine may be due to:
• Contamination with vaginal mucus or epithelial cells.
• Excess phosphate crystals precipitating in alkaline urine (no clinical significance).
• Pyuria secondary to infection.
• Chyluria (presence of chyle/lymph in the urine)
• Hyperuricosuria secondary to a diet high in purine-rich foods.
• Lipiduria.
• Hyperoxaluria.
Odour: Odour in the urine of patients who have a urinary tract infection, is often due to the
urea-splitting organisms. This makes it smell ammonia. The presence of urinary ketones, as
in diabetic ketoacidosis, leads to an acetone smell. The presence of malodorous urine does
not indicate the presence of infection and does not negate the need for testing.
1. Check the expiry date on the container.
2. Take one strip from the container and dip it into the urine sample ensuring that all
the zones are immersed into the sample.
3. Dip briefly and remove immediately to avoid dissolving out the reagents.
4. While removing the strip, run the edge against the rim of the urine container to
remove excess urine.
5. Place the strip in a horizontal position on the paper towels to prevent possible
mixing of chemicals from the adjacent areas.
6. Start the stopwatch.
7. Tests require different times to complete. These times are noted on the side of the
container. Interpret each test (colour change) at an appropriate time interval (keep
an eye on the stopwatch) and go from least time to most time) using the urine
dipstick analysis chart given on the container.
8. After interpreting, discard the materials in the clinical waste bin.
9. Document all the results in the patient notes.
So could you name two common conditions where we might get a finding in the urine
dipstick?
Infection and kidney stones?
Yes, that’s right!
Do you have any questions for me?

46
No.
Thank you, Abby. If you have any questions or want to learn something else pleased don’t
hesitate to contact me.
Erectile dysfunction
You are FY2 in GP.A middle aged man wants to talk to you. Talk to him and
address his concerns.
History
Pt:Doc,it is little bit embarrassing but it is about my erection
Dr:Please tell me more Pt: I am not able to do sex
Dr:From how long are you having this problem? Pt:2,3 months ago
Dr:Do you get erections in the morning or during masturbation?
Pt:No
Dr:Any weight loss or lumps or bumps in body? Pt:No
Dr:Do you have any health problems? Pt:I am hypertensive
Dr:What are you taking for it?
Pt:Labetolol Dr:From how long? Pt:15 years
Dr:Are you using any other medication like Nitrates? Pt:No
Dr:What you do for living? Pt:Accountant
Dr:What about alcohol? Pt:Occasionally
Dr:By any chance, any recreational drugs? Pt:No
Examination
Dr:I would like to check your vitals i.e. your BP,pulse,temperature and respiratory rate
.also examination of your genitals.is that ok?
Pt:Ok
Management
Dr:From what you have told me most likely you are having this erectile dysfunction due to
labetalol unfortunately (check BNF).It is a very common problem, so you don’t have to
worry about that.
Pt:So what can we do now?
Dr:We will talk to our seniors and then we will change labetalol to some other anti
hypertensive medicine like amlodipine, what do you think?
Pt:Ok,will it cause the same problem?
Dr:It is very rare with amlodipine, also we can offer you some medicine called Viagra to
help you in erection
Pt:Ok
Dr: It usually takes 30 to 60 minutes for sildenafil to work for erectile dysfunction. You
can take it up to 4 hours before you want to have sex.
• Taking sildenafil alone will not cause an erection. You need to be aroused for it to
work.

47
• The most common side effects are headaches, feeling sick, hot flushes and
dizziness. Many men have no side effects or only mild ones.
Dr:Any other concerns? Pt:No
Dr:We will do your blood tests to see if everything is fine with your liver,kidneys,your
sugar, cholesterol and hormones levels.
Pt:Ok
Dr:We will arrange your follow up in a month.in the meantime, if you feel that you are not
improving, any chest pains, prolong and painful erections,please come back to us. Thank
you
Treatment for erection problems depends on the cause
Treatments for erectile dysfunction are usually effective and the problem often goes away.
There are also specific treatments for some of the causes of erectile dysfunction.
Treatments for some causes of erectile dysfunction
Possible cause Treatment
Narrowing of penis blood vessels, high blood pressure, high cholesterol
Medicine to lower blood pressure, statins to lower cholesterol
Hormone problems Hormone replacement (for
example, testosterone)
Side effects of prescribed medicine
Change to medicine after discussion with GP
Things you can do to help with erectile dysfunction Healthy lifestyle changes can
sometimes help erectile Do
• lose weight if you're overweight
• stop smoking
• eat a healthy diet
• exercise daily
• try to reduce stress and anxiety
Don’t
• do not cycle for a while (if you cycle for more than 3 hours a week)
• do not drink more than 14 units of alcohol a week
Emotional (psychological) problems
It's more likely to be an emotional problem if you only have erection problems some of the
time. For example, you get an erection when waking up in the morning, but not during
sexual activity.
Anxiety and depression can be treated with counselling and cognitive behavioural therapy
(CBT).
Do not take sildenafil if you:
• have had an allergic reaction to sildenafil (Viagra) or any other medicines in the
past

48
• are taking medicines called nitrates for chest pain
• have a serious heart or liver problem
• have recently had a s troke or a heart attack
• have low blood pressure
• have a rare inherited eye disease, such as retinitis pigmentosa
Check with your doctor before taking sildenafil if you:
• have sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of
blood cells) or multiple myeloma (cancer of bone marrow)
• have a deformity of your penis or Peyronie's
disease (curved penis)
• have a heart problem. Your doctor should carefully check whether your heart can
take the additional strain of having sex.
• have a stomach ulcer or a bleeding problem like haemophilia
Stop taking sildenafil and call a doctor straight away if you get:
• chest pains - if this happens during or after sex, get into a semi-sitting position and
try to relax; do not use nitrates to treat your chest pain
• prolonged and sometimes painful erections - if you have an erection that lasts for
more than 4 hours, contact a doctor immediately
• a sudden decrease or loss of vision
• a serious skin reaction - symptoms may include fever, severe peeling and swelling
of the skin, blistering of the mouth, genitals and around the eyes
• seizures
Bacterial vaginosis
Young lady named Katherine ford is coming for her follow up. Last time her
vaginal swab was done which is positive for Gardnerella vaginalis but negative
for chlamydia and gonorrhea. Discuss results with her and discuss further
management.
History:
Dr:Hello,my name is dr.XYZ,I am one of the junior doctors in general practice. How
are you doing today?
Pt:I am fine doctor, just want to know about my results.
Dr:Sure,do you have any expectations regarding your results?
Pt:No doctor.
Dr:Alright Katherine, is it ok if I can discuss few things with you so that I can
explain your results in a better way?

49
Pt:Yes doctor
Dr:So, why did you come to the GP clinic in the first place?
Pt:I was having vaginal discharge.
Dr:Please tell me more about it? Pt:Like what
doctor?
Dr:From how long are you having this discharge? Pt:From last 2 months.
Dr:I am sorry to hear about that. Does it has a smell? Pt:Yes, it has a fishy odor.
Dr:Its color?
Pt:Its greenish white in color. Dr:And its
amount?
Pt:Its copious in amount.
Dr:Any other symptoms at all with discharge? Pt:No doctor.
Dr:Any fever?(PID) Pt:No
Dr:Any tummy pains?(PID) Pt:No
Dr:Any weight loss or lumps in bumps in body(Malignancy)?
Pt:No
Dr:Any bleeding through vagina?(ectopic pregnancy)?
Pt:No
Dr:By any chance are you pregnant? Pt:No
Dr:Is it the first time its happening to you? Pt:Yes
Dr:Do you have any idea why are you having this discharge?
Pt:Doctor I started using bubble bath from last 2 months. Can it be the
cause?
Dr:Yes ,bubble bath can lead to this infection unfortunately.
Dr: Do you have any health problems? Like DM or HTN Pt:No
Dr:A bit of talk on your sex life is it okay? Pt:Ok doctor
Dr:Are you in a stable relationship? Pt:Yes
Dr:Is your partner having any symptoms? Pt:No
Dr:Do you practice safe sex? Pt:Yes
Dr: Any other sex partner than this partner? Pt:No

50
Dr: When was your LMP? Pt:3
weeks ago
Dr:Are you using any contraception? Pt:I am using
IUCD
Dr:From how long?
Pt:From one year
Dr:Any problems with IUCD? Pt:No
Dr:What you do for your living? Pt:Homemaker
Dr:How this is affecting your life?
Pt:I am not able to do sex from last 2 months because of smell.
Dr:I am really sorry about that. We’ll do our best to help you, don’t worry
Pt:Thankyou
Examination:
Dr:Thanks a lot for talking to me .Now I would like to check your vitals i.e. your BP
,pulse, temperature and respiratory rate plus your tummy and vagina examination.is
it ok?
Pt:Ok doctor
Dr:Alright,Katherine we have your results with us. Good news is that you don’t
have any sexual transmitted infection like chlamydia or gonorrhea. However,
your swab is positive for a bug called Gardnerella vaginalis unfortunately.
Pt:Oh,what is that doctor?
Dr:It’s a bug which can disrupt normal flora of vagina causing a condition called
bacterial vaginosis, which is bacterial infection of vagina.
Pt:How did I get it doctor?
Dr:You told me that u started using bubble bath 2 months ago, that can be one of the
cause. Moreover,as you are using IUCD,that can also be one of the cause of this
infection I am afraid.
Dr:Did I get it from my husband?
Pt:No ,its not a sexually transmitted infection, so you didn’t acquire it from your
husband.
Pt:So doc,what are you going to do for me?
Management:
Dr:We have some lifestyle measures and medical management that can help
you.do you want me to explain them to you?
Pt:Yes doctor

51
Dr:Lifestyle measures are
I. Avoid bubblebaths
II. Avoiddouching
III. Avoid antiseptics and perfumedproducts
IV. Use showers instead of baths Are you
followingme?
Pt:Yes doc
Dr:Then we have an antibiotic called Metronidazole 400mg which you can take twice a
day for 7 days. What do you think about it?
Pt:Ok doctor
Dr:One more thing which is concerning me is IUCD.so for that, we will refer you to
gynecologist so that we can make sure that everything is fine with you. How does
that sound?
Pt:Ok doc.
Dr:Alright Katherine ,we will arrange your follow-up in a week, in the meantime, if
you develop any fever, tummy pains or increased discharge ,please let us know.
Pt:Ok doc.
Discharge Possible cause
Smellsfishy bacterialvaginosis
Thick and white, likecottage cheese thrush
Green, yelloworfrothy trichomoniasis
With pelvic painorbleeding c
hlamydiaorg
onorrhoea
With blistersorsores genitalherpes
Premenstrual syndrome
A 32 year old lady wants to talk to you. Talk to her and address her concerns.
History:
Dr: Hello,my name is Dr XYZ.I am one of the junior doctors in GP clinic. How can I help
you?

52
Pt:Doctor,my husband wants me to talk to you. Actually,I am not feeling myself lately.
Dr:Can you elaborate on it?
Pt:I am getting emotional and angry.I am shouting on my husband and children.I don’t
know what’s going on.
Dr:I am sorry to hear about that. That must be distressing for you. Please don’t worry, we
will look in to this matter.
Pt:Thankyou doc.
Dr:So,from how long you are feeling like this? Pt:From past 8 months.
Dr:That’s a quite long time. Did you do anything to make your situation better?
Pt:Nothing doc.
Dr:Is there anything that makes it worse?
Pt:3 to 4 days before my periods, my mood swings get worse and 1 to 2 days in to periods,
I get a lot better.
Dr:Alright,is it becoming worse or is it the same? Pt:It is same
Dr:Any other symptoms with it at all? Pt:Like what doc?
Dr:Any breast tenderness? Pt:No
Dr:Any body pains? Pt:No
Dr:Any tummy bloating? Pt:No
Dr:How is your mood now a days? (Depression) Pt:It is low
Dr:Can you please score your mood on a scale of 1 to 10,where 1 is the lowest and 10 is
the normal, happy mood?
Pt:Around 4 to 5
Dr:By any chance are you having thoughts of harming yourself or others?
Pt:No doc
Dr: How is your concentration now a days? Pt: It is low.
Dr:Is it the first time it is happening to you? Pt:Yes
Dr:Do you feel cold when others are feeling comfortable?(Hypothyroidism)
Pt:No
Dr:Any weight loss ?(Malignancy) Pt:No
Dr:Any lumps or bumps ? Pt:No
Dr:Any stresses in your life? Pt:No
Dr:Anyone in your family with similar problems? Pt:No
Dr:When was your LMP? Pt:3 weeks ago
Dr: Are they regular? Pt:Yes
Dr:Do you use any contraception? Pt:No
Dr:Did you use any contraceptive in the past? Pt:Yes,I used Depoprovera .
Dr:When did you stop it? Pt:8 months ago
Dr:May I know why?
Pt:I just stopped it without any reason Dr:What you do for your living?
Pt:I am a teacher
Dr:Is this affecting your teaching? Pt:No,I try to control it.
Dr:And how is this affecting your life?
Pt:I am getting distant from family because of these mood swings
Dr:I totally understand that.Please,don’ t worry ,we will try our best to help you.

53
Pt:Thankyou
Dr:How is your sleep? Pt:It is fine/not fine.
Dr:Do you smoke? Pt:Yes/No
Dr:Do you consume alcohol? Pt:No
Dr:Any sort of recreational drugs by any chance? Pt:No
Examination:
I would like to check your vitals i.e. your BP ,pulse
,temperature and respiratory rate. I would also like to do general physical examination of
your whole body including your thyroid gland and glands in body. Is that ok?
Diagnosis
Dr:From what we have discussed, we think that you are having a condition called
Premenstrual syndrome unfortunately.
Pt:What is it doc?
Dr:It is a common condition in women ,in which due to hormonal fluctuations, women
tend to experience mood swings and angry outbursts especially before periods.
Pt:Oh,so what can you do for me?
Management:
• Dr:We have a lot of options to tackle this.
• CBT:It helps a lot to manage mood changes.
• COCP(Continuous; if patient wants some contraception as well)
• Antidepressants(SSRI’s)
• Lifestyle measures:
o Yoga/Exercise
o Meditations
o Breathing techniques
o Indulge in to your favorite hobby
o Sleep hygiene measures(if patient has sleeping problems)
o Avoid smoking or alcohol if any.
• Keep diary of your symptoms for at least 2 to 3 menstrual cycles.
(Manage according to patient preference)
Dr:We will also take some blood to check whether you are anaemic and everything is fine
with your liver, kidneys and thyroid.
Dr: we will arrange a follow up in a month, in the meantime, if you experience more mood
swings
,anxiety, thoughts of harming yourself or others, please let us know.
What causes shifts in mood?
I. PMS(A group of symptoms that occur in women 1 to 2weeks before periods)
II. Premenstrual dysphoric disorder(PMDD)
III. Psychiatric causes
IV. Hormonal imbalances
V. Puberty
VI. Pregnancy
VII. Menopause
Non accidental injury (sexual harassment)

54
You are FY2 in GP clinic.Razia,20 year old girl came because of scalded burn on
her tummy. Nurse have seen the patient and have done the dressing. Talk to her
and address her concerns.
History
(In this station, patient will be anxious and worried, she won’t open up easily as well so
keep convincing and supporting her, acknowledge nonverbal cues)
Dr:Hello,how can I help you? Pt:I am burnt
Dr:I am sorry to hear about that, nurse have done the your burn dressing. How are you
feeling now?
Pt:Ok
Dr:How did you get the burn? Pt:Kettle dropped on me Dr:How?
Pt:It was an accident
Dr:Is it the first time it happened? Pt:Yes
Dr:I can see that something is bothering you. Do you want to share something(Offer
confidentiality)?
Pt:No
Dr:Where are you living? Pt:In a house with 2 girls Dr:How are those girls?
Pt:Fine
Dr:With whom you came to the hospital? Pt:A man, I don’t want to go back with him
Dr:May I know why?
Pt:I don’t know(She won’t easily open up) Dr:Do you have any health problems?
Pt:No
Dr:What do you do for living? Pt:Nothing
Dr:Is there anything you want to share with me? We are here to help you
Pt:I don’t want go with that man, he abuses me and my friends
Dr:I am so sorry to hear about that, how he abuses you and your friends?
Pt:He brings man daily to house
Dr:Then what do they do? Do they hurt you?
Dr:Have you ever tried to take help before or to escape?
Pt:No
Dr:Do you know the address of the place where you live?
Pt:I don’t know
(Dig in the story, from how long they are getting abused, where are their parents,family,ask
address of their accommodation to help other girls as well)
Management:
I. Involve social services and police to help her
II. Tell her about the National domestic helpline number
III. Offer support by Women’s aid group
IV. Refer to sexual assault centers (SARCs)
Reference information:Sexual abuse
Sexual abuse can happen to anyone.
• touch you in a way you do not want to be
touched?
• make unwanted sexual demands?
• hurt you during sex?

55
• pressure you to have unsafe sex – for example, not using a condom?
• pressure you to have sex?
If your partner has sex with you when you do not want to, this is rape.
Have you ever felt afraid of your partner?
Have you ever changed your behaviour because you're afraid of what your partner might
do?
If you think you may be in an abusive relationship, there are lots of people who can help
you.
Supporting a victim of sexual assault
For relatives and friends of someone who has been sexually assaulted, The advice includes:
• Don't judge them, don't blame them. A sexual assault is never the fault of the
person who is abused.
• Listen to the person, but don't ask for details of the assault. Don't ask them why
they didn't stop it. This can make them feel as though you blame them.
• Offer practical support, such as going with them to appointments.
• Respect their decisions – for example, whether or not they want to report the assault
to the police.
• Bear in mind they might not want to be touched. Even a hug might upset them, so
ask first. If you're in a sexual relationship with them, be aware that sex might be
frightening, and don't put pressure on them to have sex.
• Don't tell them to forget about the assault. It will take time for them to deal with
their feelings and emotions. You can help by listening.
Teenager confused about sexual orientation
Question: You are an FY2 in the GP Surgery.
Tom Cooper is a 15 year-old boy who has made an appointment to come and see you.
Talk to the patient and address his concerns.

56
Hello. My name is Dr. ……… I am one of the junior doctors here in the GP Surgery.
Could you please confirm your full name and your age for me?
Yes, I am Tom Cooper and I am 15 years old.
It’s nice to meet you Tom. How can we help you today?
Doctor, I had something to say but can you promise me first that you are not going to tell
my parents about this.
Of course, Tom, even though you are 15 you have the same right to confidentiality as any
adult. Confidentiality means what whatever you discuss here stays between you and our
medical team. We cannot disclose any information without your permission- not even to
your parents. But of course, we are also going to make sure that there is no risk to your
safety, okay?
Okay.
So, what did you want to talk about today, Tom?
Doctor, it’s kind of embarrassing…
Well, Tom, I know there are certain topics that might be difficult to discuss with other
people but you have come to the right place. Please take your time and be assured that we
are not going to judge you. We are only here to help you and the more information you can
give us about what is concerning you, the better we can help you.
Well, there is boy in my class at school who is gay and everyone bullies him for it.
I see. Please go on, Tom.
Well, I think that might have feelings for him.
It’s natural to start having feelings of attraction to other people at your age, Tom. Has
something been bothering you?
Doctor, I think I might be gay.
When did you first realize this?
A couple of months ago.
What has been going through your mind since then?
I am confused and worried about being treated differently if I tell someone.
I see, that must have been tough. Have you discussed your feelings with anyone?
No, nobody.

57
Have you talked about this to the boy you like, Tom?
No.
Do you have some friends you can trust, Tom?
I have friends but they won’t understand and I might lose them.
And have you considered talking to a family member?
They are very traditional. They won’t accept it.
Whom do you live with?
My parents and my older sister.
Have you thought about opening up to your sister?
No. She is traditional like my parents.
How is everything at home apart from this?
It’s fine.
I see, Tom that you are going through a challenging time. Let me just say how glad I am
that you decided to come in and open up to us. Don’t ever feel that you are alone in this.
We are going to help you in every way possible, okay?
Okay, thank you.
Tom, when someone goes though a tough time it can sometimes affect his or her mood.
How has your mood been lately Tom?
My mood is fine.
How is school going?
School is great. I have friends. I do well in studies and sports.
That’s good to hear, Tom. Have you ever been bullied at school?
No, I am pretty popular but I am afraid I might be bullied if tell someone I like another
boy.
I see, Tom.
Are you feeling more anxious or worried than usual?
No, not really.

58
Have you ever been diagnosed with any medical conditions or any mental health
conditions?
No.
Do you take any medications currently?
No.
Can I ask if you smoke?
No.
Do you drink alcohol?
No.
Have you ever used any recreational drugs?
No.
Tom, have you had a relationship before?
Only one. I had a girlfriend for a couple of months last year.
I see. May I ask if you have been sexually active?
No, never.
Have you felt attracted towards the opposite gender as well?
I don’t know. I feel confused.
It’s okay to question your sexual orientation, Tom. There's no one fixed way to work out
exactly what your feelings are. All you have to do is be patient and pay attention to your
feelings. Eventually these will show you exactly where you stand. There is no rush. No
hurry at all.
It takes time for us to fully understand who we are and what gender we are attracted to.
Sometimes sexuality is not as simple as being straight or gay but more of a continuum with
straight at one end and gay at the other. People can move along, stay in one place or change
their position as they try to define their own sexuality.
You shouldn’t feel under any pressure to attach a label to your feeling. The important thing
is to allow yourself time and space to explore how you feel. Does that make sense?
Yes.
Have you had classes on sex education and sexuality at school?

Scenarios Part 1 For PLAB 2

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Scenarios Part 1 For PLAB 2