gk’s notes – part 3

Based on Masterclass Revision by Dr. Lovaan -

November 2024

Compiled and edited with OpenAI Whisper and Anthropic Claude AI

gk’s notes – part 3 – masterclass revision – November 2024

Table of Contents
LARYNGEAL CARCINOMA ..........................................................................................................................................2
JEHOVAH’S WITNESS PATIENT WITH POST-SURGICAL ANEMIA..........................................................................................4
PRIMARY FOCAL HYPERHIDROSIS................................................................................................................................8
BLOOD CULTURE/SEPTICEMIA IN AN ELDERLY PATIENT ..................................................................................................11
ESSENTIAL TREMOR ...............................................................................................................................................14
PROSTATITIS .........................................................................................................................................................17
ANAL FISSURE IN A PREGNANT PATIENT .....................................................................................................................19
VASECTOMY REQUEST IN A YOUNG PATIENT ...............................................................................................................21
AORTIC DISSECTION...............................................................................................................................................24
METFORMIN-ASSOCIATED LACTIC ACIDOSIS (MALA) ..................................................................................................26
SUSPECTED APPENDICITIS IN A CHILD ........................................................................................................................28
ELEVATED PSA .....................................................................................................................................................30
LUNG CANCER VS. MESOTHELIOMA ..........................................................................................................................31
HEAD INJURY AND CT SCAN ....................................................................................................................................31
GENDER DYSPHORIA IN A 16-YEAR-OLD ....................................................................................................................32
SUSPECTED SCAPHOID BONE FRACTURE ....................................................................................................................32
PLANTAR FASCIITIS ................................................................................................................................................34
METATARSALGIA AND MORTON'S NEUROMA ..............................................................................................................36
Scenario 1: Metatarsalgia ...........................................................................................................................36
Scenario 2: Morton's Neuroma ...................................................................................................................38
ENDOMETRITIS .....................................................................................................................................................39
DEPRESSION IN A PATIENT WITH MYOCARDIAL INFARCTION HISTORY ...............................................................................41
TRANSMAN PAP SMEAR .........................................................................................................................................43
LOSING ERECTION .................................................................................................................................................44
ERECTILE DYSFUNCTION IN A DEPRESSION PATIENT ......................................................................................................47
DNAR ................................................................................................................................................................50
CARBIMAZOLE SORE THROAT ...................................................................................................................................52
REQUESTING ANTIBIOTICS FOR TRAVEL ......................................................................................................................54
RILUZOLE FOR MOTOR NEURON DISEASE ...................................................................................................................56
GENERALIZED ANXIETY DISORDER ............................................................................................................................60
ANTIBIOTIC REQUEST - VIRAL INFECTION IN A CHILD ....................................................................................................62
DEHYDRATION IN A CHILD WITH VIRAL FLU SYMPTOMS.................................................................................................65
MENINGITIS PROPHYLAXIS ......................................................................................................................................66
ARCUS SENILIS......................................................................................................................................................68
GLASS PIECE IN THE LEG .........................................................................................................................................69
FOREIGN BODY INGESTION IN A CHILD .......................................................................................................................71
ATROPHIC VAGINITIS .............................................................................................................................................72
Alterna;ve Scenario ....................................................................................................................................73
UTERINE PROLAPSE ...............................................................................................................................................74
RETAINED TAMPON ...............................................................................................................................................76
INCOMPLETE ABORTION .........................................................................................................................................77
HYPEREMESIS GRAVIDARUM ...................................................................................................................................79
PRIMARY DYSMENORRHEA ......................................................................................................................................81
ENDOMETRIOSIS ...................................................................................................................................................82
MEDICATION OVERUSE HEADACHE ...........................................................................................................................85
SCABIES (NEW SCENARIO) ......................................................................................................................................86
ALLERGIC CONTACT DERMATITIS ..............................................................................................................................88
ATYPICAL PNEUMONIA ...........................................................................................................................................89
NURSING HOME - CONFUSION AND FALL ...................................................................................................................91
VENOUS ULCER ....................................................................................................................................................93
MOLE (NEW SCENARIO) .........................................................................................................................................94
LITHIUM TOXICITY .................................................................................................................................................96
HUNTINGTON’S DISEASE.........................................................................................................................................98

1
gk’s notes – part 3 – masterclass revision – November 2024

Laryngeal Carcinoma
Patient Profile

• Age: 51 years old

• Setting: General Practice (GP)
• Presenting Complaint: Hoarseness of voice, intermittent, lasting for two weeks.
o Additional Detail from Patient: The hoarseness comes and goes.
o Patient Justification: Patient may mention having had COVID-19 as a possible
reason for the hoarseness.

Key Risk Factors

1. Smoking:
o The patient has a 35-year history of smoking. This is a major risk factor for
laryngeal carcinoma.
2. Occupational Exposure:
o Occupation: Works in an automobile garage.
o Exposure: Consistent exposure to diesel fumes in the garage, which poses a
significant risk due to inhalation of toxic substances.

Note: Diesel fumes are explicitly highlighted as a risk factor, and the patient may emphasize the
presence of “a lot of fumes” at their workplace.

Structured Approach to Consultation

1. Structure for Symptom Exploration:

o Onset: Confirm with the patient exactly when the hoarseness started.
o Duration: Acknowledge that the hoarseness has persisted for two weeks.
o Progression: Ask if the hoarseness has worsened over time or stayed the same.
o Relieving and Aggravating Factors: Inquire if any factors make the hoarseness
better or worse, such as resting the voice, drinking warm or cold beverages, or
environmental factors at work.
o Frequency: Confirm if the hoarseness is continuous or if it comes and goes
(intermittent, as mentioned by the patient).
o Severity: Ask how much the hoarseness affects daily activities or job
performance, and if it interferes with the patient’s ability to speak normally or
communicate at work.
2. Specific Symptoms Related to Laryngeal Carcinoma:
o Neck Pain: “Have you noticed any pain or discomfort in your neck?”
o Throat Pain: “Do you have any soreness or pain in your throat?”
o Neck Lump: “Have you felt any lumps or swellings in your neck?”
o Swallowing Difficulties (Dysphagia): “Have you had any trouble swallowing
food or liquids?”
o Earache: “Do you experience any pain or discomfort in your ears?”

Note: Each of these symptoms should be explored in detail, as they are significant for
identifying or ruling out laryngeal carcinoma.

2
gk’s notes – part 3 – masterclass revision – November 2024

3. Exploring Differential Diagnoses and Additional Causes:

o Infective Causes:
§ Ask about any history of throat infections or lung infections (such as
bronchitis), as these could also contribute to hoarseness.
o Lung Cancer Symptoms (essential to rule out, given the risk factors and
presentation):
§ Cough: “Do you have a cough, either persistent or recurring?”
§ Shortness of Breath: “Have you experienced any difficulty breathing?”
§ Haemoptysis (Coughing up Blood): “Have you ever coughed up blood
or seen blood in your sputum?”

Occupational Risks and Environmental Factors:

o Asbestos Exposure: Confirm if there’s any chance the patient has worked with
asbestos or in environments where asbestos exposure is possible.
o Exposure to Dust and Fumes:
§ Coal Dust and Wood Dust: “Have you ever worked with coal or wood
dust, or been exposed to it in your job?”
§ Paint Fumes: “Have you been around paint or chemical fumes, such as
in a factory or manufacturing environment?”
§ Diesel Fumes: Re-confirm exposure to diesel fumes in the garage, which
the patient has already mentioned.

Suspected Diagnosis and Explanation to the Patient

1. Diagnosis: Based on the history, presenting symptoms, and risk factors, suspect
laryngeal carcinoma.
2. Patient Communication:
o Explanation of the Condition:
§ Explain that prolonged hoarseness, especially with risk factors like
smoking and diesel fumes, could be due to issues in the larynx (voice
box).
§ Emphasize that persistent hoarseness may sometimes indicate a more
serious condition, like laryngeal carcinoma.
o Importance of Early Detection:
§ Reassure the patient that catching such conditions early can lead to
more successful treatment.
§ Explain that further tests will help determine the cause of the symptoms
and whether intervention is needed.
o Non-alarming Tone: Avoid alarming the patient but be clear about the
necessity of timely investigations.

Investigation and Management Plan

1. Referral: Immediate referral to ENT for further assessment on a two-week pathway.

2. Recommended Investigations:
o Nasendoscopy: A camera test that allows visualization of the larynx and
surrounding structures.

3
gk’s notes – part 3 – masterclass revision – November 2024

oLaryngoscopy: An in-depth camera examination to closely examine the larynx.

oBiopsy: Sampling of tissue, if necessary, to confirm the presence of any
malignancy.
3. Treatment Options Based on Stage:
o Early-Stage Treatment:
§ Combination of chemotherapy and concomitant radiotherapy. Explain
that this treatment approach can be very effective if initiated in the early
stages.
o Late-Stage Treatment:
§ Surgical Intervention: Surgery may be necessary if the carcinoma is
advanced. However, reassure the patient that early detection often
avoids the need for surgery.
o Prognosis:
§ Reinforce that if the condition is caught in its early stages, treatment
outcomes are typically positive.

Points to Avoid During Consultation

• Avoid making a definitive diagnosis without confirmation from the ENT team; focus
on suspicion based on symptoms and risk factors.
• Do not unnecessarily frighten the patient but stress the need for follow-up.
• Avoid discussing extensive treatment options beyond what is immediately necessary
(e.g., avoid mentioning complex surgeries unless asked directly, as this could cause
undue worry).

Jehovah’s Witness Pa7ent with Post-Surgical Anemia

Patient Profile

• Setting: Surgical Department (Orthopedics), F2-level consultation

• Procedure: Hip arthroplasty (hip surgery) conducted two days ago
• Presenting Complaint: The patient reports feeling excessively tired following the
surgery

Key Lab Findings

• Hemoglobin (Hb): Critically low at 6 g/dL, which is significantly concerning as it

should ideally be around 12 g/dL.
• Creatinine: Slightly elevated.
• Additional Tests Provided: The case includes a comprehensive blood test with multiple
markers such as ESR (Erythrocyte Sedimentation Rate), CRP (C-Reactive Protein), etc.,
although the primary concern is the low hemoglobin level.

Initial Steps in the Consultation

1. Confirm the Symptom of Tiredness:

4
gk’s notes – part 3 – masterclass revision – November 2024

o Purpose: Begin by exploring the patient's main complaint—tiredness. It’s crucial

to let the patient describe how this tiredness affects them, even though it is
likely due to post-surgical anemia.
o Suggested Questions:
§ "Could you tell me more about how you’ve been feeling tired?"
§ "How would you describe your energy levels since the surgery?"
2. Explain Why the Patient is Likely Feeling Tired:
o Reasoning: Inform the patient that the tiredness is most likely due to low
hemoglobin levels, which indicate anemia.
o Suggested Dialogue:
§ "Your blood test results show that your hemoglobin level is quite low.
Hemoglobin is important for carrying oxygen around the body, and
when levels are low, it can make you feel very tired."
3. Discuss Symptoms of Anemia:
o Goal: Confirm if the patient is experiencing other symptoms commonly
associated with anemia.
o Questions to Ask:
§ "Apart from feeling tired, do you feel dizzy or lightheaded?"
§ "Are you experiencing shortness of breath?"
§ "Have you noticed any heart palpitations or chest discomfort?"
4. Investigate Causes of Anemia - Surgical History and Complications:
o Objective: Determine whether the anemia is likely post-surgical (due to blood
loss during the procedure) or if there was a pre-existing condition.
o Suggested Questions:
§ "Did you have any blood tests done before the surgery?"
§ "Have you ever had any issues with anemia or low blood counts before
this surgery?"
§ "Did the doctors mention anything about your blood levels being low
before the operation?"
5. Explore the Surgical Procedure in Detail:
o Focus: Investigate potential blood loss or complications during the surgery.
o Questions to Ask:
§ "How did the surgery go? Were there any complications?"
§ "Did the surgical team mention if there was significant blood loss during
the procedure?"
§ "Do you know how much blood was lost?"
6. Assess Whether Any Treatment was Provided for Blood Loss:
o Goal: Understand if any interventions were offered to address blood loss
immediately post-surgery.
o Suggested Questions:
§ "Did the team offer you any treatment or intervention for the blood loss
after the surgery?"
§ "Were you informed about options to manage low blood levels?"

Diagnosis and Explanation to the Patient

1. Diagnosis of Post-Surgical Anemia:

o Explanation: Clearly explain to the patient that the cause of their tiredness

5
gk’s notes – part 3 – masterclass revision – November 2024

is likely due to low hemoglobin levels, resulting from blood loss during the surgery.

• Suggested Dialogue:
o "We did some tests, and your hemoglobin level is currently at 6, which is quite
low. Typically, hemoglobin levels should be around 12. This low level is causing
you to feel tired and is likely due to blood loss during your hip surgery."

2. Introduction of Blood Transfusion:

o Recommendation: Explain that a blood transfusion could help restore
hemoglobin levels to relieve symptoms of tiredness and address the anemia.
o Suggested Dialogue:
§ "Since your hemoglobin is significantly low, a blood transfusion would
help replenish your blood levels and improve your energy. This would
be the standard treatment to address such low hemoglobin."

Patient’s Jehovah’s Witness Belief and Refusal of Blood Transfusion

1. Patient Refuses Blood Transfusion:

o Expected Patient Response: Upon suggesting a blood transfusion, the patient
may respond with, "No, doctor, I don’t take blood."
o Follow-up Question: Politely inquire further to understand their beliefs and
preferences.
§ "I understand. Could you please explain why you feel that way about
receiving blood?"
2. Respectfully Explore the Patient’s Beliefs:
o Reasoning: Confirm if the patient is a Jehovah’s Witness and understand any
previous discussions they may have had regarding blood transfusions.
o Suggested Questions:
§ "Are you a Jehovah’s Witness? I’d like to understand more about your
beliefs."
§ "Before your surgery, did you discuss with your doctors that you prefer
not to receive blood transfusions?"

Promoting the Patient’s Best Interest and Explaining Risks

1. Explanation of Consequences Without Transfusion:

o Purpose: Emphasize the potential health risks if the patient does not receive a
transfusion, while promoting their best interest.
o Suggested Dialogue:
§ "If your hemoglobin remains this low, you may continue to feel
extremely tired, and it could strain your heart as well. Low hemoglobin
puts more pressure on your heart to pump blood, which may cause it to
work harder and potentially lead to chest pain or increased fatigue,
especially when you start doing your daily activities."
2. Encourage Patient to Consider the Benefits of a Transfusion:
o Explanation: Mention that without intervention, symptoms could worsen as
the patient becomes more active.
o Suggested Dialogue:

6
gk’s notes – part 3 – masterclass revision – November 2024

§ "If you don’t receive a transfusion, your symptoms may get worse when
you try to move around and engage in day-to-day activities. I want you to
feel well enough to recover smoothly, and a transfusion could help with
that."
3. Respect Patient’s Autonomy:
o Respecting the Patient’s Refusal: If the patient continues to refuse a
transfusion, apologize for any pressure they may feel and reaffirm their
autonomy.
o Suggested Apology:
§ "I’m sorry if I’ve made you feel uncomfortable or pressured. As your
doctor, I fully respect your beliefs and your right to make your own
healthcare decisions. I just want what’s best for your health, but we
won’t do anything you’re not comfortable with."

Alternative Options and Additional Support

1. Inquire About Advance Directives or Documentation:

o Purpose: Check if the patient has any formal documents or an advance
directive regarding their refusal of blood transfusions.
o Suggested Question:
§ "Do you have any advance directive or signed documentation regarding
your preferences for blood transfusion? We can include this in your
medical records for clarity."
2. Referral to Hospital Liaison Committee for Jehovah’s Witnesses:
o Explain the Role of the Committee: Inform the patient about a liaison
committee within the hospital that represents Jehovah’s Witnesses and can
provide additional support.
o Suggested Dialogue:
§ "In our hospital, we have a liaison committee for Jehovah’s Witnesses,
often with members from your community. They could provide
guidance, discuss options with us, and offer support. Would you like us
to involve them in your care?"
3. Offer Alternative Treatments to Blood Transfusion:
o Non-Blood Components and Iron Infusion:
§ "We could consider alternatives that might help improve your condition
without a blood transfusion. For example, in blood, there’s a
component called hemoglobin that specifically carries oxygen. Receiving
only the hemoglobin might be acceptable for you."
o Iron Infusion and Erythropoietin:
§ "We can also give you an iron infusion to help boost your iron levels,
along with a hormone called erythropoietin, which stimulates your body
to produce more red blood cells naturally."
4. Manage Patient Expectations on Recovery Timeline:
o Explain that Recovery May Take Longer Without Blood:
§ "Even with these alternative treatments, it’s important to know that
recovery might take a bit longer. Your body will gradually replenish the
blood, but it will take time. These treatments can help, but please
understand that it may still take time to feel fully better."

7
gk’s notes – part 3 – masterclass revision – November 2024

5. Reiterate Possible Complications and Need for Close Monitoring:

o Potential Risks of Refusing a Transfusion:
§ "Without a transfusion, there may be some risks, such as prolonged
tiredness or additional strain on your heart. We’ll monitor you closely,
and if you experience any new or worsening symptoms, please let us
know immediately."

Primary Focal Hyperhidrosis

Patient Profile

• Age: Young (around 20 years old)

• Setting: General Practice (GP)
• Presenting Complaint: The patient, a young individual, comes in with an
embarrassing problem.

Consultation Approach

1. Addressing the Patient’s Embarrassment:

o Purpose: Begin by acknowledging the patient’s feelings, creating a comfortable
environment to discuss sensitive issues.
o Suggested Dialogue:
§ "I understand this may feel embarrassing, but please know that, as
doctors, we’re familiar with a wide range of issues and there’s no need to
feel uncomfortable. You can feel free to share whatever is concerning
you."
§ Encourage Disclosure: "Would you like to tell me more about what’s
troubling you?"
2. Patient’s Description of Symptoms:
o Typical Presentation: The patient might describe excessive sweating, primarily
in the armpits and groin area. They may mention that it has a smell, making it
particularly embarrassing.
o Patient Question: The patient may ask, "Is this going to last forever?"
3. Exploring the Onset and History of Symptoms:
o Key Criteria for Primary Hyperhidrosis:
§ Symptoms should persist for more than six months.
§ Typically starts before the age of 25.
§ Check for a family history of hyperhidrosis.
o Questions to Ask:
§ "When did you first notice the sweating? Did it start suddenly or
gradually?"
§ "Has it been getting better or worse over time?"
§ "Does anyone else in your family have a similar problem with excessive
sweating?"
4. Locational Details (Primary Areas Affected):

8
gk’s notes – part 3 – masterclass revision – November 2024

o Objective: Determine all areas affected by sweating to differentiate between

focal and generalized hyperhidrosis.
o Suggested Questions:
§ "Where do you experience the most sweating?"
§ "Do you sweat in any specific areas like your armpits, groin, head and
neck, back, chest, hands, or feet?"
§ "Do you also experience sweating on the soles of your feet?"

Differential Diagnosis and Trigger Exploration

1. Differential Diagnosis:
o Objective: Rule out secondary causes of hyperhidrosis by asking about systemic
symptoms and other relevant medical conditions.
o Conditions to Consider:
§ Infections: Ask about fever and night sweats, which might indicate
infections.
§ Cancer: Ask about symptoms like unexplained weight loss, lumps, or
lymphadenopathy (as in lymphoma).
§ Metabolic Conditions:
§ Hyperthyroidism: "Do you have any symptoms like rapid
heartbeat, unintentional weight loss, or feelings of being overly
warm?"
§ Diabetes: "Have you been diagnosed with diabetes, or do you
experience increased thirst or urination?"
2. Possible Triggers for Hyperhidrosis:
o Environmental and Dietary Triggers: Identify possible external factors that
could worsen symptoms.
o Questions to Explore Triggers:
§ "Do you notice that certain foods make it worse, such as spicy foods or
sweets?"
§ "Does the sweating get worse in warm environments?"
§ "Have you noticed if smoking or certain drinks, like coffee, affect it?"

Evaluation of Impact on Daily Life (Affective Symptoms)

1. Assessing the Impact of Symptoms on Quality of Life:

o Purpose: Determine how much the sweating affects the patient’s social,
personal, and professional life, similar to assessing the severity of depression.
o Suggested Questions:
§ "How much is this sweating impacting your daily activities or social
interactions?"
§ "Are there any specific situations where it makes you feel particularly
self-conscious or uncomfortable?"
2. Importance of Addressing Affective Symptoms:
o Consultation Strategy: Assessing how the symptoms interfere with the patient’s
life is essential for data gathering. This is a required component for effective
consultation.

9
gk’s notes – part 3 – masterclass revision – November 2024

Examination and Diagnosis

1. Examination Offer:
o Provide a Chaperone: If examining specific areas, particularly the groin or
armpits, offer a chaperone to maintain patient comfort.
o Suggested Dialogue:
§ "Would it be okay if I take a look at the areas affected? I can arrange for
a chaperone if that would make you more comfortable."
2. Diagnosis Explanation:
o Primary Focal Hyperhidrosis: Explain that this is a condition where excessive
sweating occurs in specific areas without any other underlying cause.
o Explanation to Patient:
§ "This condition is called primary focal hyperhidrosis. ‘Primary’ means
that there’s no identifiable cause, and ‘focal’ means it only affects
certain areas, such as the armpits and groin."
§ "It’s not dangerous, and there are options available to help manage it."
3. No Testing Required:
o Point to Avoid: Avoid unnecessary testing, as this is typically not required for
primary hyperhidrosis.
o Explanation to Patient:
§ "Since this seems to be primary hyperhidrosis, we don’t need any tests.
Testing is usually done only if we suspect a secondary cause, but based
on your history, that doesn’t appear to be the case here."

Management and Advice

1. Identifying and Avoiding Triggers:

o Explanation: Encourage the patient to recognize and avoid any known triggers
to help reduce symptoms.
o Advice to Patient:
§ "Sometimes, specific triggers can worsen the symptoms. Try to identify if
there are any foods, environments, or activities that seem to make it
worse, and see if avoiding them helps."
2. Use of Antiperspirants vs. Deodorants:
o Clarification: Explain the difference between deodorants (which mask odour)
and antiperspirants (which reduce sweating).
o Suggested Dialogue:
§ "Many people use deodorants, but these only help with odour. I would
recommend trying an antiperspirant, which can actually reduce the
amount of sweating."
§ "Look for antiperspirants that contain aluminum salts, which you can
find at most pharmacies."
3. Application of Aluminum Salt Preparations:
o Details on Usage: Advise the patient on the use of aluminum salt preparations
for better control over sweating.
o Instructions to Patient:
§ "There are also specialized preparations containing aluminum salts that
you can apply in the evening. You would apply it to the affected areas,

10
gk’s notes – part 3 – masterclass revision – November 2024

leave it overnight, and wash it off in the morning. This can help reduce
sweating throughout the day."
4. Clothing Advice:
o Clothing Choices: Suggest wearing certain types of clothing to minimize visible
signs of sweating.
o Advice to Patient:
§ "You might find it helpful to wear loose-fitting clothing. Lighter colours,
like white or blue, can help mask any visible sweating. There are also
underarm pads available that you can wear to absorb the sweat."

Follow-up Approach

• Respecting Patient’s Autonomy: Ensure the patient feels supported in their choices
without feeling pressured.
• Promoting Best Interests: Offer practical solutions, while also being understanding if
they want to try different options or return for further discussion.
• Reassurance: Reinforce that primary hyperhidrosis is manageable and that there are
options available to reduce symptoms and improve quality of life.

Blood Culture/Sep7cemia in an Elderly Pa7ent

Patient Profile

• Setting: F2-level doctor handling a telephone consultation in an elderly or acute

medicine department.
• Patient History: Elderly female patient admitted two days ago with cellulitis, treated
with flucloxacillin, and discharged yesterday after a brief stay.
• Medical Background: Known diabetic on metformin.

Initial Approach to the Telephone Consultation

1. Paraphrase the Situation:

o Objective: Confirm understanding of the patient's recent admission and ensure
a clear baseline for the conversation.
o Suggested Dialogue:
§ "Hello, I understand you were admitted recently and discharged just
yesterday. I wanted to follow up on your health and discuss some
important results with you."
2. Four Essential Questions to Ask:
o Purpose: Clarify the context of the patient’s admission, treatment, and their
understanding of their condition.
o Suggested Questions:
§ "Could you tell me the reason for your recent admission?"
§ "What symptoms were you experiencing when you were admitted?"
§ "Do you know what tests were done during your stay?"

11
gk’s notes – part 3 – masterclass revision – November 2024

§ "What information were you given about your condition and the
treatment provided?"
3. Assess Current Symptoms:
o Objective: Check if the patient is experiencing any new or worsening symptoms
since discharge, focusing on signs of septicemia.
o Suggested Dialogue:
§ "How are you feeling at the moment? Do you have any new symptoms or
concerns?"

Symptoms of Septicemia (Detailed Exploration)

1. Identifying Septicemia Symptoms:

o Core Symptoms:
§ Fever: "Are you experiencing any fever or chills?"
§ Rash: "Have you noticed any unusual rash on your skin?"
o Organ-Specific Symptoms:
§ Lungs (A):
§ Fast Breathing: "Are you breathing faster than usual or feeling
short of breath?"
§ Heart (B and C):
§ Rapid Heartbeat/Chest Pain: "Have you noticed a racing
heartbeat or any chest discomfort?"
§ Brain (D):
§ Confusion or Change in Mental Status: "Are you feeling
confused or experiencing any changes in alertness?"
§ Slurred Speech: "Has anyone noticed that you’re slurring your
speech?"
§ Skin (E):
§ Pale, Cold, or Clammy Skin: "Does your skin feel pale, cold, or
clammy?"
o Explanation for Symptom Questions:
§ Septicemia affects multiple organs due to poor blood perfusion, and
each system can present with specific symptoms as listed above.
Addressing these symptoms helps in assessing the patient’s overall
condition.

Discussion of the Blood Culture Results

1. Informing the Patient of Blood Culture Findings:

o Explanation of Septicemia:
§ Suggested Dialogue:
§ "I wanted to discuss your recent blood test results with you.
Unfortunately, it appears that the bacteria from your cellulitis
wound have spread into your bloodstream, causing a condition
called septicemia. This means there’s an infection in your blood,
which is quite serious."
2. Addressing Antibiotic Resistance:
o Explain Resistance Findings:

12
gk’s notes – part 3 – masterclass revision – November 2024

§"The results also show that some of the antibiotics you were initially
given aren’t effective against this infection. This means the bacteria are
resistant to certain antibiotics, and we need to use stronger medications
to control it."
o Clarify the Urgency:
§ "Because some antibiotics aren’t working effectively, if we delay
treatment, there’s a risk that the infection could worsen."
3. Convey the Potential Risks of Delayed Treatment:
o Explanation of Risks:
§ "If left untreated, the infection could lead to more severe complications.
The bacteria could release more toxins, potentially causing shock or
even affecting your consciousness. This could be life-threatening, so
timely treatment is critical."
o Potential Consequences:
§ "Without prompt treatment, there’s a chance you could experience
complications like coma or shock, which could put your life in danger."

Encouraging Hospital Return and Handling Patient Resistance

1. Recommending Immediate Return to the Hospital:

o Explanation:
§ "Given the seriousness of septicemia, we would strongly advise you to
come back to the hospital so that we can begin treatment immediately."
2. Handling Patient’s Refusal or Delay:
o Patient Response: The patient might mention they have an event to attend, like
a cousin’s wedding, or express reluctance to return immediately.
o Negotiation Approach:
§ "I understand that you have important plans, but I want to emphasize
that this infection needs urgent attention. Septicemia in the
bloodstream can be very dangerous, and it’s not safe to delay treatment."
3. Explaining the Specific Need for Hospitalization:
o Additional Reinforcement:
§ "Since some of the antibiotics aren’t effective, we need to use stronger
ones, such as methicillin or meropenem, which are administered
directly through a vein. These are stronger medications that target
resistant bacteria, and they can only be given in the hospital."
4. Final Emphasis on Risks:
o Dialogue for Emphasis:
§ "Delaying treatment could allow the infection to become more severe,
potentially putting your life in danger. Returning to the hospital will
allow us to control the infection and prevent serious complications."

Treatment Plan and Follow-Up

1. Outline of Treatment Plan Upon Admission:

o Further Blood Tests:
§ "Once you’re here, we’ll take another blood sample to monitor your
infection and check if there are any changes in the bacterial profile."

13
gk’s notes – part 3 – masterclass revision – November 2024

2. Stronger Antibiotics:
o Explanation of Medication:
§ "We’ll start you on strong antibiotics, like methicillin or meropenem,
administered through an IV to directly target the resistant bacteria."
3. Consulting the Microbiology Department:
o Additional Support:
§ "We’ll work closely with our microbiology team, who can provide expert
advice on the best antibiotic treatment based on your blood culture
report."

Essen7al Tremor
Patient Profile

• Age: 50-60 years old

• Setting: General Practice (GP)
• Presenting Complaint: Tremor (shakiness) in the hands, primarily affecting activities
requiring fine motor skills.
• Patient Background: The patient is a violin player and notices tremors primarily when
playing the violin or attempting other fine motor tasks.

Consultation Structure (ODIPARA)

1. Initial Approach and Exploring Symptoms:

o Purpose: Begin by acknowledging the patient’s concern about the tremor and
create a comfortable environment for discussing it.
o Suggested Opening:
§ "How may I help you today?"
o Questions to Explore the Tremor:
§ "When do you notice the tremor? Does it occur when you’re at rest, or
only when you’re trying to do something?"
§ "Does anything seem to make it worse, such as stress or specific
activities?"
§ "Is there anything that makes it better?"
2. Exploration of Alcohol Use:
o Relevant Detail: Essential tremor can sometimes improve temporarily with
alcohol.
o Suggested Questions:
§ "Do you drink alcohol at all? If so, do you notice any change in the
tremor when you have a drink?"
3. Checking for Other Body Parts Affected:
o Objective: Determine if other areas are affected, as essential tremor can involve
the head, voice, and legs.
o Suggested Questions:
§ "Apart from your hands, do you notice any shakiness in other parts of
your body, like your head, voice, or legs?"

14
gk’s notes – part 3 – masterclass revision – November 2024

Detailed History and Differential Diagnosis

1. Onset and Progression:

o Clarify Onset: "When did you first notice the tremor? Did it start gradually or
suddenly?"
o Progression: "Has it been getting worse over time, or does it stay about the
same?"
2. Possible Causes of Tremor (Differential Diagnosis):
o Neurological Conditions:
§ Stroke/TIA: "Have you ever had a stroke or a transient ischemic attack
(TIA) in the past?"
§ Parkinson’s Disease: "Do you have any symptoms that might suggest
Parkinson’s, like slow movements, muscle stiffness, or difficulty with
balance?"
o Metabolic Conditions:
§ Hyperthyroidism: "Have you ever been diagnosed with thyroid issues,
or do you have symptoms like feeling overly warm, weight loss, or
palpitations?"
§ Hypoglycemia: "Do you have any issues with low blood sugar or
diabetes?"
o Mental Health and Lifestyle Factors:
§ Anxiety and Stress: "Do you feel that stress or anxiety makes the tremor
worse?"
o Medication History:
§ Specific Medications: Certain medications can cause tremors.
§ Salbutamol, Lithium, Antipsychotics: "Are you taking any
medications like salbutamol for asthma, lithium, or any other
psychotropic medications?"

Examination and Diagnosis

1. Physical Examination:
o Offer Examination: "I’d like to check your hand movements and some other
physical responses. Would that be okay?"
o Expected Findings: In cases of essential tremor, physical examination will
typically show normal power, tone, reflexes, and no cerebellar abnormalities.
Balance and coordination should also be intact.
2. Diagnosis Explanation:
o Essential Tremor:
§ Explanation:
§ "Based on what you’ve described and our findings, it sounds like
you might have a condition called essential tremor. This is a
neurological condition where certain parts of your body, like
your hands, shake involuntarily when you try to do specific
activities. It’s not dangerous but can be bothersome."
§ "Essential tremor can affect areas like your hands, head, jaw, or
even your voice, but it usually doesn’t affect your ability to
function in other ways."

15
gk’s notes – part 3 – masterclass revision – November 2024

3. No Need for Further Testing:

o Avoid Unnecessary Testing:
§ "With essential tremor, we typically don’t need any additional tests, as it
doesn’t usually indicate an underlying disease. However, a routine
referral to a neurologist may be helpful for further evaluation."

Management and Treatment Options

1. Neurology Referral:
o Routine Referral: Essential tremor generally requires a referral to neurology for
assessment and possible treatment.
o Explanation of Neurology Approach:
§ "A neurologist may suggest treatments like medication or, in some cases,
other interventions to help manage the tremor."
2. Medication Options:
o Medications:
§ Propranolol (a beta-blocker) or Topiramate (an anticonvulsant) are
typically used in low doses.
§ "The neurologist might prescribe medications like propranolol,
which is often used for migraine prevention but can also help
with tremors. Another option is topiramate."
§ Botox Injections (for targeted relief in specific areas, like hands or
head).
§ "In some cases, Botox injections can help with tremors,
especially if they’re affecting specific areas."
3. Lifestyle Modifications and Supportive Measures:
o Managing Affective Symptoms: Assess how the tremor affects daily tasks.
§ Suggested Questions:
§ "Does the tremor make it difficult for you to eat or drink, hold
objects, or write?"
o Advice on Adjustments for Activities:
§ Eating and Drinking:
§ "Using heavier cutlery can sometimes help reduce shakiness
when you’re eating."
§ "For drinking, try using a heavier mug, which may make it easier
to hold."
§ Writing:
§ "If writing is difficult, using a thicker pen or trying to type
instead might be helpful."
4. Avoidance of Aggravating Factors:
o Caffeine and Stress:
§ "Try to avoid caffeine and manage stress as best as you can, as these can
make tremors worse."
o Sleep:
§ "Getting enough sleep can sometimes improve symptoms, as fatigue can
exacerbate tremors."
o Alcohol Use:

16
gk’s notes – part 3 – masterclass revision – November 2024

§ "While it’s not generally recommended as a treatment, some people find

that a small amount of alcohol can temporarily reduce tremors. If you
choose to try this, please don’t exceed the recommended 14 units per
week."

Prosta77s
Patient Profile

• Age: Young (around 40-42 years old)

• Setting: GP or outpatient setting, using a mannequin for examination
• Presenting Complaint: Pain “down below” (pelvic pain)

Consultation Structure and Key Points

1. Initial Presentation:
o Chief Complaint: The patient will describe pain “down below.”
o Suggested Opening Question:
§ "Could you tell me more about where you feel the pain? Is it more
towards the back passage, front passage, or in between?"
2. Associated Symptoms:
o Prostate Symptoms:
§ Common symptoms include frequency (increased need to urinate) and
urgency.
§ Questions to Ask:
§ "Do you find yourself needing to go to the toilet more often or
with a sudden urge?"
§ Note: There are no symptoms of STI (sexually transmitted infection) or
UTI (urinary tract infection), so avoid focusing on these unless red flags
appear.
3. Differentiation from Similar Conditions:
o Mannequin Usage:
§ This scenario involves a mannequin, which is specific to prostatitis
cases. An anal fissure scenario (often confused with prostatitis) does not
use a mannequin and is typically seen in female patients, often post-
pregnancy or with hemorrhoids.
o Key Differentiator:
§ Prostatitis in a male patient uses a mannequin for examination, while
conditions like anal fissure do not.

History and Examination

1. Urinary Dipstick Test:

o Purpose: Identify inflammation markers but not diagnose UTI or diabetes.
o Expected Findings:
§ Protein Positive: Indicates inflammation consistent with prostatitis.

17
gk’s notes – part 3 – masterclass revision – November 2024

§ Leukocytes Positive: Another sign of inflammation.

§ Nitrates and Sugar Negative: Rules out UTI and diabetes.
o Note: Occasionally, some cases may show nitrates, but typically it’s two positives
(protein, leukocytes) and two negatives (nitrates, sugar) for prostatitis.
2. Physical Examination (using mannequin):
o Procedure: Explain that the examination may be uncomfortable, and reassure
the patient of a gentle approach.
o Expected Findings: Tenderness on examination of the prostate.
o Suggested Dialogue:
§ "This examination might feel uncomfortable, but I will be as gentle as
possible. Please let me know if you feel any significant pain."

Diagnosis and Explanation

1. Diagnosis: Prostatitis
o Explanation:
§ "It sounds like you have a condition called prostatitis, which is an
inflammation of the prostate gland, a small organ located just below
your bladder. This can cause pain in the pelvic area and other symptoms
related to urination."
2. Immediate Actions:
o Urine Culture: Always collect a urine sample for culture and send it to the lab.
o Start Antibiotics Immediately: Do not delay the start of antibiotic treatment.
3. Antibiotic Treatment:
o First Course Duration: Two weeks of antibiotics.
o Follow-Up Timeline:
§ 48 hours: Check for initial improvement in symptoms.
§ Two weeks: If symptoms persist, consider an additional two weeks of
antibiotics.

Self-Care and Additional Management

1. Pain Management:
o Paracetamol: Advise the use of paracetamol for pain relief as needed.
2. Hydration and Urination:
o Encourage Hydration: Advise the patient to avoid dehydration, but also
recognize that urination may be painful.
3. Defecation Issues:
o Lactulose for Constipation: If the patient reports difficulty with bowel
movements due to pain, suggest a stool softener like lactulose.
4. Other Symptom-Specific Guidance:
o Painful Ejaculation: If the patient reports painful ejaculation, acknowledge it as
a known symptom of prostatitis and provide reassurance.

Safety Netting

1. Additional Complications to Watch For:

o Epididymitis: Risk of infection spreading to the epididymis.

18
gk’s notes – part 3 – masterclass revision – November 2024

o Chronic Pain: Possibility of prostatitis symptoms becoming chronic if

untreated.
o Urinary Retention: Advise the patient to report any sudden difficulty in
urinating, as this could indicate retention.
2. Safety Netting Dialogue:
o "If you notice any new symptoms like severe pain, fever, or sudden inability to
urinate, please seek medical attention promptly, as these could indicate
complications."

Anal Fissure in a Pregnant Pa7ent

Patient Profile

• Age/Gender: Female, likely pregnant in the later stages.

• Setting: General Practice (GP).
• Presenting Complaint: Patient complains of "bleeding down below."

Consultation Structure and Key Points

1. Initial Presentation:
o Chief Complaint: The patient will initially state that she has "bleeding down
below," which may be misleading as it could suggest a pregnancy-related issue.
o Clarification Question:
§ "Can you clarify if the bleeding is from the front passage or the back
passage?"
o Expected Response: The patient will confirm that the bleeding is from the back
passage, indicating a rectal or anal issue.
2. Exploring Bleeding Details:
o Objective: Establish the severity, nature, and timing of the bleeding.
o Suggested Questions:
§ "How much blood do you notice when you bleed? Is it a small amount,
or would you say it’s a lot?"
§ "Is the blood fresh and bright red?"
§ "Do you see blood clots or is it mixed with your stool?"

History and Risk Factors

1. Assessing Causes and Risk Factors for Anal Fissures:

o Hemorrhoids: Common risk factor in pregnancy, especially if the patient
experienced hemorrhoids in a previous pregnancy.
§ Suggested Questions:
§ "Have you had issues with hemorrhoids in this or a previous
pregnancy?"
o Other Causes of Bleeding:
§ Cancer: "Has there been any family history of bowel cancer?"

19
gk’s notes – part 3 – masterclass revision – November 2024

§Sexually Transmitted Infections (STIs): "Have you been tested for any
STIs recently?"
§ Blood-Thinning Medications: "Are you on any medications that thin
the blood, like aspirin or warfarin?"
o Constipation and Diarrhea: Both can increase the risk of anal fissures.
§ "Have you experienced constipation or diarrhea recently?"
o Anemia Symptoms: Given the bleeding and pregnancy, assess for anemia
symptoms.
§ "Do you feel unusually tired or lightheaded?"
2. Complete History (MAP-DOSA):
o General Health: Ask about any other health concerns.
o Pregnancy-Related Questions: Since the patient is pregnant, include questions
related to the pregnancy's progress and any complications.

Diagnosis and Explanation

1. Diagnosis: Chronic Anal Fissure

o Examination Request: Mention that you would like to examine the area to
confirm the diagnosis.
o Expected Examination Findings:
§ The examination notes will describe a visible muscle fiber at the base of
the fissure and possibly a skin tag located at the 6 o'clock (posterior)
position, which is common for chronic anal fissures.
o Explanation of Condition:
§ "This condition is called a chronic anal fissure. An anal fissure is a small
tear in the skin lining of the back passage, which can cause pain and
bleeding, especially when passing stool."
2. Risk Factors:
o Hemorrhoids and Constipation: "Having hemorrhoids and issues like
constipation can increase the risk of developing anal fissures, particularly during
pregnancy."

Management and Treatment Options (FFE: Fluid, Fiber, Exercise)

1. First-Line Management (FFE):

o Fluid Intake:
§ "It’s important to stay hydrated. Aim to drink at least two liters of water
daily to help soften stools and reduce strain."
o Fiber-Rich Diet:
§ "Include more fiber in your diet, like fruits, vegetables, and whole grains,
which can help prevent constipation."
o Exercise:
§ "Gentle physical activity, as advised in pregnancy, can also support
digestion and help prevent constipation."
2. Second-Line Management (Stool Softeners):
o Lactulose or Fybogel:
§ If the patient’s symptoms persist despite lifestyle changes, recommend
stool softeners.

20
gk’s notes – part 3 – masterclass revision – November 2024

§ Expected Patient Concern: The patient may ask if these are safe during
pregnancy.
§ Reassurance:
§ "Both lactulose and Fybogel are safe to use during pregnancy and
can help ease the strain when passing stools."
3. Additional Self-Care Advice:
o Regular Toilet Routine:
§ "Try to go to the toilet at a regular time every day and avoid delaying
when you feel the urge, as this can worsen constipation."
o Avoiding Harsh Wiping:
§ "After using the toilet, avoid wiping too hard. Instead, pat gently, and
consider using soft, moist wipes if that’s more comfortable."
o Warm Baths:
§ "Soaking in a warm bath for a few minutes, especially after bowel
movements, can help ease pain and promote healing."

Safety Netting and Follow-Up

1. Signs of Complications:
o "If you experience increased pain, heavy bleeding, or any symptoms like fever or
chills, please contact the clinic or go to the hospital, as these could indicate
complications."
2. Follow-Up Plan:
o If symptoms do not improve with lifestyle changes and stool softeners, consider
a follow-up for further assessment and possible referral.

Vasectomy Request in a Young Pa7ent

Patient Profile

• Age: 26 years old

• Setting: F2 doctor in General Practice (GP)
• Presenting Complaint: The patient is requesting a referral for a vasectomy.

Core Focus of the Scenario

• This scenario is less about the specifics of the vasectomy procedure and more about
whether or not to provide a referral based on the patient’s understanding, readiness,
and reasoning.
• Use the Four-Box System to organize the consultation and gather necessary
information to determine the appropriateness of the referral.

Consultation Structure (Four-Box System)

1. Box 1: Patient’s Prior Knowledge and Expectations

o Purpose: Assess the patient’s understanding and expectations about vasectomy.

21
gk’s notes – part 3 – masterclass revision – November 2024

o Suggested Questions:
§ "Could you tell me how much you already know about vasectomy? Have
you done any reading or research?"
§ "What do you understand about how the procedure is performed?"
§ "Do you know the benefits of vasectomy?"
§ "What about the potential disadvantages?"
§ "How much do you know about the reversibility of vasectomy? Are you
aware of the success rates if you ever decide to reverse it?"
2. Box 2: Patient’s Personal and Relationship Factors
o Purpose: Gather information about the patient’s personal and relationship
circumstances, including his motivations, current relationship, and partner’s
views.
o Divide Box 2 into Him and Her:
§ Him (2.1):
§ "Is there a particular reason you’re not interested in other forms
of contraception?"
§ "Do you have any children already? If not, could I ask why you’re
sure about not wanting children?"
§ "Are you in a stable relationship?"
§ "How long have you been in this relationship?"
§ "Have you discussed this decision with your partner? If so, when
and what was the outcome of those discussions?"
§ Her (2.2):
§ "Could you share your partner’s opinion on the vasectomy? Does
she agree with this decision?"
§ "How old is your partner?" (Understanding age can impact family
planning needs, especially if the partner is younger and may
desire children later.)
§ "Does your partner have any children, or is she interested in
having children in the future?"
§ "Is your partner currently using any contraception, like the pill?"
(This can influence your discussion, as it may show there is an
existing contraception plan.)
3. Box 3: Explanation of Vasectomy Procedure
o Purpose: Ensure the patient fully understands the procedure, its benefits, and
limitations.
o Explanation:
§ "Vasectomy is a form of male sterilization where the tube carrying sperm
from the testes is disconnected. This prevents sperm from being present
in your ejaculate."
§ "The procedure is performed under local anaesthesia and is very
effective and permanent."
o Benefits:
§ "It’s a permanent solution for contraception, and once completed, it’s
highly effective for a long term."
o Disadvantages:
§ "It does not protect against sexually transmitted infections."

22
gk’s notes – part 3 – masterclass revision – November 2024

§ "It takes around three months for the vasectomy to be fully effective,
during which other contraception must be used."
o Reversibility:
§ "Reversing a vasectomy is possible, but success rates vary and are not
guaranteed. Once performed, it should be considered a permanent
decision."
4. Box 4: Considering Patient’s Age and Advising Against Immediate Decision
o Purpose: Based on the patient’s age, relationship, and desire for a vasectomy,
discuss reasons to reconsider and potential regrets.
o Advising Against Immediate Decision:
§ "Given your age, we usually advise younger patients to reconsider
permanent contraception like vasectomy. Research shows that people
under 30 who choose vasectomy often regret the decision later,
especially if life circumstances change, such as a desire to have children."
o Relationship Consideration:
§ "Since you’re in a long-term relationship, decisions around having or
not having children should ideally be mutual and fully discussed with
your partner. Such decisions can impact relationships significantly, so
we encourage clear, thoughtful discussion before making a permanent
choice."
o Counseling and Postponement Suggestion:
§ "I recommend taking some time to consider this decision further. We
can arrange counseling sessions to discuss this with you and your
partner, which may help clarify your options. Let’s give it a month to
discuss with your partner and think about it."

Handling Patient Objections and Final Counseling

1. If Patient Insists ("My body, my choice"):

o Response:
§ "I completely respect your right to make decisions about your body. As
doctors, however, we aim to guide our patients in a way that we believe
is in their best interest based on medical research and experience."
§ "Our experiences show that young patients who undergo vasectomy
sometimes regret it later. We just want to ensure you’re making the
most informed and well-considered decision."
2. Confidentiality Reassurance:
o If the Patient Asks About Partner Involvement:
§ "Please rest assured that all conversations between us are confidential. I
won’t speak to your partner unless you choose to involve them in the
discussion."
3. Encouraging an Informed and Thoughtful Decision:
o Final Advice:
§ "I encourage you to take the time to think through all aspects and
implications. We’re here to support you in whatever decision you make,
but we want you to be as certain as possible that this is the right step for
you."

23
gk’s notes – part 3 – masterclass revision – November 2024

Aor7c Dissec7on
Patient Profile

• Age: Typically older (though not specified here, usually seen in patients over 60).
• Setting: Likely an emergency or acute care setting.
• Presenting Complaint: Severe back pain between the shoulder blades.

Key Points and Differential Diagnosis

1. Differentiating Aortic Dissection from Aortic Aneurysm:

o Aortic Dissection:
§ Pain Location: Patient will report back pain between the shoulder
blades.
§ Additional Symptoms: May include dizziness or other symptoms of
bleeding.
§ Blood Pressure History: No history of hypertension (unlike aortic
aneurysm cases).
o Aortic Aneurysm:
§ Pain Location: Typically lower back pain.
§ Blood Pressure: Often associated with a history of high blood pressure.
§ Pulsatile Mass: On examination, a pulsatile mass may be felt.

History and Symptoms to Explore

1. Pain Characteristics:
o Initial Question:
§ "Can you describe where you feel the pain?"
o Expected Response: Patient will mention severe pain between the shoulder
blades, often sudden and intense.
2. Associated Symptoms (due to poor blood supply to major organs):
o Heart: Chest pain and possible symptoms of myocardial infarction (MI).
o Lungs: Fast breathing due to lactic acidosis from hypoperfusion.
o Brain: Stroke-like symptoms, confusion, or neurological deficits.
o Kidneys: Symptoms of kidney failure if renal arteries are affected.
o Spinal Cord: Lower limb numbness or weakness if spinal arteries are involved.
3. Additional Questions:
o "Are you experiencing any dizziness or light-headedness?"
o "Have you noticed any numbness or weakness in your legs?"
o "Are you feeling short of breath or having chest pain?"

Examination Findings

1. Blood Pressure:
o High blood pressure, often around 180 or higher.
2. Pulse Examination:

24
gk’s notes – part 3 – masterclass revision – November 2024

o Weak/Feeble Pulses: Pulses may feel weak or feeble.

o Pulse Delay: There may be a radial-radial or radial-femoral delay, indicating a
vascular issue.
3. Make Diagnosis: Suspect Aortic Dissection based on history, pain location, and
examination findings.

Explanation to Patient

1. Explaining Aortic Dissection:

o Definition:
§ "Aortic dissection occurs when there’s a tear between the layers of the
aorta, which is the largest blood vessel that carries blood from the heart
to the rest of the body."
o Pathophysiology:
§ "As we age, the walls of the aorta can lose their elasticity. Over time, this
weakening can cause a tear between the layers, allowing blood to enter
and create a false channel or lumen."
§ "This condition is serious as it can affect blood flow to vital organs like
the brain, heart, kidneys, and spinal cord."

Immediate Management

1. Initial Stabilization:
o Pain Relief: Administer morphine to relieve pain.
o Antiemetics: Give ondansetron to control nausea associated with the pain and
stress response.
o Blood Pressure Control:
§ Use labetalol as the first-line medication to lower blood pressure.
§ Target blood pressure: Under 120 mmHg.
2. Investigations:
o Chest X-ray: To check for mediastinal widening.
o CT Scan of the Chest: Essential to confirm the diagnosis and extent of
dissection.
o Blood Tests:
§ Troponin: To assess heart involvement.
§ Lactic Acid: To evaluate for hypoperfusion or shock.
o ECG: To rule out myocardial infarction, as chest pain may be present.

Definitive Treatment

1. Stabilize the Patient:

o Goal: Stabilize vital signs, particularly blood pressure, to prevent further
progression of the dissection.
2. Classification and Referral Based on Stanford Type:
o Stanford Classification:
§ Type A (Ascending Aorta):
§ Involves the ascending aorta (the portion of the aorta that rises
from the heart).

25
gk’s notes – part 3 – masterclass revision – November 2024

§ Management: Refer urgently to cardiothoracic surgery for

surgical intervention.
§ Type B (Descending Aorta):
§ Involves the descending aorta (the part that goes down the
body).
§ If Stable: Manage medically, often in a coronary care unit under
cardiology.
§ If Unstable: Refer to vascular surgery, as surgical intervention
may be required.

MeKormin-Associated Lac7c Acidosis (MALA)

Patient Profile

• Age: 65 years old

• Setting: Telephone consultation
• Presenting Complaint: The patient, known to have diabetes and taking metformin,
reports feeling tired, experiencing fast breathing, and having clammy hands.

Key Points and Differential Diagnosis

1. Primary Condition: Metformin-Associated Lactic Acidosis (MALA)

o Presentation: Lactic acidosis caused by metformin can present with vague
symptoms like tiredness, fast breathing, and clammy hands.
o Understanding Lactic Acidosis:
§ Lactic acidosis occurs when there’s a buildup of lactic acid in the body
due to issues with its elimination, often linked to factors like
medications (e.g., metformin), dehydration, or underlying illness.

Consultation Structure

1. Initial Questions and Symptom Exploration:

o Open with General Inquiry:
§ "How may I help you today?"
§ Expected Response: The patient may report symptoms like feeling
unusually tired, fast breathing, and clammy hands.
o Explore Symptom Details:
§ "When did you start feeling these symptoms?"
§ "Are the symptoms getting better, staying the same, or worsening?"
2. Ask About Specific Symptoms of Lactic Acidosis:
o Purpose: Identify signs of lactic acidosis by focusing on systemic symptoms
involving the heart, breathing, brain, and skin.
o Suggested Questions:
§ "Are you feeling nauseous or have you been vomiting?"
§ "Do you feel dizzy or lightheaded?"
§ "Are you experiencing any chest pain or difficulty breathing?"

26
gk’s notes – part 3 – masterclass revision – November 2024

§ "Do you notice any changes in mental clarity or are you feeling
confused?"
3. Systemic Review:
o Purpose: To rule out other causes and understand any recent changes in health
or lifestyle that might contribute to MALA.
o Key Questions:
§ "Have you been unwell recently or had any infections?"
§ "Could you tell me about your recent alcohol intake? Have you
consumed more than usual?"
§ "Have you experienced any diarrhea or dehydration?"
§ "Is there any chance you may have accidentally taken more of your
medication than prescribed?"

Explanation of MALA to the Patient

1. Diagnosis Explanation:
o Metformin-Associated Lactic Acidosis:
§ "It sounds like you may have a condition called metformin-associated
lactic acidosis, which is a rare but serious side effect of metformin."
o How It Happens:
§ "Under normal circumstances, our body produces acids that are broken
down by the liver. However, metformin can sometimes interfere with
this process, leading to a buildup of lactic acid."
o Severity:
§ "This condition is serious and requires immediate treatment as it can
affect the heart, breathing, and brain if left untreated."

Management Plan

1. Immediate Action – Call an Ambulance:

o Advice Against Driving:
§ "I strongly advise you not to drive yourself to the hospital as this
condition can worsen quickly. You could experience dizziness,
confusion, or even lose consciousness, which would make driving
unsafe."
o Call an Ambulance:
§ "The best option is to call an ambulance so that you can get to the
hospital safely and receive the necessary care promptly."
2. Hospital Investigations:
o Required Tests:
§ Arterial Blood Gas (ABG): To measure acid levels in the blood and
confirm lactic acidosis.
§ Kidney and Liver Function Tests: To assess any organ impact from
lactic acidosis.
§ Medication Level Check: To determine if metformin levels are
excessively high.
§ Other Blood Tests: Troponin (for heart), lactic acid levels, and
electrolyte balance.

27
gk’s notes – part 3 – masterclass revision – November 2024

3. Hospital Treatment:
o First-Line Treatment:
§ Stop Metformin: Discontinue the medication immediately.
§ Oxygen Therapy: To support breathing if oxygen levels are low.
§ IV Fluids: To help flush out excess lactic acid and support hydration.
o Second-Line Treatment:
§ Bicarbonate Therapy: If acidosis is severe, bicarbonate may be
administered through an IV to help neutralize acid levels.
o Third-Line Treatment:
§ Haemodialysis: If other treatments fail to control the acidosis, dialysis
may be required to filter lactic acid and metformin from the blood.

Suspected Appendici7s in a Child

Patient Profile

• Age: 12 years old

• Setting: Telephone consultation with the mother
• Presenting Complaint: Tummy pain, previously evaluated without a definitive
diagnosis.

Scenario Overview

1. Background:
o The child was brought in the previous day with abdominal pain. The initial
evaluation was inconclusive, and blood tests were taken. The child was sent
home pending test results.
o Today, the blood test results are available, showing a high white blood cell
count (14,000), suggesting an infection.
2. Objective:
o Confirm findings with the mother, explain the suspected diagnosis of
appendicitis, and advise immediate follow-up.

Consultation Structure (Telephone Approach)

1. Five Steps for Telephone Consultation:

o Identify the Patient and Parent:
§ "Hello, may I confirm that I’m speaking with [Mother's Name]?"
o Introduce Yourself:
§ "I’m Dr. [Your Name], one of the doctors from the hospital."
o Reason for the Call:
§ "I’m calling about your son’s visit to the hospital yesterday. I’d like to
discuss the results of his tests."
o Obtain Permission:
§ "Is this a good time to talk?"
o Confirm Information:

28
gk’s notes – part 3 – masterclass revision – November 2024

§ "To make sure I have the correct information, can I confirm a few
details about yesterday’s visit and your son’s current symptoms?"

History and Symptom Exploration

1. Discuss Previous Visit and Symptoms:

o Open Inquiry:
§ "Can you tell me what happened yesterday? What were his symptoms at
that time?"
o Expected Symptoms:
§ The mother will likely describe that the pain started around the belly
button and moved to the right lower side of the abdomen, typical of
appendicitis.
2. Ask About Other Symptoms of Appendicitis:
o Key Symptoms:
§ "Does he have nausea or has he vomited?"
§ "Is he having any diarrhea or has he been constipated?"
§ "Does he have a fever?"
§ "Has he been able to pass stools normally?"
o GI-Related Symptoms: You may also ask about other general gastrointestinal
symptoms like jaundice or gastroenteritis symptoms, but focus on appendicitis-
related indicators.
3. Details of Yesterday’s Evaluation:
o Questions to Clarify Past Evaluation:
§ "What tests were done yesterday? Did they take an X-ray or perform any
other scans?"
§ "What did they tell you about his condition before you left?"
§ Note: This is not considered a medical error, as the team informed the
mother that further tests were needed and did not definitively close the
case.

Current Situation and Assessment

1. Ask About Current Symptoms:

o "How is your son doing today?"
o Expected Response: The mother may report that he is still in pain, holding his
abdomen, lethargic, and perhaps experiencing nausea but no fever. She might
mention that pain relief (like Calpol) has not been effective.
2. Complete MAFTOSA (for Pediatric History):
o Ask about general health, any prior health issues, or recent infections.
o Confirm if there’s any history of similar episodes or gastrointestinal issues.

Diagnosis and Explanation to Parent

1. Explain the Blood Test Results:

o White Blood Cell Count:
§ "We received the blood test results from yesterday. It shows that the
number of white blood cells is elevated, indicating an infection."

29
gk’s notes – part 3 – masterclass revision – November 2024

2. Diagnosis Explanation:
o Suspected Appendicitis:
§ "Based on his symptoms and the blood test results, it appears that your
son may have a condition called appendicitis. This is an inflammation
of the appendix, which is a small, finger-like pouch located in the large
intestine."
o Cause and Symptoms:
§ "Appendicitis can sometimes be caused by viral or bacterial infections,
and it typically presents with pain that starts in the middle of the
abdomen and moves to the lower right side. Other symptoms may
include nausea, vomiting, fever, and lethargy."

Management and Next Steps

1. Advise Immediate Hospital Visit:

o "We recommend that you bring your son back to the hospital as soon as
possible. He may need further evaluation and treatment."
2. Further Hospital Investigations:
o Imaging and Tests:
§ "Once you arrive, we will likely perform an X-ray or CT scan to confirm
the diagnosis."
§ "We may also do additional blood tests to check his condition."
3. Treatment for Appendicitis:
o Appendectomy:
§ "The primary treatment for appendicitis is surgery to remove the
appendix, called an appendectomy."
o Antibiotics:
§ "We may start antibiotics to manage any bacterial infection."
4. Confirm Understanding and Plan:
o "Are you able to bring him to the hospital now? It’s important to come in
promptly for further evaluation and treatment."
5. No Negotiation for Delay:
o Immediate Action Required:
§ Emphasize that there is no alternative to immediate hospital evaluation.
Appendicitis can worsen quickly and may lead to complications if not
treated in time.

Elevated PSA
Patient Profile

• Reason for Consultation: The patient has come for PSA test results out of concern for
cancer.

Key Points

30
gk’s notes – part 3 – masterclass revision – November 2024

1. PSA Level Interpretation:

o PSA Level: The PSA result is 3.2, slightly above the normal range of 3.
o Follow-Up Questions:
§ "Did you engage in any sexual activity recently, such as the night before
the test?"
§ "Have you done any heavy exercise, like going to the gym, recently?"
2. Explanation of Influencing Factors:
o Impact of Sexual Activity and Exercise:
§ Explain that recent sexual intercourse or strenuous exercise can
temporarily elevate PSA levels, possibly making this result inaccurate.
o Advice:
§ "We recommend repeating the test in a day or two, but please avoid
sexual activity and intense exercise before the test for the most accurate
result."
3. Next Steps if PSA Remains Elevated:
o If the PSA level is still elevated upon retesting, initiate a cancer pathway
referral for further investigation, as persistent elevation could indicate a
potential prostate issue.

Lung Cancer vs. Mesothelioma

Patient Profile

• Symptoms: Coughing up blood, shortness of breath, smoker.

• Occupation: Carpenter.

Key Points

1. Differential Diagnosis:
o Lung Cancer: Possible due to smoking history.
o Mesothelioma: Stronger consideration due to occupational exposure, as
carpenters may have been exposed to asbestos.
o Conclusion: Given the occupational history, mesothelioma is a primary
suspicion, though lung cancer remains a possibility.

Head Injury and CT Scan

Context

• Setting: Scenarios may involve either adults or children with head injuries.
• Focus: Knowing the criteria for ordering a CT scan after a head injury.

Key Points

31
gk’s notes – part 3 – masterclass revision – November 2024

1. Indications for CT Scan in Head Injury:

o Adult Criteria: Based on specific symptoms (e.g., loss of consciousness,
vomiting, severe headache, signs of skull fracture, age over 65).
o Pediatric Criteria: Different guidelines apply, with a focus on factors like
mechanism of injury, signs of skull fracture, altered consciousness, and
vomiting.
o Recommendation: Review the specific criteria for both adult and pediatric
head injuries to make an informed decision on whether a CT scan is required.

Gender Dysphoria in a 16-Year-Old

Patient Profile

• Age: 16 years old

• Reason for Consultation: The patient desires gender transition support.

Key Points

1. Referral Pathway for Gender Dysphoria:

o Initial Referral:
§ Refer the patient to CAMHS (Child and Adolescent Mental Health
Services) for assessment.
o National Referral:
§ From CAMHS, the case is referred to the National Referral Support
Service (NRSS), which organizes further referral to a gender dysphoria
clinic.
§ Note that the previous Gender Identity Development Service (GIDS) is
now closed, and cases are now managed by a multidisciplinary team at
gender dysphoria clinics.
2. Addressing Patient Concerns:
o Support and Reassurance:
§ If the patient expresses uncertainty about their decision, acknowledge
that they have been contemplating this significant decision for a long
time.
§ Emphasize the importance of exploring their feelings with professional
support, helping them make an informed and confident decision.

Suspected Scaphoid Bone Fracture

Patient Profile

• Occupation: Builder or painter

• Presenting Complaint: Pain in the hand after a fall, Telephone call

32
gk’s notes – part 3 – masterclass revision – November 2024

Scenario Overview

1. Background:
o The patient fell from a ladder onto an outstretched arm while working (e.g.,
painting or building). Since the fall, they have been experiencing pain in the
hand.
2. Objective:
o Assess the symptoms to determine if the patient has sustained a scaphoid bone
fracture and arrange appropriate follow-up.

Consultation Structure

1. Initial Questions and Symptom Exploration:

o Open Inquiry:
§ "How may I help you today?"
§ Expected Response: The patient will describe pain in the hand (not
specifically the wrist).
o Explore Mechanism of Injury:
§ "Can you tell me how you injured your hand?"
§ Expected History: The patient fell onto an outstretched arm while
working on a ladder.
2. Ask About Fracture Symptoms:
o Key Symptoms:
§ "Do you notice any numbness or weakness in your hand?"
§ "Is there any bruising, swelling, or redness?"
§ "Are you having trouble moving your hand or wrist?"
o Additional Inquiry:
§ "Did you hit your head or lose consciousness when you fell?"
3. Complete MAFTOSA (for Fracture Evaluation):
o Obtain detailed history and assess for any other injuries or complications.

Over-the-Phone Examination for Scaphoid Fracture

1. Guide the Patient to Inspect the Hand:

o "Could you please look at your hand, both front and back? Do you notice any
swelling?"
2. Assess the Anatomical Snuffbox:
o Instructions for Anatomical Snuffbox Check:
§ "Can you spread the fingers of both hands?"
§ "Now, turn your hands so your palms are facing the floor."
§ "Look under your thumb on each hand. Do you see a small box-shaped
depression on both sides?"
§ Expected Finding: The patient may report that the anatomical snuffbox
is swollen or absent on the affected hand, indicating possible scaphoid
fracture.
3. Explain the Suspected Diagnosis:
o Diagnosis Explanation:

33
gk’s notes – part 3 – masterclass revision – November 2024

§ "Based on what you've described, it seems like you may have fractured a
bone in your wrist called the scaphoid bone. This bone is located in the
wrist area and is prone to fractures when people fall onto an
outstretched hand."

Management and Next Steps

1. Advise Immediate Hospital Visit:

o "Please come to the hospital for further evaluation. We need to perform an X-
ray to confirm if there’s a fracture."
2. Further Imaging if Necessary:
o If X-ray is Inconclusive:
§ "If the fracture isn’t visible on the X-ray, we may need to do a CT scan
or MRI to get a clearer view."
3. Treatment for Confirmed Scaphoid Fracture:
o Plaster Cast:
§ "If a fracture is confirmed, you may need to have a plaster cast placed to
allow the bone to heal properly."

Plantar Fascii7s
Patient Profile

• Age: Around 30 years old

• Setting: General Practice (GP)
• Presenting Complaint: Heel pain

Scenario Overview

1. Background:
o The patient works in a shop, which involves prolonged standing and possibly
walking, a known risk factor for plantar fasciitis.
2. Objective:
o Assess the pain and determine if the symptoms align with plantar fasciitis.

History and Symptom Exploration

1. Risk Factor Exploration:

o Occupation:
§ "I understand you work in a shop. Does your job require you to stand
for long periods?"
o Explanation: Prolonged standing and walking, especially without proper rest,
can contribute to the development of plantar fasciitis.
2. Pain Assessment:
o Questions to Explore the Pain:
§ "Where exactly is the pain located?"

34
gk’s notes – part 3 – masterclass revision – November 2024

§ Expected Location: The pain should primarily be on the heel.

§ "When did you first notice the pain?"
§ "Does anything make the pain better or worse?"
§ "Is the pain worse after periods of standing or in the morning?"
3. Explore Potential Causes of Pain (Orthopedic Differential):
o Ask About Trauma:
§ "Have you experienced any recent injuries or trauma to your foot?"
o Sports or Overuse:
§ "Do you engage in any sports or exercise that involve repetitive impact,
like running or football?"
o Occupation-Related:
§ "Does your job involve repetitive movements or long hours of standing?"
o Check for Related Symptoms:
§ "Have you noticed any swelling, redness, or stiffness in your joints?"
§ "Do you have any known joint or muscle conditions?"
§ Other Conditions: Explore autoimmune conditions and diabetes,
which may affect nerves.
4. Complete MAFTOSA:
o Obtain a full history of pain and relevant health conditions.

Examination

1. Conducting the Physical Examination:

o Expected Findings:
§ Tenderness should be localized to the heel, specifically at the origin of
the fascia, with no pain across the entire sole.
o Instructions:
§ Assess for tenderness at the base of the heel to confirm plantar fasciitis.

Diagnosis Explanation to Patient

1. Suspected Diagnosis:
o "It appears you may have a condition called plantar fasciitis."
2. Explanation of Condition:
o What is Plantar Fasciitis:
§ "Plantar fasciitis is inflammation of a thick band of tissue (the plantar
fascia) that runs across the bottom of your foot and connects your heel
bone to your toes."
§ "This tissue acts like a shock absorber, but with overuse or strain, it can
become inflamed, causing pain."

Management and Treatment Plan

1. Initial Treatment Steps:

o Pain Relief and Addressing the Cause:
§ "We’ll start with painkillers and anti-inflammatory medication (NSAIDs)
to help reduce the pain and inflammation."

35
gk’s notes – part 3 – masterclass revision – November 2024

§ "It’s also essential to try to reduce standing or walking for long periods if
possible."
o Ice Application:
§ "You can apply an ice pack to your heel to help reduce inflammation.
Ensure the ice is wrapped in a towel, and avoid applying it directly to
the skin."
§ "Only use the ice pack for a maximum of 30 minutes at a time."
2. Physiotherapy:
o Self-Stretching and Exercise:
§ "If the pain persists, we may refer you to a physiotherapist. They can
guide you on stretching exercises to relieve tension in the plantar fascia."
§ "They might also provide exercises that you can do at home to
strengthen and stretch your foot."
3. Orthopedic Referral:
o Advanced Treatment Options:
§ "If initial treatments are not effective, we may refer you to an orthopedic
specialist."
§ "Options available through orthopedics include steroid injections to
reduce inflammation, shockwave therapy, or, in severe cases, surgery."

Metatarsalgia and Morton's Neuroma

Scenario Overview

1. Trend:
o Both conditions, Metatarsalgia and Morton’s Neuroma, present with similar
symptoms, primarily foot pain, but have different diagnoses.
o This setup is used to test the candidate's ability to differentiate similar
complaints.
2. Objective:
o Assess the pain location and symptoms to distinguish between Metatarsalgia
and Morton’s Neuroma and provide appropriate management.

Scenario 1: Metatarsalgia

Patient Profile

• Occupation: Estate agent (suggests standing or walking frequently, possibly wearing

high heels)
• Presenting Complaint: Pain in the foot, specifically under the toes

History and Symptom Exploration

1. Pain Exploration:
o Location:
§ "Where exactly is the pain in your foot?"

36
gk’s notes – part 3 – masterclass revision – November 2024

§ Expected Response: Patient points under the big toe or the area near
the toes (metatarsal region).
o Character:
§ "What does the pain feel like? Is it burning, sharp, or shooting?"
o Other Sensations:
§ "Do you feel any numbness, tingling, or a sensation of pebbles or rocks
in your shoe?"
2. Risk Factors:
o Occupation:
§ "Do you wear high heels or narrow shoes for your job?"
o Injury or Exercise:
§ "Have you experienced any recent injuries or changes in your exercise
routine?"
o Foot Shape:
§ "Have you been told you have a high arch or flat feet?" (Both high arches
and flat feet can contribute to metatarsalgia.)
o Joint and Bone Conditions:
§ "Do you have any known joint conditions, like arthritis, or issues like
bunions or bursitis?"
3. Complete MAFTOSA:
o Gather full history and perform a complete assessment of pain and relevant
lifestyle factors.

Explanation to Patient

1. Suspected Diagnosis:
o "It seems you may have a condition called metatarsalgia."
2. Explanation of Condition:
o What is Metatarsalgia?
§ "Metatarsalgia refers to pain and inflammation in the metatarsal region,
which is the part of the foot just behind your toes."
§ "This condition is often due to overuse, improper footwear, or structural
issues in the foot."

Management and Treatment Plan

1. Initial Treatment Steps:

o Pain Relief and Footwear Advice:
§ "We’ll start with painkillers to manage the discomfort."
§ "It’s also essential to switch to supportive shoes with a wide toe box and
avoid high heels if possible."
o Insoles:
§ "You might find relief by using insoles, which can be purchased at a
local pharmacy. They help cushion the metatarsal area."
2. Physiotherapy:
o Self-Stretching and Exercises:
§ "If needed, we can refer you to a physiotherapist who can guide you on
foot-strengthening exercises and stretches for your calves and feet."

37
gk’s notes – part 3 – masterclass revision – November 2024

3. Orthopedic Referral:
o Advanced Treatment:
§ "If the pain persists, we may refer you to an orthopedic specialist for
options like steroid injections or, in rare cases, surgery."

Scenario 2: Morton's Neuroma

Patient Profile

• Occupation: Corporate lawyer (suggests long hours and potential stress; running is
noted as a risk factor)
• Presenting Complaint: Pain in the foot

History and Symptom Exploration

1. Pain Exploration:
o Location:
§ "Where exactly is the pain in your foot?"
§ Expected Response: Pain reported between the third and fourth toes,
with a possibility of a "pebble" sensation.
o Character:
§ "What does the pain feel like? Is it a sharp or burning sensation?"
o Other Sensations:
§ "Do you feel any numbness or tingling between your toes?"
2. Risk Factors:
o Exercise:
§ "Do you run or engage in other high-impact activities?"
o Footwear:
§ "Do you wear tight or narrow shoes?"
3. Complete MAFTOSA:
o Gather a full history and perform a complete assessment.

Explanation to Patient

1. Suspected Diagnosis:
o "It appears you may have a condition called Morton’s neuroma."
2. Explanation of Condition:
o What is Morton's Neuroma?
§ "Morton's neuroma is a thickening of the tissue around a nerve leading
to your toes, often caused by irritation or pressure."
§ "This thickening can compress the nerve, leading to pain and sensations
like numbness or tingling."

Management and Treatment Plan

1. Initial Treatment Steps:

38
gk’s notes – part 3 – masterclass revision – November 2024

o Pain Relief and Footwear Advice:

§ "We’ll start with painkillers to manage the discomfort."
§ "It’s essential to wear comfortable, well-fitting shoes to reduce pressure
on the nerve."
o Insoles:
§ "Insoles or orthotic inserts can help relieve pressure in the affected area
and can be purchased at a pharmacy."
2. Physiotherapy:
o "If necessary, we can refer you to a physiotherapist for guidance on exercises to
manage the pain."
3. Orthopedic Referral:
o Advanced Treatment:
§ "If the pain persists beyond three months, we may consider referring you
to an orthopedic specialist for further treatment, such as steroid
injections or surgery."

Summary of Differences

• Metatarsalgia: Pain under the metatarsal bones, commonly associated with high heels
or improper footwear.
• Morton's Neuroma: Pain between the third and fourth toes, often presenting with
numbness or a pebble sensation and related to nerve thickening due to irritation.

Endometri7s
Scenario Overview

• Setting: GP Clinic
• Patient Presentation: Female patient presents with abdominal pain and heavy vaginal
bleeding.
• Background Information:
o Postpartum Status: Patient had a C-section three weeks ago.
o Pregnancy History:
§ Second pregnancy.
§ First pregnancy was a vaginal delivery.
§ This time, she experienced prolonged labour of 30 hours, followed by a
C-section.

Key History Taking Points

1. Primary Complaints:
o Bleeding:
§ "Can you tell me about the bleeding? How much blood are you passing?"

39
gk’s notes – part 3 – masterclass revision – November 2024

§ Expected Response: She’s experiencing heavy bleeding, soaking her

pads.
o Pain:
§"Where exactly is the pain, and what does it feel like?"
o Feverish Symptoms:
§ "Have you noticed any fever, chills, or other symptoms?"
2. Septic Symptoms:
o Full Septic Screen:
§ "Are you feeling unusually tired or weak?"
§ "Are you experiencing any shortness of breath?"
§ "Do you have any confusion or feel generally unwell?"
3. Pregnancy and Delivery Details:
o "Can you walk me through the details of your recent pregnancy and delivery?"
o Risk Factors:
§ Prolonged Labor: "I understand the labour lasted about 30 hours.
That's quite long."
§ C-section: "I see you had a C-section this time. Did you have any
complications after the surgery?"
4. MAFTOSA (History and Examination):
o Complete a comprehensive history and examination assessment.

Examination

• Temperature: Likely to be elevated, around 37.8°C, suggesting infection.

• Abdominal Tenderness:
o "I would like to check for any tenderness in your lower abdomen."
o Expected Findings: Tenderness in the lower abdomen.
• Vaginal Exam:
o Presence of blood clots may be noted.

Diagnosis and Explanation to Patient

1. Suspected Diagnosis:
o "It seems that you may have a condition called endometritis."
2. Explanation of Condition:
o What is Endometritis?
§ "Endometritis is an inflammation or infection of the lining of the
womb."
§ "This condition can sometimes occur after childbirth, especially when
there are certain risk factors."
3. Risk Factors:
o "In your case, the prolonged labour and C-section increase the risk of
developing this infection."

Management and Treatment Plan

1. Immediate Hospital Referral:

40
gk’s notes – part 3 – masterclass revision – November 2024

o "Given your symptoms, it would be best for you to go to the hospital for further
management."
2. Hospital Care:
o Scans and Swabs:
§ "At the hospital, they will likely perform a scan to check for any retained
products of the placenta and take a swab to confirm if there is an
infection."
o Fluids and Antibiotics:
§ "You may need IV fluids and antibiotics to control the infection."
o Antibiotics:
§ "Common antibiotics include penicillin and metronidazole, which are
safe for postpartum use."
3. Patient Concerns:
o Effect on Child:
§ "If you're breastfeeding, I understand your concern about antibiotics
affecting your child. Penicillin and similar antibiotics are safe during
breastfeeding, so there’s minimal risk."
4. If Secondary Bleeding is Suspected (No Fever):
o Management for Secondary Bleeding:
§ "If there’s no fever and it's just secondary bleeding, we may manage this
with medication."
o Medications:
§ "We can consider medications like tranexamic acid to help control the
bleeding."
§ Blood Transfusion: "In severe cases, a blood transfusion might be
necessary."

Depression in a Pa7ent with Myocardial Infarc7on History

Scenario Overview

• Setting: GP Clinic
• Patient Presentation: A 49-50-year-old male, recently diagnosed with a myocardial
infarction and unstable angina, who is now suspected of having depression.
• Background Information:
o Cardiac History:
§ Diagnosed with myocardial infarction and received a stent around 4
months ago.
§ Prescribed multiple cardiac medications (e.g., statins, bisoprolol, aspirin,
clopidogrel, ramipril).
o Non-compliance with Medication:
§ Cardiology follow-up one month ago revealed the patient was not
adhering to his medication regimen.
o Recent Nurse Visit:
§ Nurses visiting him noticed non-compliance and referred him back to
the GP.

41
gk’s notes – part 3 – masterclass revision – November 2024

Key History Taking Points

1. Opening the Consultation:

o "I understand you've been referred back by the nurse after a recent follow-up."
o "I also understand you were diagnosed with a new heart condition not long ago.
Can you tell me a bit about what’s been going on?"
2. Exploring Cardiac History and Medication Compliance:
o "What kind of tests and treatments did you undergo for your heart condition?"
o "Are you currently taking your prescribed medications regularly?"
o If the patient admits non-compliance, ask: "Could you tell me more about why
you haven’t been able to take the medication regularly?"
3. Identifying Potential Depression:
o Observe and address the patient's body language if he appears down or
disheartened.
o "You seem a bit down today. Do you feel low or lack motivation sometimes?"
o Mood Assessment:
§ "How has your mood been lately?"
§ "Do you often feel sad, unmotivated, or discouraged?"
o Further Depression Symptoms:
§ Major Symptoms: Low mood, lack of interest, reduced energy.
§ Minor Symptoms: Sleep disturbances, poor concentration, low self-
esteem, or changes in appetite.
4. MAFTOSA (Comprehensive History and Examination):
o Complete a thorough assessment and review potential symptoms associated
with depression and physical health.

Diagnosis and Explanation to Patient

1. Suspected Diagnosis:
o "Based on what you've told me, it seems you may be experiencing symptoms of
depression, which could be affecting your motivation to take your medications."
2. Explanation of Depression:
o "Depression can be common after a major health event like a heart attack. It
can impact how you feel both physically and mentally, often making it harder to
keep up with daily routines or take medication."
3. Consequences of Non-Compliance with Cardiac Medication:
o "It’s important to stay consistent with your heart medications. Without them,
you might be at higher risk for complications like heart failure, shortness of
breath, or swelling in your body."

Management and Treatment Plan

1. Immediate Start of Antidepressant Therapy:

o Medication: "We can start you on an antidepressant called sertraline, which is
often used to treat depression."
o "This medication will help improve your mood over time, but it may take a few
weeks to feel the full effect."
2. Counseling and Psychosocial Support:

42
gk’s notes – part 3 – masterclass revision – November 2024

o "Alongside medication, counseling can be very beneficial. It provides support

and helps you cope with any challenges or emotional distress you may be
facing."
3. Encouragement to Continue Cardiac Medications:
o "Continuing your heart medications is crucial for your recovery and long-term
health."
o "If you’re finding it hard to keep up with them, we can explore ways to make it
easier."

Transman Pap Smear

Scenario Overview

• Setting: GP Clinic, F2 level

• Patient: A 25-year-old trans man (assigned female at birth, transitioned to male).
• Chief Complaint: Patient inquires about the need for a pap smear.
• Background: Patient has undergone psychological, hormonal, and possibly surgical
changes as part of gender transition.

Key History Taking Points

1. Establishing Rapport and Inquiry:

o "How may I help you today?"
o The patient may ask, "Should I get a pap smear done?" indicating they are
seeking information.
2. Framework: The Four Box System (used to address patient inquiries and provide
structured information):
o Box 1: Understanding Patient's Background and Knowledge (P1 and P2)
§ P1: Ask about past transition processes, including:
§ Hormonal therapy details (type and duration).
§ Surgical history, if any (e.g., top surgery, bottom surgery).
§ Menstrual history (is the patient still having periods?).
§ Cervical status (has the patient retained their cervix?).
§ P2: Assess patient’s prior knowledge about pap smears and cervical
cancer.
§ "What do you know about pap smears and why they are done?"
§ Explain that pap smears are performed to screen for cervical
cancer.
§ Discuss the benefits and potential risks or discomforts of the
procedure.
o Box 2: Risk Factors for Cervical Cancer
§ Assess sexual history and practices without assumptions about the
patient’s preferences:
§ "Are you currently sexually active?"
§ "Who do you tend to be sexually active with?" (Consider that
trans men may have partners of any gender or none at all.)

43
gk’s notes – part 3 – masterclass revision – November 2024

§ "Do you use protection consistently?"

§ Inquire about other factors like use of sex toys, duration of
sexual activity, number of partners, and any history of HPV
exposure or STI testing.
o Box 3: Providing Information and Addressing Concerns
§ Explain the importance of cervical cancer screening for anyone who
retains a cervix.
§ Discuss the procedure in terms the patient can understand and
emphasize confidentiality and sensitivity during the exam.
o Box 4: Decision Making and Encouragement
§ Emphasize that if the patient still has a cervix and is sexually active, they
are at risk for cervical cancer similarly to any other person with a cervix.
§ Encourage them to proceed with the pap smear for proactive health
care, ensuring that it aligns with their personal values and needs.

Explanation and Counseling

1. Risk Explanation:
o "As someone who still has a cervix and is sexually active, you share similar risks
for cervical cancer as anyone else with a cervix."
o "Regular screening can detect any early changes, and it’s recommended as a
preventive measure."
2. Procedure Information:
o Explain that the pap smear is a simple test, but acknowledge that it can feel
invasive.
o Assure them that the procedure will be performed with sensitivity to their
comfort and preferences.
3. Final Encouragement:
o "Given your circumstances, it would be advisable to have regular screenings.
This allows us to ensure your health and detect any early signs of cervical
changes if they arise."

Losing Erec7on
Scenario Overview

• Setting: GP Clinic with F2 level doctor

• Patient: 19-year-old male presenting with concerns about erection difficulties.
• Chief Complaint: Lost erection during an intimate encounter with his girlfriend after
receiving a comment about the size of his penis.

Key Steps for Consultation

1. Starting the Consultation with Empathy and Support:

o Begin with an empathetic opening: “I’m sorry to hear about what you
experienced. How can I help you today?”

44
gk’s notes – part 3 – masterclass revision – November 2024

o Acknowledge his concern without making assumptions; let him explain in his
own words what he is worried about.
o Maintain a non-judgmental, professional, and supportive tone throughout.
2. History Taking and Exploration:

This scenario requires sensitive handling of both general erectile health and specifics of the
incident. Here’s a structured approach:

o General Erection Health:

§ Ask if he generally experiences erections, particularly:
§ Morning erections (to assess normal physiological function).
§ Erections during masturbation (to explore his ability to achieve
and maintain an erection outside the stress of a sexual
encounter).
§ This will help rule out any organic causes, which are unlikely in a 19-
year-old with normal morning and self-stimulated erections.
o Previous Sexual Experiences:
§ Inquire about prior sexual experiences:
§ “Have you had any experiences with sexual intercourse before?”
§ If yes, ask if he has ever had similar issues previously.
§ If this is his first sexual encounter, acknowledge that first-time
experiences can often be filled with anxiety and nervousness, which can
affect performance.
o Exploring the Recent Incident:
§ Ask for details on the recent incident in a respectful manner. Key points
include:
§ “Can you tell me what happened during your recent experience
with your partner?”
§ “Did you experience an erection during foreplay?”
§ “I understand that your partner made a comment about the size
of your penis. Can you tell me more about how that made you
feel?”
§ This will help identify the moment anxiety might have set in,
affecting his performance.
§ Assess his emotional response: Ask if he felt anxious or nervous,
noting any physical symptoms of anxiety, such as sweating or a
fast heartbeat.
o Relationship Context:
§ Explore the nature of his relationship and familiarity with his partner:
§ “How long have you known your partner?”
§ “Is this a new relationship?”
§ “How would you describe your relationship overall?”
§ Understanding the relationship can provide insight into his comfort
level and whether this might be affecting his performance.
3. Physical Examination:

Since this is a mannequin scenario with a testicular model provided, you’ll need to conduct a
basic examination focusing on reassurance:

45
gk’s notes – part 3 – masterclass revision – November 2024

oPenile and Testicular Examination:

§ Explain that you’ll do a quick examination to ensure there are no
physical issues.
§ Inspect the penis for any abnormalities, and reassure him if everything
appears within normal limits.
§ Examine the testicles as well, looking for any lumps or abnormalities to
rule out physical causes of erectile issues.
4. Explanation and Counseling:

After the examination, address the psychological aspects and provide reassurance based on his
history and physical examination. Here’s how to structure your explanation:

o Normalizing the Experience:

§ Explain that losing an erection during an intimate moment, especially in
a new or first encounter, is common and does not indicate a lasting
problem. Many young men experience this, especially when they are
nervous or feel pressured.
§ Discuss performance anxiety: Explain that this anxiety can cause men
to lose their erection temporarily, particularly if they feel self-conscious
or worry about their partner's opinion.
o Reassurance about Penis Size and Sexual Satisfaction:
§ Reassure him that the size of the penis does not correlate with sexual
satisfaction or pleasure for either partner.
§ Explain that there is a wide range of normal sizes and that his size is
within this range.
§ Emphasize: “The size of the penis does not affect the degree of sexual
pleasure for you or your partner.”
§ Let him know that his examination results are normal, which means he
has no physical issues impacting his sexual health.
o Addressing Psychological and Emotional Concerns:
§ Explain that it’s very common for young men to experience loss of
erection due to anxiety, especially if it’s a first-time experience.
§ Assure him that with time and experience, these concerns generally
lessen as he becomes more comfortable with intimacy.
§ State that women may also experience nervousness or discomfort during
early sexual experiences, which can impact their own experience. This
mutual understanding can sometimes relieve pressure on both partners.
5. Practical Advice and Long-Term Solutions:

Offer practical suggestions that can help him manage anxiety and improve his future
experiences:

o Take It Slow:
§ Encourage him to approach intimacy slowly and focus on comfort and
foreplay without immediately focusing on intercourse.
§ Explain: “Intimacy doesn’t have to lead to intercourse right away. You
can take time to get familiar with each other and ease into it.”
o Relaxation Techniques:

46
gk’s notes – part 3 – masterclass revision – November 2024

§ Advise him to relax and not put too much pressure on himself for a
perfect experience. If it happens again, he should try not to worry too
much.
§ Suggest practicing relaxation techniques, such as deep breathing, to
reduce nervousness.
o Foreplay and Lowered Lighting:
§ Suggest focusing on foreplay and spending more time getting
comfortable. This can build emotional connection and reduce
performance pressure.
§ Lowering the lights or creating a relaxed environment can help reduce
self-consciousness and anxiety.
o Avoiding Unnecessary Medication:
§ Emphasize that at his age, he does not need medication such as Viagra,
as his issue is not physiological but rather related to temporary anxiety.
§ Explain: “Medication is not necessary in your case because the
underlying issue is psychological. With time, this will improve without
any medical intervention.”
6. Long-Term Reassurance:
o Explain that this experience is part of the natural learning process and that he
will become more comfortable and confident with time.
o Building Confidence: Suggest that he communicate openly with his partner,
explaining his feelings and discussing what they both enjoy, which can reduce
performance anxiety.
o Reassure him that erectile function typically improves with familiarity and
reduced anxiety. As he gains confidence, these experiences are likely to become
more satisfying.
7. Closing the Consultation:
o Summarize the main points, offering reassurance: “This is a common
experience for young men, especially in early intimate encounters. Your
examination was normal, and there’s nothing to be concerned about. The most
important thing is to take it slow and relax.”
o Encourage him to return if he has further concerns or if he would like more
guidance.
o Finally, thank him for trusting you with such a personal matter and reassure
him that his concern is valid and nothing to be ashamed of.

Erec7le Dysfunc7on in a Depression Pa7ent

Scenario Overview

• Setting: GP Clinic, F2 level

• Patient: Male patient, diagnosed with depression 8 months ago, previously on
sertraline.
• Chief Complaint: He wants to restart medication due to recurrent low mood and
fatigue but is concerned about previous side effects, specifically erectile dysfunction.

47
gk’s notes – part 3 – masterclass revision – November 2024

Consultation Steps

1. Establish Rapport and Gather Information:

o Start with a welcoming and empathetic approach. Use open-ended questions.
o Opening Line: “Hello, I understand you’ve made an appointment to discuss
how you’ve been feeling. Can you tell me more about how I can help today?”
o Encourage the patient to share in his own words to better understand his main
concerns.
2. History of Presenting Complaint:
o Ask him to describe his current symptoms in detail:
§ “Can you tell me what specific symptoms you’re experiencing right
now?”
§ Listen for major symptoms (persistent low mood, loss of interest,
fatigue) and minor symptoms (sleep disturbances, poor concentration,
appetite changes).
o Explore the timeline of his symptoms to see how they’ve evolved since he
stopped the medication.
3. Review of Past Diagnosis and Treatment:
o Confirm his history with depression:
§ “I understand you were diagnosed with depression about 8 months ago.
Could you tell me more about what symptoms led to your diagnosis at
that time?”
o Ask about the initial treatment plan:
§ “When you were started on sertraline, what kind of improvement did
you notice in your symptoms, if any?”
o Address his reason for stopping the medication:
§ “I understand you stopped taking the medication due to some side
effects. Can you describe what side effects you experienced?”
§ Specifically inquire about the erectile dysfunction he mentioned, as this
is central to his concern.
4. Assess Current Mood and Functioning:
o Gauge his current mental state and functionality by asking:
§ “How would you describe your mood at the moment compared to
before you started treatment?”
§ “Are there any specific situations or times of day when you feel
particularly low or tired?”
o Ask if he’s noticed any changes in his energy levels, daily motivation, or ability
to carry out regular activities.
o Check for other symptoms that might have returned since stopping
medication.
5. Complete the MAFTOSA Framework:
o The MAPDOSA approach (Medication, Adherence, Psychological, Diet,
Occupation, Substance, and Activity) can guide you in a comprehensive
assessment:
§ Medication: His history with antidepressants, specifically sertraline, and
his concerns about side effects.
§ Adherence: Understand why he stopped and if he struggled with
compliance due to side effects or any other reasons.

48
gk’s notes – part 3 – masterclass revision – November 2024

§ Psychological: His mood, cognitive symptoms, anxiety levels, and any

other psychological symptoms.
§ Diet: Whether he has experienced any appetite changes that might
influence his physical or mental state.
§ Occupation: How his work or daily responsibilities are being impacted
by his mood.
§ Substance: Inquire about alcohol or recreational drug use as these can
affect both mood and sexual function.
§ Activity: His level of physical activity, as exercise can significantly impact
mood and energy.
6. Medication Options and Discussion:
o Address his desire to restart medication, taking into account his previous
experience with side effects.
o Alternative Medication: Suggest reboxetine (a different antidepressant with a
different side effect profile), particularly useful if sexual dysfunction was a
notable side effect on sertraline.
o Explain that some antidepressants may have a lower risk of causing erectile
dysfunction:
§ “Reboxetine works differently from sertraline and is generally less likely
to affect sexual function. This might be a good alternative for you.”
o Non-Medication Approaches:
§ Explore non-medication options like Cognitive Behavioral Therapy
(CBT) or counseling if he’s open to it. Explain that therapy can be
effective for depression, especially when combined with or as an
alternative to medication.
7. Addressing Sexual Dysfunction Concerns:
o Acknowledge his concerns about erectile dysfunction and provide reassurance:
§ “It’s quite common for some antidepressants to have side effects like
erectile dysfunction. You did the right thing by discussing it with your
doctor.”
o Explain that side effects are individual and not all medications will have the
same impact.
o Provide lifestyle suggestions that might help with mood and energy levels, such
as regular exercise, a balanced diet, and healthy sleep habits.
8. Plan and Safety Netting:
o Summarize the agreed plan:
§ “We can start with reboxetine at a low dose and monitor for any
improvement in your symptoms. If any side effects occur, please don’t
hesitate to reach out.”
o Follow-Up:
§ Arrange a follow-up appointment in 2-4 weeks to assess his response to
the new medication and monitor for any side effects.
§ Reinforce the importance of continuing medication unless he
experiences intolerable side effects and to always consult before
stopping.
o Safety Net:
§ “If at any time you feel your mood worsens significantly or you
experience any distressing thoughts, please seek help immediately.”

49
gk’s notes – part 3 – masterclass revision – November 2024

o Document all the discussions for continuity of care and to aid in future
consultations.

DNAR
Scenario Overview

• Setting: Acute medicine (not a GP setting).

• Patient: An 80-year-old man with terminal prostate cancer, non-responsive to
treatment.
• Situation: The son, angry and upset, wants to discuss the DNAR decision placed on his
father’s records.

Step-by-Step Approach

1. Introduction and Acknowledgment:

o Start by introducing yourself and confirming the purpose of the visit: “I
understand you wanted to discuss your father’s care. Is there something specific
you’d like to talk about?”
o The son expresses anger and frustration, likely questioning the DNAR decision
and the quality of his father’s treatment.
2. Acknowledge the Emotions:
o After listening to the son’s concerns (angry statements like “Why did you sign
this?” or “Did you force him to sign?”), acknowledge his emotions: “I can see
that this situation is very upsetting for you, and I’m sorry that this has caused
distress. Would you like to tell me more about what’s on your mind?”
3. Reassure and Build Trust:
o Reassure the son by saying, “I’m here to explain everything clearly to you. I want
to address all your concerns. We genuinely have your father’s best interests at
heart.”
4. Taking History and Understanding His Perspective:
o Use the Four-Box Approach to structure the conversation effectively.

Four-Box Approach

Box 1: Prior Knowledge of DNAR and CPR:

• Ask about his understanding: “Can I ask what you understand about DNAR?”
• Clarify terms: “DNAR means Do Not Attempt Resuscitation. Have you heard about
CPR (cardiopulmonary resuscitation) before?”
• Explain CPR briefly: “CPR involves chest compressions, sometimes mouth-to-mouth
breathing, or using a balloon to try to restart the heart if it stops.”
• Educate on CPR Success and Drawbacks:
o Success Rate: “In patients with serious or terminal illnesses, the success rate of
CPR is very low.”

50
gk’s notes – part 3 – masterclass revision – November 2024

o Drawbacks: “This procedure can be very uncomfortable and may even break
bones, causing significant pain without guaranteed benefits, especially in
advanced or terminal conditions.”

Box 2: Knowledge of the Father’s Condition:

• Ask about his understanding of his father’s illness: “What have you been told about
your father’s condition and his response to treatment?”
• Assess awareness of prognosis: “Are you aware of how the treatment is working or what
the expected outcomes are?”
• Discuss how DNAR was made in the best interest due to limited benefits of
resuscitation in terminal stages, focusing on comfort and quality of life.

Box 3: Family Structure and Relationships:

• Identify if he is the next of kin or if there’s a Lasting Power of Attorney.

• Explore other family involvement: “Is there anyone else in the family who is actively
involved in your father’s care and decisions?”
• This helps to understand the family dynamics and potential expectations or conflicts
regarding his care.

Box 4: Explanation of DNAR and Possibility of Change:

• Explain DNAR Fully: “DNAR is not about stopping all treatments; it only means that
if your father’s heart were to stop, we wouldn’t perform CPR because it’s unlikely to be
effective given his condition. However, we continue to provide all other necessary care
to keep him comfortable.”
• Reassure About Patient Autonomy: Emphasize that the father wasn’t forced. “We only
proceed with a DNAR if we believe it’s in the best interest of the patient. If he was
capable, we would explain and let him decide, but we don’t force anyone.”
• Discuss the Option to Revisit DNAR: “As long as your father has the capacity to make
decisions, he can change this at any time. If he wishes to revoke it, we can support
that.”

5. Addressing the Son’s Final Questions:

o Validity Across Institutions: “A DNAR order is valid across different healthcare
settings, whether in the hospital, GP, or nursing home.”
o Role of Doctors in DNAR Decisions: Explain that doctors make DNAR
recommendations to avoid unnecessary suffering, particularly when CPR has
limited benefits. “We aim to make such decisions proactively, so they’re in place
if needed. It’s never a rush decision in an emergency.”
o Emphasize that the aim is not to withhold care but to prioritize the patient’s
comfort and dignity.

Key Takeaways for PLAB 2

• Empathy and Active Listening: Acknowledge emotions and validate concerns before
explaining medical procedures.

51
gk’s notes – part 3 – masterclass revision – November 2024

• Clear Explanations in Lay Terms: Ensure the son understands CPR and DNAR in
terms he can relate to and empathize with.
• Focus on Patient-Cantered Care: Reinforce that DNAR decisions are about respecting
the patient's dignity and minimizing suffering, not about giving up on the patient.
• Prepare for Misunderstandings: Expect confusion and anger from family members;
they may think DNAR means "no treatment at all." Correct this assumption carefully.

This scenario highlights both the emotional and clinical aspects of discussing DNAR with
family members in an empathetic, structured, and thorough way, essential for your PLAB 2
preparation.

Carbimazole Sore Throat

Scenario Overview:

• Setting: F2 in the GP clinic.

• Patient: Female, recently diagnosed with hyperthyroidism and started on carbimazole
two weeks ago.
• Presenting Complaint: Sore throat.

Approach and Conversation

1. Initial Greeting and Opening Question:

o Begin with a polite greeting, "How may I help you today?"
o The patient mentions a sore throat, which immediately raises a red flag,
considering she is on carbimazole. This medication has potential side effects,
especially agranulocytosis, which can present with a sore throat due to reduced
white blood cell count.
2. Exploring Symptoms (OLIPARA):
o Perform a thorough OLIPARA on the sore throat:
§ Onset: When did the sore throat begin?
§ Location: Any specific part of the throat?
§ Intensity: How severe is the pain?
§ Progression: Has it been getting worse?
§ Associated Symptoms: Focus on septic symptoms—ask about fever,
chills, dizziness, feeling generally unwell, rash, etc., which may indicate
sepsis or systemic infection.
o Also ask about any signs of lactic acidosis if the patient appears significantly
unwell.
3. Investigate for Carbimazole Side Effects:
o Since she is on carbimazole, inquire about other side effects:
§ Infections: Any history of recent infections or swollen glands?
§ Joint Pain: Any painful joints?
§ Skin Reactions: Itchy skin, thin hair?
§ Digestive Issues: Any abdominal pain, which might indicate
pancreatitis?

52
gk’s notes – part 3 – masterclass revision – November 2024

o Key Carbimazole Risks:

§ Agranulocytosis: Decreased white blood cells, leading to increased
infection risk.
§ Pancreatitis: Inflammation of the pancreas, which can present with
abdominal pain.
4. Medication History:
o Ask about the carbimazole specifically:
§ Duration: How long has she been taking it?
§ Reason: Confirm her diagnosis of hyperthyroidism.
§ Control of Symptoms: Has the medication been effective in controlling
hyperthyroid symptoms so far?
5. Complete MAFTOSA:
o Finish with MAFTOSA (Medications, Allergies, Past medical history, Dietary
restrictions, Occupation, Social history, Additional relevant information).
6. Examination:
o Vital Signs: Check temperature; if she has a high temperature, it suggests an
active infection.
o Throat Examination: Look for signs of inflammation, tonsillar swelling, or
exudate.
o Lymph Nodes: Assess for any swollen lymph nodes.
7. Diagnosis and Explanation:
o Diagnosis: Inform the patient, “It seems like you may have developed a
complication called agranulocytosis.”
o Explanation:
§ Explain that carbimazole can affect the white blood cells. There are two
main types of blood cells: white and red. The white blood cells are
essential for fighting off infections.
§ Due to carbimazole, her white cell count might have dropped, which
can lead to infections like a sore throat.
§ Describe how agranulocytosis is a condition where there’s a severe
reduction in white blood cells, increasing her vulnerability to infections.
8. Management Plan:
o Immediate Action: Emphasize that this is an emergency and explain the
urgency.
o Stop Medication: Advise her to stop taking carbimazole immediately.
o Referral to Hospital:
§ Inform her that she needs to go to the hospital immediately for further
management.
o Blood Tests:
§ A full blood count (FBC) will be done to assess her white cell levels.
o Antibiotics:
§ Explain that in the hospital, she will likely receive broad-spectrum
antibiotics to manage any infection and prevent further complications.
9. Further Explanation for Patient Understanding:
o Mention that the hospital specialist (often an endocrinologist) will review her
case and may decide on alternative treatments for her hyperthyroidism since
carbimazole caused this reaction.

53
gk’s notes – part 3 – masterclass revision – November 2024

o Describe the potential seriousness: If left untreated, this condition could worsen
and lead to sepsis, a life-threatening response to infection.
10. Summarized Plan:
o Reiterate the three main steps:
§ 1. Stop carbimazole.
§ 2. Go to the hospital.
§ 3. Get a blood test and antibiotics.
o Explain that specialists will decide on her next steps and may discuss different
medication options.

Reques7ng An7bio7cs for Travel

Scenario Overview:

• Setting: F2 in the GP clinic.

• Patient: 49-year-old male patient who made an appointment as he is preparing for
upcoming travel.
• Presenting Request: The patient is concerned about contracting a "tummy bug" while
traveling and requests antibiotics as a preventive measure, mentioning that he was given
ciprofloxacin in the past during a previous trip.

Approach and Conversation

1. Initial Greeting and Opening Question:

o Begin with a polite greeting: "How may I help you today?"
o The patient explains that he’s preparing for a trip and is worried about potential
"tummy bugs." He is requesting antibiotics to prevent any issues and mentions a
previous experience where he was prescribed ciprofloxacin.
2. Exploring the Patient’s Travel and Past Experiences:
o Ask About the Current Travel Plan:
§ Destination: "Where are you traveling this time?" (He might mention a
specific destination, such as Thailand, indicating a different
environment compared to his previous travels).
§ Timeline: "When are you planning to travel?"
§ Companions: "Who will be traveling with you?" (The patient mentions
traveling with his wife).
o Past Travel Experience:
§ Previous Destinations: "Where did you travel last time?" (He might say,
for example, he went to Brazil, which involved travel through areas like
the Amazon).
§ Timeframe: "How long ago was that trip?" (Could be several years, like
10 years ago).
§ Use of Previous Antibiotics: "Did you end up using the antibiotic that
was prescribed for that trip?" (The patient might respond that he didn’t
need it or didn’t have any symptoms of diarrhea).
3. Assessing Risk Factors:

54
gk’s notes – part 3 – masterclass revision – November 2024

o Current Trip Risk Factors:

§ Accommodation: "Where will you be staying?" (The patient might
mention staying in a five-star hotel, which typically reduces risk due to
better sanitation standards).
§ Activities:
§ "Are you planning any activities in water bodies like rivers?"
§ "Any plans to visit rural or jungle areas, such as farms, paddy
fields, or remote villages?"
§ "Will there be any interaction with animals or camping?"
§ Food and Drink Plans:
§ "Where do you plan to eat during your trip?" (Hotel dining,
restaurants, street food, etc.).
§ "Will you be consuming bottled water, or do you plan to drink
tap water?"
§ "Do you enjoy any specific types of food when traveling, such as
dairy, meat, or street food?"
o Personal Health Factors:
§ "Do you have any long-term health conditions or recent surgeries?"
§ "Are you on any medications, or have any conditions that might
compromise your immunity, such as diabetes or a history of cancer?"
§ Partner’s Health: "Does your wife have any long-term health conditions
or immune concerns?"
4. Explanation and Education:
o Types of Tummy Bugs:
§ Explain that there are different types of gastrointestinal illnesses people
commonly refer to as "tummy bugs," primarily:
§ Food Poisoning: Caused by consuming food contaminated with
toxins already produced by bacteria.
§ Traveler’s Diarrhea: Often due to ingestion of contaminated
water or food, leading to infections, like those caused by the
Giardia parasite or certain bacteria.
§ Serious Infections: Mention other risks like typhoid, which is more
common in certain areas.
o Food Poisoning:
§ Explain that food poisoning often results from pre-formed toxins in
contaminated food, which cause symptoms quickly after ingestion (e.g.,
nausea, vomiting, diarrhea).
§ Commonly caused by bacteria like Campylobacter.
§ Emphasize that antibiotics are not effective as a preventive measure for
food poisoning, as it’s usually self-limiting.
§ If the patient develops severe symptoms like bloody diarrhea or
dehydration, they should seek medical care locally.
o Traveler’s Diarrhea:
§ Traveler’s diarrhea typically results from contaminated water or poor
sanitation.
§ In the past, antibiotics like ciprofloxacin were sometimes given as a
preventive measure, but guidelines have since changed due to antibiotic
resistance concerns.

55
gk’s notes – part 3 – masterclass revision – November 2024

§ Current guidelines recommend azithromycin as the preferred treatment

for active traveller’s diarrhea, but only for specific high-risk individuals.
§ Prophylactic antibiotics are not generally recommended for most
travellers due to risks like antibiotic resistance and side effects.
o Alternative Preventive Measures:
§ Encourage good travel insurance so he can seek care if needed.
§ Educate on practical preventive measures, such as drinking bottled
water, avoiding street food, and choosing cooked foods over raw foods
when possible.
5. Addressing Requests for Over-the-Counter Medications:
o Imodium (Loperamide):
§ Explain that Imodium is available over-the-counter and can be taken if
he experiences mild diarrhea.
§ Instructions on Use: Avoid using Imodium for more than two days or if
he has a high fever, blood in the stool, or abdominal pain with diarrhea,
as these could indicate a more serious infection requiring medical
attention.
6. Vaccinations and Preventive Medications:
o Vaccinations:
§ Suggest he consider vaccines for Hepatitis A, Yellow Fever, and any
others recommended based on his destination.
o Malaria Prophylaxis:
§ Mention that depending on his travel destination, he might need
malaria prophylaxis but avoid specifying antibiotic types (as some might
misinterpret them as general antibiotics).
7. Final Summary:
o Emphasize No Prophylactic Antibiotics: Reinforce that preventive antibiotics
are not recommended or necessary for his upcoming trip.
o Alternative Preparations: Good travel insurance, adherence to food and water
safety measures, and awareness of signs that require medical attention.

Riluzole for Motor Neuron Disease

Scenario Overview

• Setting: GP practice, F2 doctor in the GP

• Patient: 55-year-old male, diagnosed with Motor Neuron Disease (ALS) about 8
months ago.
• Background:
o Patient is under specialist care and is receiving supportive therapies
(physiotherapy, occupational therapy, speech and language therapy).
o He has recently heard about the medication Riluzole, which is used to slow the
progression of ALS, and is requesting a prescription.

Key Points to Address

56
gk’s notes – part 3 – masterclass revision – November 2024

1. Introduction & Greeting

o Start by asking how you may assist him and confirm understanding that he
wishes to discuss Riluzole.
2. Data Gathering Using the Four Box System
o Box 1: Medical History
§ Ask how long he has had symptoms and how he was diagnosed.
§ Assess if symptoms have been getting worse, impacting his quality of life.
§ Inquire about specific symptoms he is experiencing (e.g., mobility
issues).
o Box 2: Understanding of Riluzole
§ Ask if he’s read about the medication, including benefits, risks, and
eligibility.
o Box 3: Understanding of ALS and Riluzole Indications
§ Ensure the patient understands that Riluzole is specifically for ALS (not
all types of MND).
§ Explain that Riluzole is not a cure but may slightly prolong life.
o Box 4: Impact on Daily Life
§ Explore how the disease is affecting his day-to-day activities (e.g., driving,
mobility).
3. Explanation of Riluzole
o What Riluzole Does:
§ It’s prescribed to potentially slow the progression of ALS by a small
margin.
§ It’s not curative and only mildly extends life expectancy.
o Side Effects and Monitoring Needs:
§ Serious side effects include liver toxicity, pancreatitis, increased
infection risk, drowsiness, and sleep issues.
o Specialist Prescription:
§ Riluzole must be initiated by a specialist. Only after a specialist has
started the medication can it be continued by a GP.
o Specialist Decision-Making:
§ Emphasize that the timing of starting Riluzole is based on the patient’s
best interests.
§ Reinforce that it’s not about cost-saving but ensuring the benefits
outweigh the risks.
4. Reassurance and Managing Expectations
o Explain that the decision to prescribe Riluzole involves careful consideration by
the specialist team.
o Highlight that if he is eligible and if it’s the right time, he will receive the
medication.
o Reassure the patient that he will have access to the medication when deemed
appropriate.
5. Follow-up and Next Steps
o Advise the patient to discuss Riluzole with his specialist during his next regular
review.
o Encourage the patient to share any concerns at his upcoming appointment.
o Avoid suggesting an early referral for this specific medication request, as regular
appointments are in place for such discussions.

57
gk’s notes – part 3 – masterclass revision – November 2024

Four-Box Approach

Box 1: Patient Understanding and Background

1. Greeting and Opening the Discussion:

o You: "Hello, I understand you’re here to discuss a medication called Riluzole. Is
that right?"
o Patient: "Yes, I heard it might help with my condition, so I wanted to know if
you could prescribe it."
2. Exploring the Patient’s Symptoms and Experience with the Condition:
o "How long have you had this diagnosis?"
o "What symptoms were you experiencing when you were first diagnosed?"
o "Have you noticed any change in your symptoms since starting your current
treatments, such as with physiotherapy or occupational therapy?"
3. Evaluating Impact on Daily Life:
o "How is this condition affecting your daily life, like walking or daily activities?
Are there specific things you’re finding more challenging?"
o "Has it impacted your ability to drive or do things independently?"

Box 2: Knowledge about Riluzole and ALS

1. Assessing Knowledge of Riluzole:

o "Could you tell me what you know about Riluzole? Have you had a chance to
look into it or discuss it with your specialist?"
o "Do you know about the potential side effects or when it’s typically prescribed
for people with your condition?"
2. Providing Information about Riluzole:
o "Let me give you a bit more detail. Riluzole is a medication used specifically for
ALS, a type of Motor Neuron Disease. I understand this is the type of MND
you have."
o "It’s important to understand that Riluzole isn’t a cure. Studies show that it may
extend life by a few months, but it doesn’t halt the progression of the disease."
3. Explaining Side Effects and Risks:
o "Riluzole does come with some risks, particularly to the liver and pancreas. It
can also lower your immune system’s ability to fight infections, which is why it’s
closely monitored."
o "Some people also experience drowsiness, difficulty sleeping, and it can
sometimes affect quality of life due to these side effects."

Box 3: Relationship/Context (Understanding the Patient’s Social Context and Expectations)

1. Understanding the Patient’s Social and Treatment Context:

o "It sounds like you’ve already been working with a specialist team and receiving
therapies such as physiotherapy, speech therapy, and occupational therapy. Has
that been beneficial for you?"
o "I also understand you recently had a review with your specialist. Did they
mention anything about Riluzole at that appointment?"
2. Exploring Reasons for Request and Addressing Concerns:

58
gk’s notes – part 3 – masterclass revision – November 2024

o "Can you tell me a bit more about why you’re interested in Riluzole now? Did
you hear about it from a friend or another source?"
o "I understand you might be concerned about whether you’re receiving all
available treatment options."

Box 4: Explanation and Recommendation

1. Explaining Riluzole’s Role in ALS Treatment:

o You: "Riluzole is typically prescribed by specialists, especially at certain points in
the disease progression. It’s used primarily for ALS patients who are likely to
benefit most from it."
o "This medication is usually started by a specialist, and after that, it may be
continued in primary care. But the initial decision lies with the specialist team
to ensure it’s the right time."
2. Addressing Patient’s Concerns about Accessibility and Cost:
o If Patient Questions Cost: "I understand if it seems like Riluzole isn’t being
prescribed due to cost, but that’s not the case. The NHS provides Riluzole to
those who need it, regardless of cost. The specialist team considers the timing
and appropriateness to ensure maximum benefit."
3. Clarifying the Current Status and Reassurance:
o "It seems that your specialist team might be waiting until the right time to
introduce Riluzole, balancing the risks and benefits. Since you recently had a
review, they would have likely discussed this option if it were necessary now."
o "You’re entitled to this medication when the time is right, and I want to assure
you that you’ll receive it if your specialist believes it’s in your best interest."
4. Planning Next Steps:
o "In the meantime, it’s a good idea to continue with your current therapies, as
they’re aimed at supporting your quality of life as much as possible."
o "When you have your next specialist appointment, you can ask them about
Riluzole again, and they can reassess if it might be appropriate to start it then."
5. Offering Support and Closing:
o "Thank you for discussing this with me today. If you have any more questions
about Riluzole or need further assistance with your treatment, please don’t
hesitate to reach out."

Communication Tips

• Empathy: Show understanding of his frustration and desire for treatment options.
• Reassurance: Reiterate that his care is guided by what’s in his best interests and that he
will receive the appropriate interventions in due time.
• Clarity: Make it clear that Riluzole is only for ALS and must be prescribed by a
specialist, not a GP.
• Professional Boundaries: Kindly but firmly communicate the limitations of the GP's
role in prescribing certain medications like Riluzole.

59
gk’s notes – part 3 – masterclass revision – November 2024

Generalized Anxiety Disorder

F2 in GP

Patient: 28-32-year-old female, single, working in IT/accounting (white-collar job)

Consultation Dialogue

Opening the Conversation

Doctor: "Hello, I understand you’ve come in because you're feeling 'on edge' and having some
difficulties at work. Could you tell me a bit more about what’s been going on?"

Patient: "Yes, I’ve been feeling really anxious, almost constantly. I’ve started making careless
mistakes at work, and my concentration is just terrible."

Doctor: "That sounds difficult. I’d like to ask you a few more questions to understand what
you’re experiencing. Aside from feeling on edge and the issues with concentration, have you
noticed any physical symptoms?"

Patient: "Yes, I’ve been getting shoulder pain and headaches too."

Exploring the Symptoms Further

Doctor: "Thank you for sharing that. To get a clearer picture, I’ll ask you about some common
symptoms people with anxiety might experience. Please let me know if you have these regularly
or nearly every day.

1. "Do you feel restless or nervous, like it’s hard to sit still?"
2. "Do you feel tired or fatigued often?"
3. "How about concentration—are you finding it hard to stay focused on things outside of
work, too?"
4. "Do you get irritated or feel like you get angry more easily than usual?"
5. "You mentioned shoulder pain; does it feel like there’s tension in your muscles in
general?"
6. "How has your sleep been? Do you have trouble falling asleep or staying asleep?"

Additional Screening Questions for GAD

Doctor: "Thank you. I’d also like to ask about some feelings that often come with anxiety. Do
any of these resonate with you?

• "Do you often feel afraid, like something awful might happen?"
• "Do you find yourself getting annoyed or irritated more easily?"
• "Do you feel that it’s hard to relax, like you’re always ‘on edge’ or tense?"
• "Do you worry about a variety of things, not just work, and find it difficult to stop or
control your worries?"

60
gk’s notes – part 3 – masterclass revision – November 2024

Exploring Potential Differential Diagnoses

Doctor: "To make sure we understand everything that might be affecting you, I’d like to rule
out a few other things. Have you noticed any changes in your mood overall, like feeling sad or
down, or losing interest in activities you normally enjoy?"

Patient: "No, not really. It’s mostly just the anxiety and the physical symptoms."

Doctor: "That’s helpful to know. And just to clarify, have you ever had any panic attacks where
you felt sudden, intense fear or discomfort, with symptoms like a racing heart or sweating?"

Patient: "No, I haven’t had anything like that."

Doctor: "Thank you. Have you experienced any recent traumatic events that might be causing
flashbacks or nightmares?"

Patient: "No, nothing like that either."

Effect on Daily Life

Doctor: "It sounds like work has been quite challenging with these symptoms. How about
outside of work—do you find that anxiety is affecting your hobbies or other aspects of your life?"

Patient: "Not so much. It’s really worst at work, especially when my boss points out mistakes."

Explanation of Diagnosis

Doctor: "Based on everything you've told me, it sounds like you could be dealing with
something called Generalized Anxiety Disorder, or GAD. This is a mental health condition
where people experience excessive worry and feel anxious about everyday things. These worries
are often more intense than the actual risks involved."

Patient: "That makes sense. I do feel like I’m worrying all the time, even if there’s no real
reason."

Doctor: "Yes, and the physical symptoms you mentioned, like shoulder pain and headaches,
are common as well, since muscle tension is often a part of GAD."

Management Plan

Doctor: "Let’s talk about how we can help you manage this anxiety. There are a few different
approaches, and I’d like to start with some initial steps that you can try yourself."

1. Self-Help and Lifestyle Changes:

o "We’ll provide you with some information on Generalized Anxiety Disorder to
help you understand it better. Reading about it can sometimes be the first step
to feeling more in control."

61
gk’s notes – part 3 – masterclass revision – November 2024

"Exercise can also be really helpful for anxiety. Regular physical activity has been
o
shown to reduce anxiety symptoms significantly."
o "There are also support groups for anxiety that you might find helpful. Talking
to others who are going through similar experiences can be reassuring."
2. Psychological Therapy:
o "If self-help and lifestyle changes aren’t enough, we can explore therapy options.
Cognitive Behavioral Therapy, or CBT, is a type of talking therapy that can help
with anxiety. It usually lasts for about 12-15 weeks."
o "CBT can be done in different ways: some people prefer in-person sessions,
others find video consultations or even group therapy useful. We’ll find what
works best for you."
3. Medication (if necessary):
o "Medication is another option, but we usually consider it if other methods don’t
work over time. If needed, we might discuss starting a medication like an
antidepressant to help manage the anxiety symptoms."

Patient: "I think I’d like to try the lifestyle changes and therapy first."

Doctor: "That’s a great plan. We’ll start with those, and I’ll arrange a follow-up to see how
you’re doing. If you feel that the anxiety is still affecting you significantly after trying these, we
can discuss other options. Remember, you’re not alone, and help is available. Feel free to reach
out anytime."

Follow-up and Reassurance

Doctor: "Before we finish, I just want to emphasize that what you’re experiencing is common
and manageable. We’ll work together to find the best approach for you, and I’ll be here to
support you throughout. I’ll schedule a follow-up so we can check in and see how you’re feeling
with these initial steps. And if you notice any new symptoms or need further support, don’t
hesitate to contact us."

An7bio7c Request - Viral Infec7on in a Child

Setting: Telephone consultation with the mother of a 3-year-old child.

Presenting Concerns:

• Child has been unwell for two days with sore throat, cough, and fever.
• Initial fever was 38°C, now reduced to 36°C.
• Child is playful and eating normally.
• Recent visit to grandmother who had pneumonia.
• Mother is worried and requests antibiotics and an X-ray.

Objectives:

• Assess the child's symptoms to rule out serious illness.

62
gk’s notes – part 3 – masterclass revision – November 2024

• Reassure the mother that antibiotics and an X-ray are not necessary.
• Provide advice on home care and signs that require medical attention.
• Educate the mother on viral infections and appropriate management.

Questions to Ask:

1. Symptom Assessment:
o Respiratory Symptoms:
§ "Does your child have difficulty breathing or rapid breathing?"
§ "Is there any wheezing or noisy breathing?"
§ "Is the cough dry or producing phlegm?"
§ "Has your child complained of chest pain?"
o Fever:
§ "What was the highest temperature recorded?"
§ "How did you measure the temperature?"
§ "Has the fever responded to paracetamol or ibuprofen?"
o General Well-being:
§ "Is your child alert and responsive?"
§ "Are they playing and engaging as usual?"
§ "Are they feeding well and drinking fluids?"
o Septic Signs:
§ "Has your child been unusually sleepy or hard to wake?"
§ "Is there any rash on their body, especially one that doesn't fade when
pressed?"
§ "Any episodes of vomiting or diarrhea?"
o Hydration Status:
§ "Is your child passing urine normally?"
§ "Any signs of dehydration like dry mouth or sunken eyes?"
2. Exposure History:
o "When did you visit your grandmother with pneumonia?"
o "Did your child have close contact with her?"
o "Has anyone else in the family been unwell recently?"
3. Medical History:
o "Does your child have any underlying health conditions?"
o "Are their vaccinations up to date?"
4. Mother's Concerns:
o "What specifically worries you the most about your child's illness?"
o "Have you administered any medications so far?"
o "Do you have a thermometer at home to monitor the fever?"

Explanations to Provide:

1. Nature of Viral Infections:

o "From what you've described, it seems your child has a common viral infection,
which is very typical in children their age."
o "Viral infections usually cause symptoms like sore throat, cough, and fever, and
they often improve on their own within a few days."
2. Why Antibiotics Aren't Necessary:

63
gk’s notes – part 3 – masterclass revision – November 2024

o "Antibiotics are designed to fight bacterial infections, and they don't work
against viruses."
o "Using antibiotics when they're not needed can lead to side effects and
antibiotic resistance, making future infections harder to treat."
3. Regarding the Pneumonia Exposure:
o "It's understandable to be concerned after visiting someone with pneumonia."
o "Pneumonia can be caused by bacteria or viruses, but since your child didn't
have close contact and is showing mild symptoms, it's unlikely they've
contracted pneumonia."
o "Your child is active and feeding well, which are good signs that they aren't
severely ill."
4. Why an X-ray Isn't Needed:
o "An X-ray is typically used when we suspect a serious lung infection or if
symptoms are severe."
o "Since your child doesn't have difficulty breathing or other severe symptoms, an
X-ray isn't necessary at this time."
o "We also aim to avoid unnecessary radiation exposure, especially in young
children."
5. Home Care Advice:
o "Ensure your child stays well-hydrated by offering plenty of fluids."
o "Encourage them to rest as much as they need."
o "You can continue to give paracetamol or ibuprofen for fever and discomfort,
following the recommended dosages."
o "Use a thermometer to monitor their temperature periodically."
6. Symptoms to Monitor (Safety Netting):
o "Watch for any signs of breathing difficulty, such as fast or labored breathing, or
if they are using extra muscles to breathe."
o "If the fever persists for more than five days or becomes very high and doesn't
respond to medication, please seek medical attention."
o "Be alert for signs of dehydration, like fewer wet nappies, dry mouth, or sunken
eyes."
o "If your child becomes unusually drowsy, unresponsive, or develops a rash that
doesn't fade when pressed, please contact us or visit the emergency department
immediately."
7. Reassurance:
o "It's positive that your child is playful and eating well; these are strong indicators
they're coping well with the infection."
o "Most viral infections resolve on their own without the need for antibiotics."
o "We're here to support you, and it's always okay to call back if you're worried."
8. Follow-Up Advice:
o "If you notice any worsening of symptoms or new symptoms developing, don't
hesitate to reach out."
o "We'll be happy to reassess and provide further guidance if needed."

64
gk’s notes – part 3 – masterclass revision – November 2024

Dehydra7on in a Child with Viral Flu Symptoms

Setting: Parent calling about their young child who is unwell, possibly dehydrated, and has a
cough.

Presenting Concerns:

• Child has symptoms of a viral infection, including cough and fever.

• The parent is concerned about dehydration due to the child's reduced food and fluid
intake.

Objectives:

• Assess for dehydration and signs of serious illness.

• Reassure and advise the parent on home management, focusing on hydration and
symptom relief.
• Educate the parent on why antibiotics are unnecessary for viral infections.
• Provide clear safety netting for when to seek further help.

Questions to Ask:

1. Hydration Status:
o "Has your child been drinking fluids? If so, how much?"
o "Have you noticed any signs of dehydration, like dry mouth or fewer wet
nappies?"
o "Is your child able to eat small amounts of food, or are they refusing all food?"
2. General Well-being:
o "Is your child still alert, active, and playful?"
o "How are they responding to you? Do they seem more sleepy or less responsive
than usual?"
3. Symptom Assessment:
o "What symptoms does your child have? Any sore throat, cough, or runny nose?"
o "Has your child had a fever? If yes, how high and for how long?"
o "Is there any vomiting or diarrhea?"
4. Urine Output:
o "How many times has your child passed urine in the past day?"
o "Is there any change in the colour or amount of urine?"
5. Mother’s Concerns and Expectations:
o "What concerns you the most right now about your child’s health?"
o "Are there any specific treatments or medications you were hoping to discuss?"

Explanations to Provide:

1. Nature of Viral Flu and Expected Course:

o "It sounds like your child may have a viral infection, which can cause symptoms
like fever, cough, and a sore throat."

65
gk’s notes – part 3 – masterclass revision – November 2024

o"Viral illnesses tend to peak within the first two to three days and then gradually
improve over a few days. However, it’s common for a cough to linger for two to
four weeks, even after other symptoms have gone."
2. Why Antibiotics Are Not Necessary:
o "Antibiotics are effective against bacterial infections, but they don’t work for
viral infections. This is because antibiotics target bacteria, not viruses."
o "Using antibiotics when they’re not needed can lead to antibiotic resistance,
which means that in the future, antibiotics may not work when they are
genuinely needed."
3. Importance of Hydration in Recovery:
o "The most important thing for your child right now is to stay well-hydrated.
Children often stop eating and drinking when they’re unwell, and this can lead
to dehydration, which can be more concerning than the illness itself."
o "Encourage your child to take small sips of water or fluids frequently, even if
they’re not eating much solid food right now."
4. Symptom Management:
o "For fever and discomfort, you can give paracetamol. Be sure to follow the
recommended dose: every 4-6 hours, not exceeding four doses in a 24-hour
period."
o "Avoid any medications with chlorpheniramine, as they’re not suitable for
young children. For cough relief, simple over-the-counter remedies or natural
honey (for children over one year) can be helpful, but it’s best to check with
your pharmacist."
5. Safety Netting:
o "If your child develops any of the following symptoms, please seek medical help
immediately:"
§ Difficulty breathing or rapid breathing.
§ Persistent high fever despite paracetamol.
§ Vomiting or diarrhea that doesn’t improve.
§ Signs of severe dehydration, like no wet nappies for over 12 hours, dry
mouth, or sunken eyes.
§ Unusual drowsiness or inability to wake easily."

Meningi7s Prophylaxis
Setting: F2 GP consultation with a 40-year-old woman whose mother-in-law has been
diagnosed with meningitis and is in the ICU. The hospital advised the family to get
prophylactic treatment.

Objectives:

• Determine if prophylaxis is necessary and appropriate for the patient and her family.
• Educate on types of meningitis, chemoprophylaxis, and vaccination.
• Provide reassurance and clear advice for the family.

Questions to Ask:

66
gk’s notes – part 3 – masterclass revision – November 2024

1. About the Grandmother (Infected Person):

o "When was your mother-in-law diagnosed with meningitis?"
o "What symptoms did she have? Did she have a rash?"
o "Did the hospital tell you what type of meningitis it is? (e.g., meningococcal,
Haemophilus influenzae, pneumococcal)."
2. About the Level of Contact:
o "What level of contact have you and your family had with her recently?"
o "Did she live with you, or did you visit her often?"
o "Has anyone in your family, especially the children, had close or kissing contact
with her?"
o "Has anyone else, like other relatives or friends, had close contact with her
recently?"
3. Health and Medical History of Family Members:
o "Do you or any of your family members have any long-term medical conditions
or take medications?"
o "Has anyone in your family been vaccinated for meningitis, including your
children?"

Explanations to Provide:

1. Overview of Meningitis and Why Prophylaxis Might Be Needed:

o "Meningitis is an infection of the protective membranes covering the brain and
spinal cord, and certain types can be contagious."
o "Close contacts, such as household members or those with kissing contact, may
need prophylactic treatment to prevent infection."
2. Types of Meningitis and Treatment Approach:
o "There are different types of meningitis that can be caused by bacteria like
meningococcal, Haemophilus influenzae, and pneumococcal bacteria. Knowing
the type is important because it determines if and what kind of prophylaxis is
needed."
o "For instance, if it’s meningococcal meningitis, we often prescribe an antibiotic
called ciprofloxacin as a single dose for those over 12. Another option is
rifampicin, which would be taken twice daily for two days."
o "If it’s Haemophilus influenzae type, we also use rifampicin. But if it’s
pneumococcal meningitis, prophylaxis is usually not needed."
3. Chemoprophylaxis and Vaccination:
o "Chemoprophylaxis, which means preventive antibiotics, is typically
recommended for close contacts to reduce the risk of infection."
o "After taking antibiotics, we also advise vaccination within four weeks if
appropriate, especially for household and close contacts. Vaccination provides
longer-term immunity in case of future exposure."
4. Addressing Specific Questions:
o Returning to Work: "You should be able to return to work, but it’s a good idea
to take the prophylactic antibiotic before going."
o Children's Vaccination Status: "Even if your children are vaccinated, we
recommend prophylaxis. Vaccines may lose effectiveness over time, and
prophylaxis offers an additional layer of protection."

67
gk’s notes – part 3 – masterclass revision – November 2024

Management Plan:

1. Determine Type of Meningitis:

o "I’ll contact the hospital to confirm the specific type of meningitis your mother-
in-law has. This will help us decide the exact prophylactic measures needed for
your family."
2. Provide Chemoprophylaxis:
o "If meningococcal or Haemophilus influenzae is confirmed, we’ll provide
ciprofloxacin or rifampicin based on age and health conditions."
3. Consider Vaccination:
o "Once chemoprophylaxis is completed, we recommend vaccination within a
month to provide longer-term immunity for close contacts."
4. Safety Netting and Follow-up:
o "If you or any family member develop symptoms such as fever, headache, neck
stiffness, or a rash, seek medical help immediately. Early symptoms of
meningitis can be non-specific but require urgent attention."

Arcus Senilis
Setting: A lady comes to the GP with concerns about a ring around her eye. She mentions that
her vision was blurry, prompting her to get new glasses, which resolved the blurriness. She now
sees a ring or something growing around her eye.

Objectives:

• Assess the visual symptoms and rule out other conditions.

• Educate on arcus senilis, its causes, and its management.
• Reassure the patient regarding the benign nature of the condition.

Questions to Ask:

1. Visual Symptoms:
o "Can you tell me about your vision recently? Do you experience any blurry
vision?"
o "How is your vision at night or in low light? Is it worse?"
o "Do you have any problems with recognizing faces, reading, or watching TV?"
2. Differential Symptoms to Consider:
o Cataracts: "Do you find your vision particularly blurry at night or in dim light?"
o Age-Related Macular Degeneration (ARMD): "Do you see any patches or
scotomas in your vision? Any issues with seeing family members’ faces or
recognizing objects clearly?"
o Other Changes: "Have you noticed any flashes, floaters, or sudden vision
changes?"
3. History of Eye Care:
o "Have you been to an eye specialist recently for any other issues?"
o "Are you aware of any other conditions affecting your eye?"

68
gk’s notes – part 3 – masterclass revision – November 2024

Examination Findings:

• Visual acuity is reported as completely normal.

• A characteristic ring around the cornea is present, confirmed to be arcus senilis based
on appearance.

Explanation to the Patient:

1. Diagnosis:
o "This condition is called arcus senilis. It gets its name because it starts as an arc
(like a half-moon shape) and typically occurs in older adults, which is why we
call it 'senilis.' In younger individuals, we refer to it as arcus juvenilis."
2. Cause and Nature of Arcus Senilis:
o "Arcus senilis is essentially a deposition of fat in the blood vessels around the
cornea, which is a normal age-related change. It’s very common and is generally
harmless."
o "To give you an idea, about 60% of people over the age of 60 have it, and nearly
100% of people by the age of 80 develop it."
3. Reassurance and Management:
o "Arcus senilis does not affect your vision and does not require any treatment. It
will not go away on its own, but it also doesn’t interfere with eye function or
your quality of life."
o "You don’t need to get it removed, as it doesn’t pose any health risks. However,
if you’re ever concerned about the appearance, you could consider wearing
contact lenses, especially for occasions like weddings or events where you may
feel more self-conscious."

Patient's Potential Questions and Responses:

• Q: Do I need any treatment for this?

o "No, arcus senilis doesn’t require any treatment, as it’s a benign condition
related to aging."
• Q: Will this affect my vision over time?
o "No, it doesn’t impact your vision at all. You can continue with your normal
activities without worry."
• Q: Can I get it removed for cosmetic reasons?
o "Removal is generally not advised as it’s harmless and doesn’t impair vision. But
if the appearance bothers you, wearing contact lenses is an option for special
events."

Glass Piece in the Leg

Setting: A 33-year-old was brought to the hospital by his father following an injury. An X-ray
was done initially, which was reported as normal. However, after a radiology consultant
reviewed the scan, a piece of glass was found in the tissue. The doctor must call the father to
discuss the management plan.

69
gk’s notes – part 3 – masterclass revision – November 2024

Objectives:

1. Gather detailed history about the incident and current symptoms.

2. Explain the findings and management plan, including an apology for the initial
oversight.
3. Reassure the father and outline the next steps for treatment.

Approach and Questions to Ask:

1. Incident History (Yesterday’s Events):

o “I understand your son was brought in yesterday. Could you tell me what
happened?”
o “What symptoms did he have at the time of the injury?”
o “Did they mention any findings after the X-ray was done?”
o Key Follow-up Question: “Were you informed that everything was normal with
the X-ray?”
2. Current Symptoms (Today’s Condition):
o “How is he feeling today? Any pain, swelling, redness, or discharge around the
injury?”
o “Is he experiencing any numbness or weakness in the leg?”
3. Previous Management and General Health:
o “Was any treatment provided yesterday, like dressing, antibiotics, or
vaccinations?”
o “Is he up to date with his vaccinations, especially tetanus?”

Explanation to the Parent:

1. Apology and Explanation of the Error:

o “I’m very sorry to inform you that there was a mistake in the initial assessment.
Although the X-ray was initially reported as normal, it was reviewed again by a
specialist, and they found a piece of glass in your son’s leg.”
o “Please accept our sincere apologies. This error is taken very seriously, and we
will report it as a significant incident. There will be an investigation to
understand what went wrong and to ensure it doesn’t happen again.”
2. Management Plan:
o “We would like you to bring your son back to the hospital so that we can safely
remove the glass piece.”
o “We’ll provide proper dressing, and he may need antibiotics to prevent
infection.”
o “We may also need to update his tetanus vaccination if required.”
3. Reassurance and Follow-up:
o “We’ll make sure that he receives the best care moving forward and will keep
you updated on any further findings or necessary steps.”
4. Avoiding Unnecessary Tests:
o “It’s not necessary to repeat the X-ray in this case, as we already know there’s a
glass piece in the tissue.”

70
gk’s notes – part 3 – masterclass revision – November 2024

Foreign Body Inges7on in a Child

Setting: F2 in A&E, a mother has brought in her child after the child ingested a foreign object.
A metal detector was inconclusive, and an X-ray has been done.

Objectives:

1. Gather detailed history about the incident and current symptoms.

2. Review the X-ray and determine management based on the location and type of foreign
body.
3. Provide clear instructions to the parent about next steps, safety measures, and follow-
up.

Approach and Questions to Ask:

1. Incident History:
o “Can you tell me what happened?”
o “Did you witness the incident?”
o “When did this occur?”
2. Symptoms Assessment:
o Gastrointestinal (GI) Symptoms:
§ “Has your child had any vomiting, tummy pain, or discomfort?”
§ “Is there any difficulty swallowing, gagging, or drooling?”
§ “Has your child been eating and drinking normally?”
o Respiratory Symptoms:
§ “Has your child experienced any coughing, choking, wheezing, or noisy
breathing?”
3. Review of Initial Evaluation:
o “What were you told about the X-ray results yesterday?”
o “Did they provide any treatment, like dressings, antibiotics, or a tetanus
vaccine?”

X-ray Findings and Explanation:

1. Scenario 1: Coin in the Stomach

o X-ray Findings: The X-ray shows the coin is in the stomach.
o Management:
§ “The coin is in the stomach, which is below the suprasternal notch, so it
should pass on its own within 48 to 72 hours.”
§ “We don’t need to take any immediate action but will follow up in three
days in the pediatric outpatient clinic.”
§ “We might do another X-ray then, but you do not need to inspect your
child’s stools unless you happen to notice the coin has passed.”
2. Scenario 2: Button Battery in the Upper Oesophagus
o X-ray Findings: The button battery is above the clavicle in the upper
oesophagus.

71
gk’s notes – part 3 – masterclass revision – November 2024

o Management:
§ “Since the battery is above the clavicle, we need to refer your child to a
pediatric surgeon immediately.”
§ “Please do not give your child anything to eat or drink, as we will need
to admit them to have the battery removed with the help of a camera
test (endoscopy).”

Explanation to the Parent:

1. If a Coin is Ingested:
o “A coin in the stomach usually doesn’t pose a significant risk and will likely pass
naturally.”
o “We will observe your child and arrange a follow-up, but there is no need for
surgical intervention unless symptoms develop.”
2. If a Button Battery is Ingested:
o “Button batteries can be dangerous if lodged in the oesophagus, so we must act
quickly to prevent potential complications.”
o “The pediatric surgery team will need to remove it as soon as possible under
careful monitoring.”

Atrophic Vagini7s
Patient Profile:

• 65-year-old female
• Presents with vaginal itching (pruritus) without discharge
• History of cleaning and douching to manage the itch

Objectives:

1. Gather a comprehensive history related to the itching, sexual health, and menopausal
symptoms.
2. Assess for potential differential diagnoses including UTI, STI, and cancer.
3. Explain the diagnosis of atrophic vaginitis and the appropriate management options.

Approach and Questions to Ask:

1. Symptom History:
o Main complaint: “Can you describe the itching in more detail? Does it feel
worse at any particular time or after any specific activities?”
o Menopausal Symptoms: “When was your last period?”
o Any accompanying symptoms: “Have you noticed any bleeding or unusual
discharge?”
2. STI and UTI Symptoms:
o Sexual History: “Are you sexually active? Have you had any new sexual partners
recently?”

72
gk’s notes – part 3 – masterclass revision – November 2024

Urinary Symptoms: “Have you experienced any burning while urinating,

o
frequency, or urgency in going to the toilet?”
3. Menopausal Syndrome Symptoms:
o Vasomotor Symptoms: “Do you experience any hot flashes, palpitations, or
sweating?”
o Urogenital Symptoms: “Do you have frequent or urgent urination, or any
discomfort during intercourse?”
o Psychological Symptoms: “Have you felt more irritable or tired, experienced
low mood, or had trouble sleeping?”

Physical Examination:

• Visual Inspection: When an examination is requested, they will provide a picture

showing redness and potential thinning of the labial or vaginal tissue.
• Interpretation: The picture may show signs consistent with atrophic vaginitis, such as
redness or a thin, fragile appearance.

Diagnosis:

Atrophic Vaginitis:

• Explanation to the Patient: “This condition is known as atrophic vaginitis. After

menopause, the levels of hormones, especially estrogen, decrease, which can make the
lining of the vaginal skin thin and more sensitive. This leads to dryness and can cause
itching and irritation.”

Management:

1. Lifestyle Modifications:
o Stop Douching and Excessive Cleaning: “It’s important to avoid excessive
cleaning, as this can worsen the dryness and irritation.”
2. Medication:
o Estrogen Cream: “We can prescribe an estrogen cream that can be applied
locally to help restore the moisture in the tissue and reduce the itchiness.”
o Vaginal Moisturizers: “Over-the-counter vaginal moisturizers can also be helpful
to maintain moisture and reduce irritation.”
3. Follow-Up:
o Duration: “Try this treatment for one to two months, and if symptoms do not
improve, we can consider referring you to a specialist to ensure nothing has
been missed.”

Alterna7ve Scenario

Scenario Description:

• A postmenopausal woman, around 50-55 years old, who was not sexually active for a
while but recently resumed sexual activity (e.g., a new partner).
• Presents with vaginal pain and bleeding after intercourse.

73
gk’s notes – part 3 – masterclass revision – November 2024

Diagnosis and Management:

• This may also indicate atrophic vaginitis, especially due to the trauma from intercourse
with atrophic, sensitive vaginal tissue.

1. Non-Hormonal Treatment:
o Use of Lubricants: “In such cases, we recommend water-based or silicone-based
lubricants during intercourse. Avoid using petroleum-based products like
Vaseline, as it’s not suitable for this purpose.”
2. Hormonal Treatment:
o If menopausal symptoms are present, consider discussing local oestrogen
options as above, only if suitable.

Key Points for Patient Education:

1. Why Antibiotics Aren’t Prescribed: Explain that antibiotics aren’t needed as this is
not an infection but rather related to the lack of oestrogen and tissue thinning.
2. Expected Outcome: Inform the patient that this condition is chronic and management
will help reduce symptoms but may not fully cure the dryness.
3. Follow-up Plan: Encourage follow-up after treatment to evaluate effectiveness and
consider specialist referral if symptoms persist.

Uterine Prolapse
Patient Profile:

• 50-55 years old female

• Complains of an "embarrassing problem" with something coming down or out below

Objectives:

1. Obtain detailed history on the nature of the prolapse, related symptoms, and any
associated urinary symptoms.
2. Assess for differential diagnoses, including uterine prolapse, possible cancers, and other
pelvic floor issues.
3. Explain the diagnosis and management options clearly to the patient.

Approach and Questions to Ask:

1. Presenting Problem:
o Nature of the Prolapse: “Could you describe what exactly is coming out? What
does it look like? Is it pink and rounded?”
o Size and Evolution: “Is it getting bigger, smaller, or staying the same? Does it
become more noticeable with coughing, sneezing, or lifting heavy objects?”
2. Symptoms:
o Constant or Intermittent: “Does it come and go, or is it always there?”

74
gk’s notes – part 3 – masterclass revision – November 2024

Associated Urinary Symptoms: “Have you noticed any leakage of urine,

o
especially when you cough or sneeze? Any urinary incontinence?”
3. Risk Factors:
o Past Obstetric History: “How many children have you had? Were they vaginal
deliveries?”
o Lifestyle Factors: “Do you often lift heavy objects? Any issues with chronic
constipation?”
4. Differential Diagnosis:
o Cancer Symptoms: “Have you experienced any abnormal bleeding, weight loss,
or other unexplained symptoms?”
o Other Pelvic Conditions: Consider incontinence, hernia, or lymph node
enlargement as potential differentials.

Examination:

• Physical Examination Findings: On examination, the report may describe a lump in

the introitus (vaginal opening) and a positive stress test, indicating prolapse.

Diagnosis:

Uterine Prolapse:

• Definition for the Patient: “This condition is known as uterine prolapse. It happens
when the womb (uterus) slips down from its usual position and presses against the
vaginal wall. It can even come out partially through the vaginal opening.”

Management:

1. Pelvic Floor Exercise and Pessary:

o Explain Pelvic Floor Exercises: “Exercises to strengthen the pelvic floor muscles
can help manage symptoms and prevent worsening of the prolapse.”
o Pessary Insertion: “We can also insert a pessary, which is a removable silicone
or plastic ring that supports the vaginal walls and keeps the uterus in place. This
can be done in the clinic.”
2. Lifestyle Modifications:
o Weight Management and Reducing Strain: “Losing weight if needed and
avoiding heavy lifting can help. If you have constipation, managing it to reduce
straining is also beneficial.”
3. Surgical Option:
o Future Consideration: “Surgery is an option if other treatments don’t relieve
the symptoms adequately, but it is usually considered later if these measures are
not effective.”

Patient Education and Follow-Up:

1. Expected Outcome and Monitoring: Explain that pelvic floor exercises and lifestyle
modifications can significantly help manage symptoms and may prevent the need for
surgery.

75
gk’s notes – part 3 – masterclass revision – November 2024

2. Addressing Questions on Surgery for Anal Fissures (If Mentioned): In cases where the
patient also has an anal fissure, surgery is an appropriate treatment for chronic cases,
but it is usually deferred if she’s had recent childbirth or until necessary.

Retained Tampon
Patient Profile:

• Woman in her 30s with vaginal discharge for the past two weeks.
• Greenish, smelly discharge noticed by her husband (who has had a vasectomy).
• No symptoms suggestive of infection (fever, systemic signs of sepsis).

Objectives:

1. Take a thorough history focusing on symptoms, sexual health, and menstrual hygiene
practices.
2. Consider risk factors for discharge, such as tampon use, sexual activity, and personal
hygiene habits.
3. Diagnose the problem and advise on proper tampon usage and hygiene.

Approach and Questions to Ask:

1. Presenting Problem:
o “How long have you been experiencing the discharge?”
o “Can you describe the discharge? Is there an odour, colour, or change in
consistency?”
2. Detailed Symptom Inquiry:
o STI and UTI Symptoms: “Any pain during urination, itching, or burning
sensation?”
o Infection Symptoms: “Have you noticed any fever, chills, muscle aches, or
fatigue?”
o Menstrual History: “When was your last period? Any recent changes in your
cycle?”
3. Risk Factors:
o Tampon Use and Hygiene Practices: (Only if indicated by findings) “Do you
use tampons regularly?”
o Hygiene Habits: “Do you use any special cleaning products, bubble baths, or
douching?”

Examination:

1. Speculum Examination (Mention Specifically):

o “I would like to use a speculum to look at the neck of your womb and check for
any foreign objects.”
2. Findings:

76
gk’s notes – part 3 – masterclass revision – November 2024

o You may find a “dark tampon-like structure” or a “thread” indicating a retained

tampon in the posterior fornix of the vagina.

Diagnosis:

Retained Tampon:

• Explanation for the Patient: “It appears that a piece of tampon or a tampon itself may
have been retained in the vagina, causing the discharge and smell.’”

Management:

1. Immediate Removal and Swab:

o Procedure: “We will remove the tampon using forceps and clean the area.”
o Swab for Infection: “We’ll take a swab to check for any infection, which should
take about 48 hours for results.”
2. Tampon Usage Advice:
o Changing Frequency: “It’s important to change tampons every 4 hours and
avoid leaving them in for more than 8 hours.”
o Night Use: “Try to avoid using tampons overnight. Use pads instead if
possible.”
o Hand Hygiene: “Always wash your hands thoroughly with soap and water
before inserting a tampon.”
3. Toxic Shock Syndrome (TSS) Education:
o Explanation of TSS: “Tampons can sometimes lead to a rare but serious
infection called toxic shock syndrome. While you don’t have it, it’s good to be
aware of the symptoms.”
o Safety Netting: “If you experience a sudden high fever, rash, sore throat, or feel
generally unwell, please seek medical attention immediately, as these could be
signs of TSS.”

Addressing Patient Concerns:

1. Antibiotic Use: “We don’t need antibiotics right now. If the swab shows any infection,
we can prescribe one at that time.”
2. Referral to a Specialist: “There’s no need for a specialist referral at this point. We’ll
manage it here unless further complications arise.”

Incomplete Abor7on
Patient Profile:

• 30-year-old woman presenting with vaginal discharge.

• History of recent medical abortion.

77
gk’s notes – part 3 – masterclass revision – November 2024

Objectives:

1. Take a comprehensive history focusing on symptoms, recent abortion details, and

potential infection signs.
2. Explain findings, diagnosis, and management options clearly.

Approach and Questions to Ask:

1. Presenting Problem:
o “Can you describe the discharge? Is there an odour, colour, or change in
consistency?”
o “Have you experienced any other symptoms, such as fever, chills, or feeling
generally unwell?”
2. Systemic Symptoms Inquiry (Sepsis):
o Septic/Lactic Symptoms: “Have you noticed any high temperature, chills,
muscle pain, or fast breathing?”
o Pain and Tenderness: “Are you experiencing any pelvic pain, abdominal
cramps, or tenderness?”
o “Do you have any discomfort when passing urine?”
3. Pregnancy and Abortion History:
o “Could there be a possibility that you were recently pregnant?”
o “Did you undergo an abortion? If so, was it a medical abortion?”
o Details about the Abortion: “When did you have the abortion? What
medication was given? Was it administered at a clinic or somewhere else?”
o “Since the abortion, have you passed any tissue or experienced heavy bleeding?”
4. Past Medical History:
o Complete a thorough review of past medical conditions that could impact
current management.

Explanation and Diagnosis:

Findings and Diagnosis:

• “We performed an ultrasound, and it shows some remaining tissue in the uterus, which
we refer to as an incomplete abortion. This means that not all the pregnancy tissue was
expelled from the uterus.”

Management Plan:

1. Treatment Options:
o Expectant Management: “One option is to wait and allow your body to pass
the remaining tissue naturally over time.”
o Medical Management (Medication): “We can administer misoprostol again to
help expel the tissue. This medication can be taken as a tablet or dissolved in
the mouth.”
o Manual Vacuum Aspiration (MVA): “If medication does not work, we might
consider a minor procedure called manual vacuum aspiration, where we remove
the tissue through a gentle suction process.”

78
gk’s notes – part 3 – masterclass revision – November 2024

2. Swab and Infection Screening:

o “We will take a vaginal swab to check for any signs of infection.”
3. Antibiotics (Only if Infection is Confirmed):
o “If the swab shows any infection, we may prescribe antibiotics, such as
doxycycline and metronidazole.”
4. Pain Management:
o “You will also be given pain relief to help manage any discomfort during the
process.”
5. Follow-Up:
o Arrange follow-up to monitor the progress and ensure that all tissue is expelled.

Hyperemesis Gravidarum
Patient Profile:

• 25-year-old woman, 12 weeks pregnant

• Complains of persistent vomiting for the past 2-3 weeks

Objectives:

1. Take a detailed history of vomiting and assess for dehydration.

2. Identify risk factors and assess the impact on eating, drinking, and weight.
3. Explain diagnosis, management, and potential effects on the baby.

Approach and Questions to Ask:

1. Presenting Problem: Vomiting

o “Can you describe your vomiting? How often are you vomiting?”
o “Do you have any other symptoms, such as headaches, or are you experiencing
vomiting in specific situations?”
2. Assessment for Dehydration and Severity:
o Dehydration Symptoms: “Are you experiencing any dizziness, dry mouth, or
reduced urination?”
o Weight Loss: “Have you noticed any weight loss since the vomiting began?”
o Note: Weight loss of more than 5% in pregnancy can indicate hyperemesis
gravidarum.
3. Risk Factors for Hyperemesis Gravidarum:
o Family History: “Has anyone in your family, like your mother, experienced
severe vomiting during pregnancy?”
o BMI: “Do you know your weight before pregnancy?”
o Medical Conditions: “Do you have any medical conditions like asthma or
hypothyroidism?”
o Pregnancy History: “Is this your first pregnancy, or have you had others
before?”
o Multiple Gestations: “Are you carrying one baby or multiples?”
o

79
gk’s notes – part 3 – masterclass revision – November 2024

4. Impact on Day-to-Day Life:

o Eating and Drinking: “Are you able to keep food or liquids down?”
o Daily Activities: “Is the vomiting impacting your ability to carry on with your
daily activities?”

Examination Findings to Request:

1. Weight Measurement:
o Confirm weight loss; significant if more than 5%. (e.g., 7% weight loss is
indicative)
2. Urine Dipstick:
o Check for ketones due to starvation ketosis (presence of ketones indicates
inadequate caloric intake).

Explanation and Diagnosis:

Diagnosis:

• Hyperemesis Gravidarum: “Based on your symptoms and weight loss, it appears you
may have hyperemesis gravidarum. This condition involves severe nausea and vomiting
during pregnancy, making it difficult to eat, drink, or carry on with day-to-day
activities.”

Possible Impact on Baby:

• “Severe hyperemesis gravidarum can potentially lead to a baby born with a low birth
weight. However, with proper management, we aim to minimize any risks.”

Management Plan:

1. Hospital Admission:
o “I would advise an admission to the maternity assessment unit, where you can
receive intensive treatment.”
2. Treatment Measures:
o IV Fluids: To address dehydration.
o IV Thiamine: Given to replace essential vitamins lost due to persistent
vomiting.
o IV Antiemetics: Medication to help control nausea and vomiting.
o Steroids: If antiemetics are ineffective.
o Heparin (Blood Thinner): To prevent clot formation due to immobility.
o Lansoprazole: To reduce stomach acid and prevent further irritation.
3. Monitoring and Follow-Up:
o “We will also conduct a scan to check on the baby’s health and monitor your
progress. After initial management, you may need follow-up appointments to
monitor symptoms and weight gain.”
4. Reassurance:
o “We’ll do our best to ensure you and the baby remain healthy, with measures to
help manage your symptoms effectively.”

80
gk’s notes – part 3 – masterclass revision – November 2024

Primary Dysmenorrhea
Patient Profile:

• Age: 15 years old

• Presenting Complaint: Tummy pain associated with periods

Background:

• The patient is accompanied by her father as her mother has passed away due to breast
cancer, potentially contributing to emotional stress.
• She started menstruating four months ago, and since then, has experienced pain during
periods.

Data Gathering

History of Presenting Complaint:

1. Pain Characteristics (SOCRATES):

o Site: Below the belly button, lower abdomen.
o Onset & Timing: Pain occurs with the period, starting just before and ending
with the cycle.
o Character: Cramping pain.
o Radiation: To the back and thighs.
2. Associated Symptoms:
o Gastrointestinal Symptoms: Nausea, vomiting, diarrhea.
o Psychological Symptoms: Fatigue, irritability, dizziness, emotional sensitivity.
3. Menstrual History:
o Cycle Regularity: Inquire about regularity of periods.
o Cycle Duration: Ask about the number of days in her cycle and bleeding
duration.
o Flow: Assess if she has heavy bleeding.
4. Risk Factors:
o Early Menarche: Starting menstruation at a younger age.
o Heavy Menstrual Flow: If she experiences a heavy period, it could increase
dysmenorrhea risk.
o Family History of Dysmenorrhea: Any maternal or sibling history of menstrual
pain.
o Emotional Stressors: Potential impact due to loss of her mother.
o Low BMI and Smoking: Although unlikely at this age, these factors can
contribute to the condition.
5. Impact on Daily Life (MAPTOSA):
o School and Social Life: Impact on attending school, relationships, and daily
routine.
o Sleep: Any disruptions due to pain.

81
gk’s notes – part 3 – masterclass revision – November 2024

Explanation to the Patient

Diagnosis: Primary Dysmenorrhea

• Definition: “You may have a condition called primary dysmenorrhea. This means you
experience painful cramps in your lower abdomen that occur just before or during your
period.”
• Why it Occurs: “This is common with menstruation and is related to hormonal
changes during the cycle.”

Management Plan

1. Pain Management:
o First-line Treatment: NSAIDs (e.g., Ibuprofen or Naproxen) to reduce pain and
inflammation.
§ Note: Avoid paracetamol as NSAIDs are more effective for this type of
pain.
o Alternative Options: Combined oral contraceptive pills (if acceptable) to
regulate hormonal fluctuations that may reduce pain intensity.
2. Non-Medical Interventions:
o Heat Application: “Using a hot water bottle on your abdomen can provide
comfort.”
o TENS (Transcutaneous Electrical Nerve Stimulation): “This is a device that
uses mild electrical pulses to relieve pain. It’s safe and effective for some
people.”
3. If Symptoms Persist:
o Monitoring Duration: “Let’s try this approach for about 3 to 6 months.”
o Referral: If there’s no improvement, consider referral for further evaluation.
4. Educational Material:
o Provide Leaflet: Information on primary dysmenorrhea and self-care tips.

Endometriosis
Patient Profile:

• Age: 25 years old

• Referral Reason: GP referred to OB-GYN suspecting endometriosis.

Data Gathering

History of Presenting Complaint:

1. Primary Symptoms:
o Painful Periods: Persistent lower abdominal pain that occurs during
menstruation and has been ongoing for more than six months.

82
gk’s notes – part 3 – masterclass revision – November 2024

o Dyspareunia (Pain During Intercourse): Patient experiences pain during sexual

intercourse. If not currently sexually active, check if they previously experienced
pain during intercourse.
2. Associated Symptoms and Systemic Involvement:
o Bowel Symptoms: Painful bowel movements, rectal bleeding, or blood in the
stool during periods.
o Urinary Symptoms: Painful urination or haematuria (blood in the urine)
during menstruation.
o Infertility: Explore if the patient has tried to conceive, as endometriosis can
affect fertility.
3. Menstrual History:
o Detailed menstrual history, including cycle length, flow, and associated
symptoms.

Risk Factors for Endometriosis:

1. Reproductive and Menstrual Factors:

o Early menarche (onset of menstruation).
o Late menopause.
o Delay in childbirth or nulliparity (having no children).
2. Family History:
o Family history of endometriosis, particularly in close relatives like mother or
sister.
3. Autoimmune Conditions:
o Some autoimmune diseases may co-occur with endometriosis, although this is
rare.

Physical ExaminaKon

• Abdominal Examination: Check for tenderness or masses, as endometriosis can

sometimes mimic other conditions like fibroids.
• Pelvic Exam (if indicated): While this might not be conducted in a primary care
setting, it may be relevant if referred to a specialist.

ExplanaKon to the PaKent

Diagnosis: Suspected Endometriosis

• What It Is: "Endometriosis is a condition where tissue similar to the lining of the
womb grows outside of the uterus, commonly on the ovaries, fallopian tubes, or other
areas within the pelvis. These tissues respond to hormonal changes during your
menstrual cycle, which can lead to pain, inflammation, and other symptoms."
• Why It Happens: "The exact cause is unknown, but family history and certain
reproductive factors increase the risk."

Management Plan

1. Confirming the Diagnosis:

83
gk’s notes – part 3 – masterclass revision – November 2024

oUltrasound (Transvaginal or Pelvic): Often done first, though it may not

always detect endometrial tissue outside the uterus.
o Laparoscopy (Keyhole Surgery): "A minimally invasive surgery where a camera
is inserted through a small incision to look for endometriosis directly. This is
the gold standard for confirming the diagnosis."
§ Timing of Laparoscopy: Ideally performed around the time of
menstruation for better visualization of endometrial implants.
2. Treatment Options:
o Surgical Treatment:
§ Laparoscopic Excision or Ablation: "During laparoscopy, the surgeon
may remove or destroy the endometrial tissue to help alleviate
symptoms. This is often done with heat or laser and is considered one of
the definitive treatments."
o Medical Management:
§ Combined Oral Contraceptives: Taken without a break to help reduce
hormonal fluctuations and minimize symptoms.
§ NSAIDs for Pain: Ibuprofen or naproxen can help relieve pain but are
not curative.
§ Hormonal Therapy: Other hormonal treatments, like progestins or
GnRH analogues, may be considered by a specialist if initial treatments
are ineffective.

Lifestyle and SupporKve Care:

o Pain Management Techniques: Encourage regular physical activity, stress

management, and relaxation techniques to help manage chronic pain.
o Support Groups and Counseling: Given the emotional and physical burden of
endometriosis, psychological support and counseling may be beneficial.

PaKent Concerns and QuesKons

If the patient asks, "Will this affect my fertility?"

• "Endometriosis can sometimes impact fertility, especially if it causes scarring around the
reproductive organs. However, many women with endometriosis can still conceive. We
can discuss fertility options if you are planning to have children."

If the patient asks, "Can endometriosis spread to other parts of my body?"

• "Endometriosis primarily affects the pelvic organs, but in very rare cases, it can be found
in other parts of the body. This is uncommon, and most cases are limited to the pelvic
area."

Follow-Up and Support

• Referral to Specialist: Arrange for a follow-up with an OB-GYN or specialist in

endometriosis for further evaluation and management.

84
gk’s notes – part 3 – masterclass revision – November 2024

• Educational Material: Provide leaflets on endometriosis, covering symptoms,

management options, and self-care tips.

Medica7on Overuse Headache

Patient Profile:

• Age: 35 years old

• Presenting Complaint: Daily headache for the past six months, described as a band-like
headache, occurring almost every day from midday.

Data Gathering

History of Presenting Complaint:

1. Headache Characteristics:
o Type: Band-like, similar to tension-type headache.
o Frequency: Daily occurrence, persists from midday until evening.
o Duration of Issue: Six months.
2. Associated Background and Triggers:
o Past Medical History of Migraine: Patient has a history of migraine from
teenage years, managed with Sumatriptan.
o Psychosocial Stressors: Undergoing separation and court case, which could
contribute to stress.
3. Medication Use:
o Current Medication: Using Paracetamol daily, with 8 tablets (4 doses) per day.
o Potential Cause of Headache: Excessive use of Paracetamol may have led to a
medication overuse headache.

Explanation to the Patient

Diagnosis: Medication Overuse Headache

• What It Is: "Medication overuse headache occurs when pain relief medications are used
too frequently, causing headaches to become more persistent over time. This can
happen with various pain medications, including paracetamol."
• Why It Happens: "Your body starts to react to the regular intake of medication, leading
to rebound headaches when the medication wears off. It becomes a cycle where the
medication used to treat the headache actually starts causing it."

Management Plan

1. Discontinuing Medication Use:

o "The best treatment for medication overuse headache is to gradually reduce and
stop the frequent use of painkillers."

85
gk’s notes – part 3 – masterclass revision – November 2024

o Withdrawal Effects: "For the first few days after stopping, you may experience
withdrawal headaches, which can be challenging, but this should improve over
time."
2. Alternative Pain Management:
o "During the withdrawal period, we can explore other methods to manage your
pain. Techniques like relaxation exercises, stress management strategies, and
possibly non-medication options may be beneficial."
3. Preventive Measures for Migraine:
o "Given your history of migraine, once the medication overuse headache is
under control, we might consider preventive treatment specifically for migraine
rather than frequent painkillers."

Patient Concerns

If the patient asks, "Will my headache get worse if I stop?"

• "It may feel more intense for a few days, but this should improve. The overall frequency
and intensity of headaches will likely decrease once your body adjusts to not having the
medication daily."

Follow-Up and Support

• Monitoring: Arrange follow-up to support withdrawal and address any emerging

symptoms.
• Educational Material: Provide information on managing migraines without overuse of
painkillers and techniques for handling stress-induced headaches.

Scabies (New Scenario)

Scenario Summary:

• Setting: Telephone consultation with a father (part of a same-sex couple).

• Complaint: Rash on child’s leg; itchy.
• Key Clues:
o Father mentions a “golden crust,” a term often associated with impetigo but can
be confusing in this scenario. Here, it’s a distractor.
o Rash actually started in the finger webs (between fingers) and spread.
o The child attends a crowded nursery, a potential source of infection.
o The child is very young (around 3 years old).

Key Points to Clarify:

1. Rash Characteristics:
o Location: Initially started in the finger webs but now on the leg.
o Appearance: Red, itchy, may have a crusting appearance.
2. Itchiness and Distribution:

86
gk’s notes – part 3 – masterclass revision – November 2024

Itching, especially in areas typical for scabies (finger webs).

o
Other family members or contacts with symptoms? This could indicate spread
o
within a household or nursery.
3. Risk Factor Inquiry:
o Crowded environments are a risk factor for scabies.
o Confirm if any other nursery children or family members have similar
symptoms.

Diagnosis:

• Scabies: Due to itching, location in finger webs, and exposure in a crowded setting
(nursery).

Explanation to the Parent:

• “This looks like scabies, a common skin condition caused by tiny mites that burrow
under the skin and cause intense itching. It’s particularly common in crowded
environments like nurseries, where it can spread easily.”

Treatment Plan:

1. Medication:
o Permethrin 5% cream as first-line treatment.
o Apply to the entire body from neck down, including under the nails (where
mites may hide).
o Repeat treatment after 7 days to ensure all mites and eggs are eradicated.
2. Family & Contacts Treatment:
o All household members should also be treated simultaneously to prevent
reinfestation.
o Recommend notifying the nursery about the condition so they can inform
other parents and possibly treat other children if necessary.
3. Environmental Measures:
o Wash clothing, bedding, and towels in hot water and dry on high heat.
o Items that cannot be washed (like soft toys) can be sealed in a plastic bag for at
least 72 hours to kill mites.

Advice for Symptom Management:

• Use antihistamines if itching is severe.

• Avoid scratching to prevent secondary infections.

Follow-Up:

• Inform the parent that itching may persist for a few weeks after treatment due to the
body’s reaction to the mites, but the rash should start improving after treatment.
• Encourage them to call if symptoms do not improve within a week or worsen,
indicating potential reinfestation or secondary infection.

87
gk’s notes – part 3 – masterclass revision – November 2024

Allergic Contact Derma77s

Scenario Summary:

• Setting: Patient consults with a rash on her finger.

• Symptoms: Rash on the finger that is sore, mildly itchy, and a bit painful.
• Exposure History:
o Works as a florist (new job or has been using new chemicals recently).
o Has been working without gloves.
o Recent exposure to chemicals like pesticides.
o Rash improves when she stops working.

Structured Approach:

1. Rash Analysis (Morphology, Evolution, Symptoms):

o Morphology: Red, sore, possibly inflamed.
o Evolution: Developed over time due to exposure; symptoms improve with rest
from work.
o Symptoms: Mild itchiness, soreness, and some pain localized to one finger.
2. Exposure & Risk Factors:
o Ask about specific contacts with potential irritants:
§ Chemicals: Pesticides, sprays, fertilizers.
§ Wet Conditions: Working with flowers and plants often involves
moisture exposure.
o Check for any other known allergies.
o Any other recent environmental changes or use of new products (e.g., hand
sanitizers, lotions).
o Other parts of the body: Confirm if rash or irritation is present elsewhere.
o Other individuals: Any known cases of a similar rash in her colleagues or other
contacts.
3. Differential Diagnosis:
o Contact Dermatitis (two types):
§ Allergic Contact Dermatitis: Immune reaction (IgG mediated) to a
specific allergen, more generalized.
§ Irritant Contact Dermatitis: Localized response to an irritant substance.
o Based on her job and exposure to chemicals, this scenario likely points to
Allergic Contact Dermatitis.

Explanation to the Patient:

• “It appears you may have a condition called allergic contact dermatitis, a skin reaction
due to contact with certain chemicals, likely related to the pesticides or sprays you've
been handling without gloves.”
• “There are two types of contact dermatitis:
1. Allergic contact dermatitis involves an immune response to specific substances.

88
gk’s notes – part 3 – masterclass revision – November 2024

2. Irritant contact dermatitis results from direct irritation to the skin without an
immune reaction.
o In your case, the symptoms align with allergic contact dermatitis, as it’s localized
to the area in contact with the chemicals.”

Management & Treatment Plan:

1. Avoidance of Irritants:
o Advise the patient to avoid contact with the allergen as much as possible.
o Wear gloves when handling chemicals or working with plants.
2. Topical Treatments:
o Emollient Creams: To moisturize and soothe the skin.
o Mild Steroid Cream: To reduce inflammation and relieve symptoms (use
sparingly as directed).
3. Infection Prevention:
o Ensure cleanliness to prevent secondary infections.
o If signs of infection (increased redness, warmth, pus) occur, return for possible
antibiotic cream.
4. Contact Reduction Measures:
o Reduce frequency of exposure if total avoidance is not feasible.
o Wash hands immediately after any contact with chemicals or plants.
5. Timeline for Healing:
o Inform the patient that it may take 8-12 weeks for full resolution once exposure
stops.

Follow-Up:

• Monitor for Improvement: Check if symptoms reduce with preventive measures.

• Return if Symptoms Persist or Worsen: Advise the patient to seek further help if the
rash spreads, worsens, or if signs of infection appear.

Atypical Pneumonia
Scenario Summary:

• Patient Profile: 70-year-old man presenting to A&E with persistent cough, chest pain,
shortness of breath, and feeling hot.
• Background Information:
o Patient has a history of recent antibiotic treatment from GP, which was
ineffective.
o Reports coughing up white sputum, not blood-stained.
o Smoker with a possible weight loss (about half a stone).
o Recent travel history to Spain, though four months ago (may or may not be
significant).
o Profession: Judge (white-collar job).

89
gk’s notes – part 3 – masterclass revision – November 2024

Structured Approach:

1. Symptom Analysis:
o Cough: Persistent, with white sputum.
o Shortness of Breath: Experienced alongside cough.
o Chest Pain: Presence of pleuritic chest pain.
o Fever: Feels hot, suggesting possible infection.
o Weight Loss: Recent, minor weight loss.
2. Risk Factors:
o Age: 70 years, which increases the risk and complexity of respiratory infections.
o Smoking History: Raises suspicion for potential complications or chronic
respiratory conditions.
o Travel History: Recent travel could imply exposure to atypical infections.
o Failed Antibiotic Therapy: Suggests that the initial treatment was ineffective,
possibly due to atypical or resistant organisms.
3. Differential Diagnosis:
o Pneumonia: Likely bacterial or atypical, given symptoms of cough, fever,
shortness of breath, and pleuritic chest pain.
o Atypical Pneumonia: Possibly due to organisms like Legionella or Mycoplasma,
especially with travel history.
4. NEWS (National Early Warning Score) Chart Analysis:
o Vitals will be plotted on the NEWS chart to assess severity and need for
immediate intervention.
o Key parameters:
§ Temperature: Marked in yellow at 38°C (indicating fever).
§ Saturation: Low at 91% (hypoxia, requires attention).
§ Pulse and Blood Pressure: Recorded on the chart, but hypothetically
within concerning range if relevant to scenario.
§ Level of Consciousness (AVPU): Checked for alertness; if confused,
this would indicate increased severity.
o Interpretation: Patients above age 65 with low saturation (<92%) or significant
infection signs like fever and respiratory symptoms should be considered for
admission.
5. Diagnostic Testing for Pneumonia:
o Chest X-Ray: Confirm consolidation indicative of pneumonia.
o Microbial Tests:
§ Mycoplasma: Detected through throat swab.
§ Legionella: Urine antigen test.
o Atypical Pathogen Testing: Given recent travel and antibiotic failure, test for
atypical causes.
6. Diagnosis:
o Based on symptoms, age, smoking history, and failed response to initial
antibiotics, the likely diagnosis is atypical pneumonia. Given travel history,
suspect Legionella.

90
gk’s notes – part 3 – masterclass revision – November 2024

Explanation to the Patient:

• "It seems you may have pneumonia, which is an infection in the lungs. Your symptoms,
especially the fever and breathing difficulty, indicate that this could be a bacterial or
atypical infection."
• "Pneumonia in someone your age, along with your symptoms of low oxygen saturation,
often needs hospital treatment to ensure proper management."

Management & Treatment Plan:

1. Hospital Admission: Recommended due to:

o Age (70+), low oxygen saturation (91%), and infection severity.
2. IV Antibiotics:
o Start with Clarithromycin to cover atypical organisms like Mycoplasma and
Legionella.
3. Supportive Care:
o Oxygen Therapy to improve oxygen saturation.
o IV Fluids if dehydrated or febrile.
4. Monitoring:
o Regular observation using the NEWS chart for early detection of worsening
condition.
5. Follow-Up:
o Repeat assessments with chest imaging and check microbial test results.
o Discharge planning with home care and oral antibiotics if condition improves
significantly.

Safety Netting:

• Advise the patient that if symptoms worsen (e.g., increased shortness of breath, high
fever, confusion), immediate hospital care is necessary.
• Discuss that although the infection might be severe, early treatment should help with
recovery.

Nursing Home - Confusion and Fall

Scenario Summary:

• Patient Profile: Elderly nursing home resident, presenting with confusion and recent
history of a fall.
• Background Information:
o Patient has a sudden onset of confusion.
o Unlike the sepsis scenario, this patient's vital signs are within normal limits:
temperature, oxygen saturation, and heart rate are all normal.
o Glasgow Coma Scale (GCS) is lower than usual, indicating altered mental
status.

91
gk’s notes – part 3 – masterclass revision – November 2024

o Patient reportedly fell two days ago when getting up from a chair, suggesting a
potential cause for confusion.

Structured Approach:

1. Symptom Analysis (Confusion):

o Primary Symptom: Confusion, with a low GCS.
o Infection Exclusion: Since vital signs are normal (no fever, no respiratory
distress), infection such as sepsis is less likely.
o Differential Diagnosis for Confusion:
1. Electrolyte Imbalances: Check for abnormalities in sodium, calcium, or
kidney function.
2. Dementia: However, the nursing staff reports that the patient’s memory
was sharp prior to this episode, making acute confusion due to
dementia less likely.
3. Recent Fall: The fall two days ago raises suspicion for a possible head
injury, particularly a subdural hematoma, which can lead to subacute or
chronic confusion in elderly patients.
2. Detailed Fall History:
o When and How: Fell two days ago while rising from a chair.
o Symptoms Post-Fall: Check if the patient was confused, had amnesia, or lost
consciousness immediately following the fall.
o Injuries Sustained: Inquire about any visible head trauma, bruising, or
neurological deficits that may have followed.
o Neurological Symptoms: Ask about any subsequent weakness, changes in
vision, speech difficulties, or balance issues post-fall.
3. Diagnostic Steps:
o Suspected Diagnosis: Subdural hematoma, likely subacute due to the delayed
onset of confusion.
o Imaging: Order a CT scan to confirm the presence of a subdural hematoma or
other cranial injury.
o Further Management: If a subdural hematoma is confirmed, refer the patient
to neurosurgery for potential intervention (e.g., burr hole drainage or
craniotomy).
4. Explanation to Nursing Home Staff:
o "Based on her recent fall and sudden confusion, we are concerned about a
potential head injury, such as a subdural hematoma, which is a collection of
blood on the surface of the brain."
o "A CT scan will help confirm if there is any bleeding that might be causing her
confusion."
o "If bleeding is found, she may need a surgical procedure to relieve the pressure."
5. Social and Legal Considerations:
o The nursing staff may repeatedly ask, "Is it our fault, doctor?" indicating concern
about liability.
o Response: "It’s difficult to say what exactly led to her condition. Our priority is
to provide the necessary medical care. Once she’s medically stable, we’ll conduct
a full assessment, including involving social services if needed, to ensure her
safety and address any concerns."

92
gk’s notes – part 3 – masterclass revision – November 2024

o Further Steps: After treatment, ensure a social services referral to assess the
patient’s safety and care needs before discharge.
6. Management Plan:
o Immediate Medical Management: Observation and symptomatic treatment
while awaiting CT results.
o Potential Neurosurgical Intervention: If subdural hematoma is confirmed, a
procedure like burr hole surgery or craniotomy may be required.
o Social Services Assessment: Arrange for a comprehensive social care assessment
before discharge to address any concerns about her safety in the nursing home.

Venous Ulcer
Scenario Summary:

• Setting: F2 doctor in a GP clinic.

• Patient Profile: 40-50-year-old man presenting for a follow-up regarding a venous ulcer.
• Primary Complaint: Persistent wound on the leg, suspected to be a venous ulcer.

Structured Approach:

1. History Taking:
o Symptom Inquiry: "How have you been? What sort of symptoms are you
experiencing with the wound?"
o Wound Analysis:
§ Morphology: Describe the appearance of the wound.
§ Evolution: Duration and any changes over time.
§ Symptoms: Pain, itching, oozing, or any other associated symptoms.
o Venous Symptoms: Check specifically for the following eight symptoms
associated with venous issues:
1. Ulcers (current and previous episodes)
2. Discoloration (e.g., hyperpigmentation around the ulcer site)
3. Pigmentation changes
4. Pain around the ulcer area
5. Itchiness
6. Swelling
7. Bleeding
8. Oozing
2. Risk Factor Assessment:
o Occupation: Long-standing occupations, such as painting, which this patient
has.
o Other Risk Factors:
§ History of varicose veins
§ Diabetes (if present)
§ Obesity
o Past Medical History: Any previous leg wounds or ulcers.
3. Examination:

93
gk’s notes – part 3 – masterclass revision – November 2024

o Conduct a physical examination focused on:

§ Appearance of the ulcer (depth, discharge, color, surrounding skin)
§ Signs of infection or poor healing
4. Diagnosis and Explanation to Patient:
o Diagnosis: Venous ulcer
o Definition: "A venous ulcer is an unhealed wound on the leg, often due to poor
blood flow in the veins."
o Cause: Explain that factors like long-standing periods, varicose veins, and poor
blood circulation contribute to these types of ulcers.
5. Management Plan:
o Referral: "You’ll need to be referred to a specialist team for further
management."
§ Tissue Viability Clinic: Managed by specialist nurses to provide wound
care.
§ Vascular Team: For specialized treatment to address venous
insufficiency.
o Treatment:
§ Compression Therapy: The primary treatment involves compression
therapy to improve circulation and promote healing.
§ Compression Stockings: After healing, wearing compression stockings is
essential to prevent recurrence.
o Medications:
§ Pentoxifylline: A medication that improves blood flow and circulation,
prescribed by the GP to aid healing.
o Lifestyle Modifications:
§ Leg Elevation: Regularly elevating the leg to reduce swelling.
§ Exercise: Engaging in gentle exercises to improve blood circulation.
6. Patient Education and Follow-Up:
o Educate the patient on the importance of consistent use of compression
stockings even after the ulcer heals.
o Reinforce lifestyle changes to support circulation and reduce the risk of
recurrence.
o Schedule follow-up appointments to monitor healing and adjust treatment as
necessary.

Mole (new scenario)

Scenario Summary:

• Setting: GP or primary care consultation.

• Patient Profile: Young female presenting with a concern about a mole.
• Primary Complaint: Patient has noticed a pigmented lesion on her arm, which has
been present for 2-3 years without any recent changes.
• Background: The patient is anxious, especially because colleagues at her workplace
suggested it could be cancer.

94
gk’s notes – part 3 – masterclass revision – November 2024

Structured Approach:

1. History Taking:
o Chief Concern: “How can I help you with this mole today?”
o Lesion History:
§ Duration: Mole has been present for 2-3 years.
§ Evolution: No changes in size, shape, or color during this time.
§ Associated Symptoms: Any itching, bleeding, pain, or other symptoms
with the lesion.
o Background Information:
§ Workplace concern: Colleagues at work mentioned it could be cancer,
increasing her anxiety.
§ Anxiety Diagnosis: The patient has a history of anxiety, which may be
affecting her perception of risk.
2. Focused Dermatological Exam:
o Lesion Morphology:
§ Appearance: Lesion is not very brownish or dark, possibly a pale or
neutral pigmentation.
§ No obvious characteristics indicating malignancy.
o ABCDEs of Melanoma Screening:
§ Asymmetry: Check if one half of the mole differs from the other.
§ Border: Look for irregular, scalloped, or poorly defined borders.
§ Colour: Any variation in colour or if the lesion is multi-coloured.
§ Diameter: If it’s larger than 6mm, this might need attention.
§ Evolution: Most critical factor here – confirm that there has been no
change in the lesion over time.
3. Diagnosis and Explanation to Patient:
o Diagnosis: Likely a benign mole.
o Explanation: “It appears to be a benign mole, which is a common, pigmented
lesion and is usually harmless.”
o Evolution: “The most important sign we look for in moles that might turn into
skin cancer is evolution, meaning changes in size, shape, or color. Since you’ve
noticed no changes over the past few years, it’s unlikely to be concerning.”
4. Patient Reassurance:
o Address her anxiety by reassuring that there is no indication of cancerous
changes.
o Supportive Statement: “I understand you’re worried, especially with what your
colleagues have mentioned, but based on what I’m seeing, there’s no reason for
concern. I’ll provide you with some pointers on what to monitor, just in case.”
5. Patient Education and Follow-Up:
o Self-Monitoring: Educate her on the importance of monitoring for any future
changes and explain the “ABCDE” rule for checking moles.
o Evolution Signs: “If you notice any changes in the mole’s size, shape, or colour,
or if it becomes painful or starts bleeding, please come back to see us.”
o Routine Checks: Encourage regular self-examinations of all skin areas,
especially areas exposed to the sun.
6. Follow-Up:
o No immediate follow-up necessary if there are no concerning changes.

95
gk’s notes – part 3 – masterclass revision – November 2024

o Suggest returning for an annual skin check if she remains concerned.

Additional Notes:

• Management of Anxiety: Given her background, consider addressing general anxiety

management, perhaps referring her to counseling or recommending stress-relief
strategies if her anxiety persists.
• Documentation: Record details of the lesion and patient’s response to the reassurance
provided.

Lithium Toxicity
Scenario Summary

• Setting: Emergency Department (A&E).

• Patient Profile: 70-year-old male.
• Presenting Complaint: Brought in by his son due to shakiness (tremor) of hands and
balance issues (unsteadiness).

Structured Approach:

1. History Taking:
o Chief Concern: "What brought you to the hospital today?" or "Can you tell me
about the symptoms?"
§ Symptoms: Tremors and unsteady gait.
o Differentials for Tremor:
§ Essential tremor, Parkinson's disease, medication side effects,
neurological issues.
§ Ask about any known neurological conditions (e.g., Parkinson’s, stroke
history).
§ Differentiation from Parkinson's Disease: In Parkinson’s, tremor is
typically a resting tremor with a “pill-rolling” quality, unlike an action
tremor seen here.
o Medication History:
§ Ask if the patient is on any medications that could contribute to tremor,
such as salbutamol (asthma), antidepressants, or antipsychotics.
§ Ask if the patient is taking lithium (often not immediately disclosed, so
prompt carefully).
o History of Lithium Use:
§ Duration: How long has he been taking lithium?
§ Indication: Usually prescribed for bipolar disorder.
§ Monitoring: Has he been having regular blood tests to monitor lithium
levels? (weekly/monthly).
§ Dosage and Compliance: Any changes in dosage, recent missed doses, or
accidental overdose?
o Risk Factors for Lithium Toxicity:

96
gk’s notes – part 3 – masterclass revision – November 2024

§ Kidney Function: Ask if the patient has any history of kidney disease, as
this can lead to lithium accumulation.
§ Alcohol Use: Contributes to dehydration and renal issues.
§ Medications: Ask about any new or recent medications, especially:
§ Diuretics
§ ACE inhibitors (used in blood pressure)
§ NSAIDs (painkillers, e.g., ibuprofen)
o Symptoms Associated with Lithium Toxicity:
§ Gastrointestinal: Nausea, vomiting, metallic taste.
§ Neurological: Confusion, lethargy, tremors, vision disturbances.
§ Musculoskeletal: Muscle twitching, jerky movements, unsteadiness,
speech difficulties.
§ Urinary Symptoms: Difficulty urinating or controlling urine.
o Social History:
§ Ask if there are any recent life stressors, and if he has had any suicidal
thoughts or attempts in the past.
2. Diagnosis and Explanation:
o Diagnosis: Suspected lithium toxicity.
o Explanation to Patient/Son:
§ “It seems that your father’s symptoms could be related to high levels of
lithium in his body. Lithium, while effective for certain mental health
conditions, can become toxic if not carefully monitored.”
3. Initial Management:
o Immediate Actions:
§ Stop Lithium: Discontinue lithium immediately due to signs of toxicity.
§ Fluids: Start IV fluids to help flush out the lithium and support kidney
function.
§ Regular Monitoring: Check lithium blood levels every 6-12 hours.
§ Target Lithium Levels: Therapeutic range is between 0.6 to 1
mmol/L.
§ Levels above 1.5 mmol/L are considered toxic and may require
urgent intervention.
o Further Interventions:
§ Dialysis: If levels are critically high or symptoms severe, dialysis may be
necessary to remove lithium from the body.
§ Supportive Measures: For symptoms such as nausea or tremors, provide
symptom relief.
4. Addressing Concerns:
o Son’s Concerns about Mental Health:
§ Reassure that the temporary pause in lithium is to prevent further harm.
Once the levels normalize, the plan is to restart lithium or consider
alternative management options.
o Son’s Question about Antidote:
§ Unfortunately, there is no specific antidote for lithium toxicity. The best
approach is stopping lithium and using fluids to help flush it out.
5. Follow-Up:
o Psychiatric Consultation: Once stabilized, a psychiatrist should assess and
advise on restarting lithium or alternative treatments.

97
gk’s notes – part 3 – masterclass revision – November 2024

o Long-Term Monitoring:
§ Re-establish regular monitoring of lithium levels and reinforce the
importance of consistent blood tests to prevent future toxicity.

Hun7ngton’s Disease
Scenario Summary

• Setting: GP Clinic (General Practitioner).

• Patient Profile: 25-year-old female.
• Presenting Complaint: Patient is worried about the possibility of inheriting
Huntington's disease, as her mother has been diagnosed with it.

4-Box Approach

1. Box 1: Patient's Knowledge and Concerns (ICE - Ideas, Concerns, Expectations)

o Explore Concerns:
§ Begin by asking, "How can I help you today?" The patient may express
concerns about possibly inheriting Huntington's disease and what that
might mean for her health and future.
o Prior Knowledge:
§ "Can you tell me how much you already know about Huntington's
disease?" and "Do you know what kind of symptoms it can cause?" This
will help understand her baseline knowledge and any misconceptions.
o Expectations and Ideas:
§ "What are you hoping to learn or accomplish from this appointment?"
This can clarify if she is considering genetic testing, simply seeking
information, or needs reassurance.
o Exploring Additional Concerns:
§ Address any further concerns: "Are you worried about how this might
affect your future or your family?"
2. Box 2: Risk Factors and Family History
o Mother’s History:
§ Ask specific questions about her mother’s condition, such as, "How old
was your mother when she was diagnosed with Huntington's?" and
"What symptoms has she experienced?" This includes any cognitive,
motor, or emotional symptoms (e.g., memory issues, mood changes,
chorea).
o Extended Family History:
§ "Do you know if anyone else in your family, like your grandparents,
uncles, or aunts, had similar symptoms?"
o Marital and Sibling Status:
§ "Are you the only child, or do you have siblings?" and "Are you married
or planning to have children?" This can be helpful in understanding
family dynamics and the broader risk within the family.
o Presence of Symptoms:

98
gk’s notes – part 3 – masterclass revision – November 2024

§ If relevant, gently inquire about her own health status: "Have you
noticed any unusual symptoms yourself, like changes in mood, memory,
or movement?" While we don’t expect symptoms at this age, it can help
provide reassurance if she’s symptom-free.
3. Box 3: Explanation and Education about Huntington’s Disease
o Nature of Huntington’s Disease:
§ Explain that Huntington’s is a genetic disorder affecting the brain,
causing progressive decline in cognitive, motor, and emotional function.
Clarify that it’s typically a late-onset condition, but symptoms can
sometimes appear earlier.
o Genetics - Autosomal Dominant Inheritance:
§ Explain that Huntington’s is autosomal dominant, meaning that each
child of an affected parent has a 50% chance of inheriting the gene.
o Visual Aid:
§ Use a simple 4-box Punnett square to illustrate the 50% inheritance
pattern.
§ Label one column "Father" and one "Mother" and use symbols
(like "H" for Huntington and "N" for normal gene).
§ Show how, in autosomal dominant conditions, there’s a 50%
chance for each child to inherit the faulty gene if one parent is
affected.
o Symptoms and Onset:
§ Briefly outline the symptoms associated with Huntington's, categorized
into:
§ Cognitive: Memory, decision-making, and concentration
problems.
§ Motor: Chorea, tremors, and clumsiness.
§ Emotional: Mood swings, irritability, apathy.
o Risks for Children:
§ If the patient has children, explain that if she carries the gene, each
child also has a 50% chance of inheriting it. This information is
particularly relevant for family planning.
4. Box 4: Counseling on Genetic Testing and Next Steps
o Genetic Testing:
§ Discuss the option of genetic testing to determine her Huntington’s
status. Explain that this testing is usually voluntary and that genetic
counseling is available to support her decision-making process.
§ Emphasize that a genetic counsellor can discuss the implications of
knowing her genetic status, the impact on life planning, and coping
strategies.
o Support and Referral:
§ "I can refer you to a genetic counsellor who specializes in conditions like
Huntington’s. They can help you decide if testing is the right choice for
you and support you through the process."
o Discussing Future Risk and Reproductive Options:
§ Explain that genetic counsellors can also provide information about
reproductive options, such as pre-implantation genetic diagnosis (PGD),
if the patient is concerned about passing on the gene.

99
gk’s notes – part 3 – masterclass revision – November 2024

o Reassurance and Emotional Support:

§ Validate her feelings: "It’s completely normal to feel worried or
uncertain when it comes to conditions like this."
§ Offer information on support groups or mental health resources if she is
experiencing anxiety over this situation.

Anticipated Questions

1. Will I definitely get Huntington’s if I have the gene?

o "If you inherit the gene, it’s very likely that you’ll eventually develop symptoms,
but the age of onset and progression can vary widely."
2. Is Huntington’s disease treatable or curable?
o "Currently, there’s no cure, but there are treatments that can help manage
symptoms. Research is ongoing."
3. Can I prevent passing it to my children?
o "If you carry the gene, there are reproductive options available, such as PGD,
that can help reduce the risk of passing on Huntington’s. A genetic counsellor
can provide more information about this."

100