4122 Video not available

Back pain - Cauda Equina

70 year old man
In GP or A&E
Mechanical injury (was picking something from the floor)
Wets himself once
Not able to urinate
constipation
Hx of back pain
MAFTOSA
ICE
Examination:
Neurological reflexes all reduced and bilateral (reflexes - tone and sensation)
Abdominal ex: palpable bladder
Diagnosis :
Cauda equina 2ry to disc prolapse
MGT:
Blood test
Catheterization
Admit
Orthopaedic referral : (they may perform an operation to relieve the compression of the nerve)
MRI Spine
Mostly: L4-5 L5-S1

4123 Video not available

Ankylosing Spondylitis:
You are FY2 in GP
33 years old man with back pain for the last 6 months
Bus driver
Walking around not helping
Pain SOCRATES
MAFTOSA
ICE
Examination:
Spine examination (tenderness on the sacroiliac joint)
Schober test to check flexibility of your hip
Lower limb neurological examination
PR
Explanation: chronic inflammation of joint of the spine cause stiffness

MGT:
Xray on spine
Refer to rheumatologist Routine referral
Refer to physiotherapist
Blood test (Routine and Inflammatory) + HLA B27
NSAID: Ibuprofen
Advice : encourage exercise

4124 Video not available

Hypoglycaemic fits
Question
You are the FY 2 in the A&E department.
45 year admitted after the fall. He had multiple episodes of fits after brought into A&E.
Assess and manage.
HR- 122, BP – 100/55, SPO2 – 98%, RBS – 2.2mmol

Patient may be lying down with cannula in the hand.

D- How can I help you? P- I am feeling dizzy.

D- Since when? P- Since last few hours.
D- How do you feel the dizziness - do you feel as if the room is spinning or light headed?
P- I feel light headed.
D- Anything else? P- I fell down few hours ago.
D- Do you have any injuries? P- No, I feel dizzy
D- Did you faint? P- I don't know. I feel dizzy I am not feeling well. [ Patient may not
talk to you for long time unless you treat him first].
D- I had a look at our vital signs. It shows that you have very low blood pressure and we
checked your blood sugar that is also very low. P- Okay
D- We will give you glucose (dextrose 200ml of 10% or 100ml of 20%) to bring up your
blood sugar and also we will give you some fluid through your vein. You will feel better.
P- Yes, doctor I feel better now.
D- I need to check your blood pressure and blood sugar again. (Examiner may or may not
say they are normal now).
D- You need to eat something now. I will tell the nurses to give some biscuits or bread.
D- Do you know what happened to you? P- I don't know.
D- Your blood sugar was very low what we call as hypoglycaemia and you fainted and
fell down because of that and also you had some fits here in the hospital because of low
blood sugar. Do you understand? P-Yes.
D- I need to examine you to check whether you have any injuries because of your fall. Do
you have any pain or bleeding anywhere? P- No
D- I need to check why you had a low blood sugar? Have you been diagnosed with any
medical conditions? P- Yes, diabetes.
D- Since when? P- Since I am 16 years old.
D- Do you take any medicine for that? P- Yes, Insulin.
D- What type of Insulin? P- I take short acting in the morning and long acting one in the
night. Did you take it last night and today morning? P- Yes.
D- Did you eat after that? P- No
D- Why not? P- I was too busy to go to my office. I didn't get time.
D- Did you vomit today? P- No
D- Did you take more Insulin than usual? P- No
D- Did you do any heavy exercise today? P- No
D- Did you drink alcohol today? P- No
D- I think you had a low blood sugar because you didn't eat after taking Insulin.
D- Did you faint like thus before because of low blood sugar? P- No, this is the first time.
D- Do you know what us the danger of having low blood sugar? P- No
D- Well, it can cause sudden death. Make sugar you will never have low blood sugar
again. D- Reasons for having low sugar are taking large dose if Insulin, not eating after
taking Insulin, vomiting, doing too much exercise or drinking alcohol. You should avoid
all these things. Do you follow me? P- Yes.
D- Do you know the symptoms of having low blood sugar? P- No
D- Symptoms of low blood sugar are shaking, sweating, feeling very hungry, feeling very
irritable, feeling faint. If you have any of these symptoms you should eat some sweets
immediately so it is very important that you should keep some sweets with you always.
Do you understand? P- Yes.
D- Do you drive? P- Yes.
Were you driving at the time when you passed out? Yes/ No

If yes, then they have to stop driving and inform DVLA.

If you have more than one severe hypo while awake in a
12-month period, stop driving and tell the DVLA. Your
licence will be revoked. You can reapply for it 3 months
later.

D- You should stop driving for now and inform the DVLA about this incident if have low
sugar and fainting and having fits because of low blood sugar. Will you please do that?
P- Yes, I will.
D- You should wear diabetic bracelet all the time. P- Okay.
D- You need to be admitted now to the hospital. Will that be Okay? P- No
D- Why not? P- I have too much backlog at my work. I need to complete that soon.
D- What is your job? I work as engineer.
D- It is very important to be admitted because we need to monitor you for some time to
check whether you will have low sugar again. Otherwise you may have firs again which
can be even life threatening sometimes. Do you understand? P- Yes, but I have to do my
job.
D- Can you do your job remotely using computer? P- Yes.
D- Can you do the work on your computer staying here in the hospital? P- Yes, I can.
D- Okay that is good. We will arrange that for you.
D- Do you have anyone to look after you? P- Yes, I have my wife.
D- Good, you can tell her about your admission to the hospital.
D- Do you have any questions? P- No
D- Anything else you are expecting from us? P- No
4125 Video not available
Driving and diabetes
For most people with diabetes, driving isn’t a problem, and they can hold a driving
licence and carry on driving. Here you’ll find everything you need to know about
diabetes and driving.
How diabetes can affect driving
There are two main things about diabetes that can affect your ability to drive safely:

 If how you treat your diabetes means you’re at risk of having a hypo (where your
blood sugar drops below 4mmol/l).

 If you develop diabetes complications that make it harder for you to drive – like
problems with your eyes (retinopathy) or nerve damage (neuropathy).
If these things affect you, you need to know what the rules are and what you need to tell
your local driver and licensing authority.
The rules are different depending on what vehicle you want to drive. Here we’ll talk mainly
about what you need to know if you want to drive a car or motorbike (called a Group 1
licence ).
To drive a lorry or larger vehicle, you’ll need a Group 2 licence . There are different rules
for this type of licence and they can be more complicated when you are driving with
diabetes.

These rules come from the Driver and Vehicle Licensing Agency (DVLA) in England,
Scotland and Wales, and the Driver and Vehicle Agency (DVA) in Northern Ireland. We
use DVLA throughout this information, to make things simpler.
And remember, you need to know these rules if these things could affect you in the future if
not now.

Driving and how you treat your diabetes

Can you still drive if you have diabetes? It depends if how you treat your diabetes means
you're at risk of hypos, as this can affect your ability to drive safely.
So what makes you at risk of having hypos? Hypos can affect people who take certain
medication to treat their diabetes, including insulin and medications like sulphonylureas .
And some hypos can be really severe where you need help to treat them. Speak to your
healthcare team if you’re not sure whether you’re at risk of having these and what you can
do to prevent them. If you already know you're at risk of hypos, follow our checklist each
and every time you drive.

However you treat your diabetes, use our table explaining the rules for your driving
licence based on each type of treatment.
Driving and eye complications
Retinopathy is damage to the blood vessels supplying the eye’s retina (the seeing part at
the back of the eye) and it can cause sight loss. It’s linked to high blood sugars and high
blood pressure so it’s more common in people with diabetes.
If you start having problems with your eyes, you need to let the DVLA know and you may
need a special diabetes eye test for driving. It’ll be done at an optician near you that’s
recommended by the DVLA and they’ll pay for it.
Some eye problems can be treated successfully which means you can reapply for your
licence. Ask your healthcare team if you’re not sure.

Other diabetes complications that can affect driving

Neuropathy affects your nerves. Damage to your nerves can mean you lose feeling in your
hands and feet, as well as causing problems in various other parts of your body. If it’s
severe then you should ask your healthcare team or the DVLA for more advice.
If neuropathy or an amputation mean you need an adapted vehicle, you’ll have to apply for
an adapted vehicle licence from the DVLA. Diabetes complications shouldn't have to stop
you driving.
Heart complications can affect your ability to drive and being able to hold a licence. Your
specialist heart team must advise you here.
Other conditions the DVLA need to know about include things that could cause loss of
consciousness or concentration, like sleep apnoea. This can make it harder for you to
concentrate in the day due to extreme sleepiness. Talk to your healthcare team or sleep
clinic about this.
They also need to know about any problems you develop that make it difficult to negotiate
traffic or act quickly. For example a stroke , which is a cardiovascular complication, is when
blood can't get to the brain and it's starved of vital oxygen and nutrients. This can happen if
your blood vessels are damaged or blocked and can make it harder for you to react quickly.
Your driving checklist if you’re at risk of hypos

Follow this diabetes driving hypo checklist each and every time you drive. It’s how you
reduce your risk of a hypo at the wheel. And it’s how you can carry on driving safely.
  Know the symptoms of a hypo – if you’ve lost hypo awareness, you can’t drive.

 Keep spare test strips in the car and bring your meter with you.
 Check your blood sugar levels before you set off and every two hours on long
journeys.
 Five to drive – your blood sugars have to be 5mmol/l or above before you drive. If
they’re between 4mmol/l and 5mmol/l, eat some carbs before heading out.
 If they’re under 4mmol/l – treat your hypo and check your levels again before
driving.
 Always keep hypo treatments where you can easily reach them in the car.
 Take breaks on long journeys.
 Don’t delay meals or snacks.
Remember, the rules are more complicated around diabetes and truck driving or if you want
to drive a large vehicle, with a Group 2 licence .

When to check blood sugar levels for driving

If you usually check your blood sugar levels , then you must follow the rules about when to
check them. This means checking them within two hours of driving – however short the
trip. On longer journeys, you must check them every two hours.
It's fine to use a flash glucose monitor or a continuous glucose monitor to check your
sugar levels before you drive.
These rules are only about checking for low blood sugar levels – the DVLA don’t have any
specific limits on high blood sugar levels.
Speak to your healthcare team if you’re not sure whether you should be checking your blood
sugars – it depends what medication you’re on.

If you start having a hypo while driving

It’s the law that you must stop. And it’s what you must do to avoid any risk of an accident.
So find somewhere safe to pull in as soon as possible.
 1. Pull over safely. If you feel like your blood sugar is low then make sure you pull
over as soon as possible.
2. Switch off the engine. Take the keys out and move from the driver’s seat – if you
don’t, the police can think you’re still in charge of the car and you could be
prosecuted.
3. Take fast-acting carbs, like glucose tablets or sweets, and some longer-acting
carbohydrates too, like plain biscuits or crackers.
4. Don’t drive until 45 minutes after your blood sugar level has gone back to 5mmol/l
or above. This is the time it takes for your concentration to go back to normal.
If you’re struggling with hypos, talk to your healthcare team about whether you should be
driving.
You don’t need to let the DVLA know that you’ve had a hypo – only if it’s a severe
hypo (where you need help to treat it). Severe hypos are a lot more serious so the rules are
more detailed. We have more information about severe hypos if you don't know what they
are.

Diabetes and car insurance

Most car insurance companies won’t charge more if you have diabetes. You should
complain if they do and if you’re still not happy then try somewhere else.
You’ll have to declare your diabetes as a material fact when applying for insurance. We’ve
information about insurance and diabetes to help you.

Driving for work when you have diabetes

If you drive as your job or use a car to get to work, you’re bound to worry about how
changes to your driving licence could affect your job.
We have lots of advice and information on driving and work to help you understand what
your rights are.

Can diabetes affect your driving license?

If you have your licence revoked then you can nearly always reapply for it after some time.
It depends why you lost your licence. The most common reason is because of severe hypos ,
which is where you need help and can’t treat it on your own.
You can apply for a new licence up to eight weeks before the date given on your refusal
notice. What happens then will depend on why your licence was taken away . We have lots
more information on what happens if you lose your licence.

4126 Video not available

Telling DVLA about a medical condition or disability

You must tell DVLA if you have a driving licence and:

 you develop a ‘notifiable’ medical condition or disability

 a condition or disability has got worse since you got your licence
Notifiable conditions are anything that could affect your ability to drive safely. They can
include:

 diabetes or taking insulin

 syncope (fainting)
 heart conditions (including atrial fibrillation and pacemakers)
 sleep apnoea
 epilepsy
 strokes
 glaucoma

4127 Video not available

Hair Loss
Causes
People typically lose 50 to 100 hairs a day. This usually isn't noticeable because new hair is
growing in at the same time. Hair loss occurs when new hair doesn't replace the hair that has fallen
out.
Hair loss is typically related to one or more of the following factors:

 Family history (heredity). The most common cause of hair loss is a hereditary condition
that happens with aging. This condition is called androgenic alopecia, male-pattern baldness
and female-pattern baldness. It usually occurs gradually and in predictable patterns — a
receding hairline and bald spots in men and thinning hair along the crown of the scalp in
women.
 Hormonal changes and medical conditions. A variety of conditions can cause permanent or
temporary hair loss, including hormonal changes due to pregnancy, childbirth, menopause
and thyroid problems. Medical conditions include alopecia areata which is immune system
related and causes patchy hair loss, scalp infections such as ringworm, and a hair-pulling
disorder called trichotillomania.
 Medications and supplements. Hair loss can be a side effect of certain drugs, such as those
used for cancer, arthritis, depression, heart problems, gout and high blood pressure.
 Radiation therapy to the head. The hair may not grow back the same as it was before.
 A very stressful event. Many people experience a general thinning of hair several months
after a physical or emotional shock. This type of hair loss is temporary.
 Hairstyles and treatments. Excessive hairstyling or hairstyles that pull your hair tight, such
as pigtails or cornrows, can cause a type of hair loss called traction alopecia. Hot-oil hair
 treatments and permanents also can cause hair to fall out. If scarring occurs, hair loss could
be permanent.
Hair loss due to tacrolimus
Question
You are the FY 2 in the GP clinic.
50year old lady presents with hair loss.
Assess and manage.

How can I help you? I am losing to much hair.

Since when? Since the last 4 to 5 months.
From where you are losing hair – is it from your head only or all over your body (eye
lashes, eye brows, genital areas, axilla)? From my head.
Which part of your head you are losing hair – all over your head or some parts of your
head (patchy areas) (alopecia areata)? From all over my head.
Do you think this not normal to you? Yes, this is not normal to me lose so much hair so
little time.
Are you trying any new hair styles which may be pulling your hair tight? No
Are you using any tight hair clips? No
Do you have any itching on your head (Tinea capitis)? – No
Any of your blood relatives have similar type of hair loss (hereditary)? No
Do you have any medical conditions - thyroid problems (thyroid problem can cause hair
loss)? No
Any recent surgeries? Yes, I had kidney transplant 5 months ago.
Are you taking any medications? Yes, Tacrolimus.
Since when? Last 5 months
Did you start losing hair before you started taking medications or after you started taking
the medications? After I started taking the medications.
Have you been told about the side effects of this medication before it was started?
Do you have any kind of stress or worries? No
Did you have any stressful event before you started losing hair? No
Any chance you are pregnant (pregnancy can cause loss of hair)? No
When was your last menstrual period (menopause can cause loss of hair)?
Did you have any radiation therapy? – No
Have you been pulling your hair yourself for any reason (Trichotillomania)? No
Is there anything else you want to tell me? No
Are you worried about your appearance?

Examination
I need to examine your head and other parts of body to check hair loss anywhere else
Patient may or may not show a picture.
Alopecia areata Female pattern baldness Male pattern baldness
 Tinea capitis Trichotillomania After kidney transplant

Radiation induced Traction alopecia (cornrows, Wearing tight bands

pig tails) (Traction alopecia)

Diagnosis and management:

I suspect you are losing hair because of the medication tacrolimus what you are taking.
This is a known side effect of this medication.
Tacrolimus is a medication which suppresses the body immunity so that body does not
reject your transplanted kidney. Unfortunately, you need to take this medication whole of
life. However, sometimes reducing the dose of this medication can decrease the hair loss.
I will speak to my seniors and the specialist who has prescribed this medicine to you to
check whether we can reduce the dose.
Sometimes hair loss may stop on its own after sometime.
Sometimes stress of surgery also contribute to hair loss.
There are other things you can try if you are very concerned of your appearance – wear a
hat or wig.

1. Diet. Make sure you are consuming a diet rich in vitamins B and A. ...
2. Follow A Hair Care Regimen. A hair care regimen based on your hair type should be
followed to ensure healthy hair. ...
3. Avoid Using Heat-Inducing Styling Tools.

If you are very worried about your appearance, we can offer talking therapy/counselling
therapy.

Is that Okay if you ask you few other questions to see if you have any other side effects of
this medicine?
Do you have any problems passing urine, any yellowish discolouration of skin – it can
affect kidney and liver. You need to have regular blood tests to check your kidney and
liver function.
It can interact with many other medicines. Please check with us before you take any other
medicines including pain killers like NSAIDS.
St John’s wort and some other herbal preparations should be avoided.
You should avoid ‘live’ vaccines but most travel vaccines and the ‘flu jab are ok.
Avoid drinking grapefruit juice. Grapefruit and Grapefruit juice increase Tacrolimus blood levels
significantly leading to side effects like abdominal pain, confusion, decreased urination, dizziness, headache,
mood changes, nausea-vomiting, tremor, yellowing of skin or eyes, weakness, or other problems.
---------------------------
Biotin has gained commercial popularity for its claimed benefits on healthy hair and nail growth.
Despite its reputation, there is limited research to support the utility of biotin in healthy individuals.
Does tacrolimus interfere with my other medicines?
Tacrolimus can interact with other medicines. You should tell your
doctor which medicines you are taking before starting tacrolimus.
Other medicines which can cause problems with tacrolimus include:
 Some antifungal and antibiotic medications, e.g. fluconazole and
clarithromycin.
 Anti-epileptic medication, e.g. phenytoin and carbamazepine.
 Some blood pressure medications, e.g. diltiazem and verapamil.
 You should only take non-steroidal anti-inflammatory drug
(NSAIDs) on the advice of your GP or clinician.
 St John’s wort and some other herbal preparations should be
avoided.
 Avoid drinking grapefruit juice.
 Always check with your doctor or pharmacist first before starting
any new medication.
 You should avoid ‘live’ vaccines but most travel vaccines and the
‘flu jab are ok.
It is safe to drink alcohol in moderation while taking tacrolimus but you
are recommended to have alcohol free days without saving units up to
drink all in one go.

Can tacrolimus cause side effects?

All medicines can cause unwanted side effects. Side effects that can
occur with tacrolimus include:
 Stomach upsets, such as feeling sick or diarrhoea.
 Headache, tremor or high blood pressure.
 High blood sugar levels or unmask diabetes.
 Tacrolimus can affect your kidneys and liver, so you will need to
have regular blood tests to monitor the levels.
 Hair loss, rash.
 You are more likely to catch infections so avoid close contact with
people with severe active infections

4165 video not available

 Headache due to CO poisoning
18 yr old girl complains of headache for one month
With or without dizziness
Pain 4 out of 10
Not localized in one place
Started gradually
As soon as moved from home headache disappeared
Moved to a new home with her friends ( also complaining of same headache)
Heater or cooker
She does not open the windows (No ventilation)
Approach for headache ( Hx — SOCRATES - DD — CO)
Why do I have this headache?
Do I need to come to the hospital?
C Co habits or Co occupants (anyone with the same symptoms around you)
O Outdoors. Symptoms improve when outside the house
M Maintenance if there are fuel burning appliances and vents that is not properly fitted
A Alarm (do you have a carbon monoxide alarm in your house)
——Have you recently had heating or cooking appliances installed?
——Have you ever used the oven or gas stove for heating or cooking?
——have you had ventilation changes at the home recently? (For example, any new heaters fitted at
home?)
——Anyone affected with the same headache in your house?
——Any soot stains around the appliances or increased condensations?
——Do you do any work where you are exposed to more smoke or fumes or motor vehicle exhaust at
work?
——Do the symptoms improve when leaving the home?
Other symptoms:
Low exposure. (Dizziness- Flushing - Headache -Nausea - Vomiting. - Muscle pain - Personality
changes- Vertigo)
High exposure. (Confusion - LOC - MI - Respiratory failure - Movement problems)
MG:
Likely cause of the headache is Carbon monoxide exposure and most likely due to the new heater and
we suspect this, as the headache improved after moving from the home and same headache in the
house holder
Refer immediately to emergency
They will give you 100% oxygen
And they will measure the level of CO in your blood (carboxy Hb)
They will examine you (neurological examination) and do blood tests
How to prevent:
Do not use the suspected device (Heater etc)
Advice other people to go to the hospital
Contact local health protection team
CO Alarm
Open the windows
Check all the appliances
NB:
Levels of CO
Normal 1-3%
Smoker 10%
Toxic effect appear 15-20%
CO levels at 30% indicate severe exposure
—————————————————————————————————————
 4129

Video not available

Genital warts
15 years old girl - swelling in the private area
FY 2 in GP
Sexually active - not practiced safe sex -partner 33 (consensual) - since 6 months - just noticed the
swelling
ODPARA —- DD —- MAFTOSA — ICE — Effect
When did you notice this swelling?
What does the swelling look like?
How many swelling have you noticed?
How big are the swellings?
What is the color of the swelling?
Any bleeding?
Itchy? pain?
Burning sensation while passing urine?
Do you pass urine more than usual?
Sexually Hx
Are you sexually active?
Are you in a stable relationship?
Is your partner male or female?
Do you practice safe sex?
How old is your partner?
How did you meet ?
How long have you been together?
What type of sex do you practice?
How are things with your partner?
Has your partner ever forced you to have sexual intercourse?
Has he ever been abusive to you in any way? Verbally ? Physically? Or emotionally?
Your partner seem to be much older than you. Do you feel comfortable in your relationship?
Do you ever get concerned that he might be far older than you?
Have you ever thought that you are in wrong relationship?
Does your parents know about your relationship?
Does your parents know that you are sexually active?
Is there any particular reason why you have not told your parents?
Do you ever worry how your parents are going to react if they found about your relationship?
MAFTOSA
ICE
Is there anything worried you the most?
Examination:
Observation - Speculum - and mouth
Diagnosis: Genital warts
Common way of transmission is sexual intercourse - they are benign lesions and not cause any
symptoms
Management :
referral to GUM clinic ( are you comfortable with that? No test in the GP)
They will run some investigations and screening for sexually transmitted infections
NO treatment
30% of cases will disappear spontaneously
Topical creams or solutions (eg. Podophyllotoxin) applied twice per day for 3 consecutive days then
4 days no applications then repeat for maximum four times (4 weeks)
Follow up in 4-5 weeks
For your knowledge (other options: Ablation methods <Cryotherapy-Excision-Electrocautery>)
Advice : use condom - test partner for STI
Address the sexual abuse issue :
There is a big age difference between you and your partner
And he is a teacher has authority of you
Your partner hold a position of trust
This is abuse relation
This relation is not illegal relationship
I will take second opinion from my senior
I have a duty to involve social service and the local authority
At some point your partners will be informed
—---------------------------------------------------------------------------------------------------------

4165
Video not avaible

Genital Herpes:
26 years old lady
28 weeks pregnant
Rash in the genital area -Painful

Dr I am embarrassed
We are professional and we see many patients every day with similar problems and we are here to
help you
Will it affect my baby?
Is my husband cheating on me?
Hx:
Where is this rash?
When did it appear?
Is it single or multiple?
Rash Hx- PID - any ulcers
Urinary symptoms: Dysuria - Vaginal Urethral discharge?
Any flu like illness - fever? - runny nose?
Is it the first time to develop this rash?
Has your partner had cold sores before?
Sexual Hx:
.
.
.
Any new Partner?
How many partners have you had in the last 6 months?

Genital Herpes: viral STD infection

Refer to GUM clinic (are you comfortable to go for GUM clinic)
They will take swabs from the base of the lesion and will do screening for STI
Will my baby be affected?
This can affect your baby so you need to continue on medication till delivery
Prescribe Acyclovir 400 mg daily until deliver (before 28 weeks only for 5 days)
And we will refer to the obstetrician he may suggest to do C section to protect the baby from the
infection
Advice:
Clean the affected area with salt water to prevent secondary infection
Drink plenty of fluids
Numbing gel lidocaine
Avoid wearing tight clothes
Take adequate pain relief
Avoid sharing towels and flannels
Avoid practicing sex till lesion cleared

4130 Video not available

Depression for work stress:

You are Fy2 in GP
Hanah James
Complains of feeling pressure at work
Opening (Dr I cannot cope with the work)
Works as accountant
This started 6 months ago
Mood 4 out of 10
Cannot fall asleep till 2 am and wakes up at 5 am
Your husband says that your behaviour has changed
Made some mistakes but manager did not complain
Boss is very supportive
She used to go for exercise but now does not go
GRIPS —---
What job do you do?
How long have you been in this job?
When did you start feeling this?
Can you tell me what you mean by cannot cope?
Have you spoken to anyone at work?
Does this cause anxiety?
Have you experienced any palpitations, shortness of breath or feeling on edge?
How do you cope with this stress ? (Alcohol - smoking)
Core symptoms: (to diff between mild stress and depression)
1- In the last month have you been feeling hopeless or down?
2- Do you have a little interest or pleasure in doing things?
Sleep problems
Any weight change
Any fatigue
Problem with concentration
Feeling guilty
Any Suicidal thoughts ?
Effect
Relation
Are you able to do your day to day activity
Cooking
Take care of yourself
Do you have children?
MAFTOSA
ICE
Examination: (obs + thyroid)
Diagnosis: Moderate depression
MGT:
CBT
Medication
Blood test to rule out other causes (routine and TFT)
Talk with your manager
Talk to friends
Talk to your partner
Refer for couple therapy
Follow up in 2 weeks
Offer leaflets
Safety netting
Crisis card

4131 Video not available

Mild depression in young man
You are FY2 in GP
Insomnia for the last three months
Divorced 6 months ago
Go to bed 11 wake up 2 am
Feeling tired during the day
Mood 4 out of ten
Can manage day to day activity
Diagnosis: Mild depression
MGT talking therapy CBT
FU one week if 30 and less / two weeks if more than 30
Safety netting: Crisis card if you feel low or if you have an suicidal thoughts call this number

Advice:
Talk with family and friends
Play exercise
Hobbies
Stop alcohol and smoking
—-------------------------------------------------------------------------------------------------------

4132 Video not available

Back pain - Cauda Equina
70 year old man
In GP or A&E
Mechanical injury (was picking something from the floor)
Wets himself once
Not able to urinate
constipation
Hx of back pain
MAFTOSA
ICE
Examination:
Neurological reflexes all reduced and bilateral (reflexes - tone and sensation)
Abdominal ex: palpable bladder
Diagnosis :
Cauda equina 2ry to disc prolapse
MGT:
Blood test
Catheterization
Admit
Orthopaedic referral : (they may perform an operation to relieve the compression of the nerve)
MRI Spine
Mostly: L4-5 L5-S1

4133 Video not available

Ankylosing Spondylitis:
You are FY2 in GP
33 years old man with back pain for the last 6 months
Bus driver
Walking around not helping
Pain SOCRATES
MAFTOSA
ICE
Examination:
Spine examination (tenderness on the sacroiliac joint)
Schober test to check flexibility of your hip
Lower limb neurological examination
PR
Explanation: chronic inflammation of joint of the spine cause stiffness

MGT:
Xray on spine
Refer to rheumatologist Routine referral
Refer to physiotherapist
Blood test (Routine and Inflammatory) + HLA B27
NSAID: Ibuprofen
Advice : encourage exercise

4134 Video not available

Intertrigo:
You are FY2 in GP
35 year old woman with rash under the left breast then spread to the Rt also
Dr my bra is irritating me
Work as teacher
Embarrassing
Hx of RASH
DD
MAFTOSA
Effect of symptoms
Since when
When did this problem start?
Is it on one side or both?
Do you change our bra regularly?
Any change of material of bra recently?

Pain?
Itchy?
Discharge?
Where did this rash start?
Has this happened before ?
Is there any rash anywhere else?
Any new clothes? Any infection? Any type of allergy? Any fever? FLAWS?
MAFTOSA
ICE
JARS
Examination: Examine rash + BMI

Intertrigo which is skin inflammation caused by skin to skin rubbing commonly caused by fungal
infection
Sites: abdomen and breast
Medications:
Clotrimazole topical cream + Steroid cream to reduce the redness of the skin
Advice:
Wear loose fitting closes made of cotton material
Maintain good hygiene by wash the affected area with water daily and dry the area after washing
Avoid scratching affected skin to avoid spread of the lesions
Do not share towels
Wash clothes and bed lining
Wear loose fitting bra
Lose weight and calculate BMI
Leaflet and Safety netting

4135 Video not available

 Alopecia:
You are FY2 in GP
57 year old with concerns
Kidney transplant 5 months ago
In the last 2 months his hair start to fall
Dr my hair falling off
When did this start?
Is there any specific area ? or the whole head is affected?
How much hair is falling?
Has that happened before?
DD:
Any change in Diet ?
Tinea Capitis: Patchy hair loss
Traction alopecia
Family history of hair loss
Drug induces: Chemotherapy - Tacrolimus - TCA
MAFTOSA
What medication? Tacrolimus
Any stress in your life?
I will check my book
Examination:
It is medication used to avoid the body from rejecting the new kidney we cannot stop it
MGT:
Refer to the specialist
Advice:
Continue on medication
Use hat
Using cosmetic hair style
Use wigs
Offer leaflet

4136 Video not available

Bilateral itchy eyes: Allergic Conjunctivitis

You are FY2 in GP
30 year old presented with itchy eye, eye discharge and sticky , runny nose
On antihistamine
Started 2 days ago
Itchy eye
ODPARA
When did it start?
Is it in one eye or both?
Is it the first time?
Worse?
Better?
What do you do to relieve the symptoms?
Ask about allergens (pets - pollens - carpets)
DD:
Bacterial conjunctivitis ( discharge? - color of discharge? - Recent flu illness? - Redness of the eyes)
Acute Glaucoma (Eye pain - painful eyes - decrease in vision)
Keratitis (Eye pain - Reduced or blurred vision - Contact lenses - recent flu hx of previous ocular
herpes simplex)
Uveitis ( Eye pain - IBD - RA -Ankylosing spondylitis)
Foriegn body
Allergic conjunctivitis (Bilateral - discharge - hx of allergy)
MAFTOSA
ICE

Examination:
Visual acuity - Inspection - Fundoscopy
Diagnosis:
Allergic conjunctivitis -
Advice:
Avoid allergens (Pets - animal)
Wash hair before going to the bed
Avoid eye rubbing
Apply cold compress to the eye
Use artificial tears
Prescribe antihistamine
FU in one week
Offer leaflet

4137 Video not available

Bilateral eye pain: Keratitis
You are FY2 in GP practice
Bilateral eye pains
Sticky discharge in the morning
Yellowish discharge
Blurring in the vision
Started when she slept with contact lenses
Student

Hx:
Eye pain
One or both?
Any discharge?
Recent flu like symptoms?
Any foriegn body sensation?
Any hx of ocular herpes simplex?
Any nausea ?
Any vomiting?
Keratitis RF (sleeping or swimming with contact lenses)
Systemic
MAFTOSA
ICE
Effect

Examination:
Visual acuity - inspection - back chamber
Diagnosis: Keratitis
Bacterial keratitis : infection of the eye that affect cornea due to use of contact lenses
MGT:
Refer to ophthalmologist NOW Immediately
Do not start antibiotics (this wll be started by the ophthalmologist after take swabs)
Stop wearing contact lenses
Take the contact lenses with you we might need to find out the cause of infection (send it to lab)

4138 Video not available

Bulimia Nervosa:
You are FY2 in GP
16 year old with vomiting
(Telephone or video)
Vomiting for the last 8 months
She well tell you that she is doing it by myself
As i am fat
What is your BMI 22
How do you cause yourself to vomit?
Why do you make yourself vomit?
Do you know why your mom is concerned about you?
Since when you are vomiting? 8 months ago
ODPARA for vomiting
Eating habits ( can you tell me what you eat for your breakfast, lunch and dinner? )
History should include recurrent episodes for binge eating
Do you binge eating at times?
How often does that happen?
Do you make sure that no one sees you when binge eating?

At least once weekly for 3 months

Do you do anything to lose weight?
Do you exercise?
Do you use laxatives ? water tablet?
Do you have fear of gaining weight?
Do you have mood disturbance?
Have you ever felt guilty after eating?
ICE
MAFTOSA
Menstrual
Mood
Examination:
Observation - BMI - oral examination -abdominal - CVS
Diagnosis:
Bulimia nervosa this eating disorder when you feel that your weight in the higher side even it is
normal
Your BMI is 22 which is normal
MGT:
Arrange face to face appointment
Refer to eating disorder clinic or pediatrician
Refer to child and adolescent mental health team
Arrange follow up after 2 weeks
Advise to rinse the mouth after vomiting as acid will affect the mouth and teeth
4139 Video not available
Oral Candidiasis:
You are FY2 in GP
8 years - soreness of the mouth
Asthma on blue and orange inhalers
Blue inhaler: salbutamol
Orange inhaler: long acting and steroids
Why happened?
Can the child go to the school?
Hx:
Soreness of the mouth ODPARA
Any rash or ulcers in the mouth?
Any swallowing difficulties?
Is he able to eat and drink?
Does he pass urine?
Is he lethargic?
BPINDS
PAMGUU
Examination: picture

Diagnosis: this is a condition called oral thrush or candidiasis the cause is the orange inhaler because
it contain steroids
As we need to rinse the mouth with water after using the inhalers as particles stay in the mouth and
this cause one type of fungal infection called oral thrush
MGT:
Refer to the pediatrician to review the medication
Topical miconazole oral gel (if unsuitable we can offer nystatin suspension)

Advice:
Rinse the mouth after using the inhaler
Good dental and oral hygiene
Use spacer to avoid particle to stay on the mouth cavity
Good inhaler technique
Offer leaflet

4140 Video not available

Epilepsy follow up
28 years old come for annual review
On NA Valproate
6 years since diagnosis
After 3 years of seizures free → license back
About a month ago he stopped the medication
After week he had two fits again so restarted NA valproate again
How are you generally?
How have you been since the last visit?
Any seizure since the last visit?
What about your medications?
Are you taking your medications regularly?
Triggers :
Do you know about the triggers
(Driving, Bicycling. Mountain climbing, swimming)
Explain:
You have to inform DVLA again, Unfortunately they may stop the license again
For a period of time
This is risky for yourself and anyone in the road
We may inform DVLA
Advice :
Avoid flashing lights, take shower instead of bath, avoid alcohol, swimming
Offer leaflet to give for the people who you are living with to know how to deal with the attack of
convulsion
If fits continued more than 5 min they need to call the ambulance

4141 Video not available

Vaginal Discharge:
ONSET
Duration
Color
Odour
Consistency
Bacterial Vaginosis(Gardnerella): white grey -fishy foully - thin (PH= higher than 4.5)
Candidiasis: white - no smell - thick - itchiness (PH= less than 4.5)
Trichomoniasis: Green / yellow frothy discharge - Itchiness and soreness - Dysuria (PH= higher than
4.5)
PID: Discharge and abdominal pain for long time
RF:
Vaginal douching - bubble bath - avoid using shampoo in bath
IUCD
EX: abdominal examination + PV + speculum + test of PH of the vagina

Investigation: High vaginal swab - Urine dipstick

MGT: not STI
BV: Metronidazole 400 mg twice day for 7 days ( if no improvement refer to remove IUCD)
Candidiasis: Fluconazole tablet 150 mg single (if not resolved in two weeks you have to come back)
if CI give vaginal
Trichomonas: Metronidazole
There is a case only white discharge without itchiness ( so we need high vaginal swab)

4142 Video not availabe

Social media:
James is one of other FY1 Is complaining about another FY1 posting on social media about patients,
the hospital and staff
When did you find out about this?
Has he written about one patient or many?
What kind of things has he written about the patient?
Any photos of the patients?
Is he using the names of the patients?
What about the colleagues?
Does he post anything about hospital or department?
1- Confidentiality
2- Reputation about the hospital and profession
3- Commitment to profession
You need to talk with him he might do not know the effect of this posts
It is our duty to maintain the public confidence
Plan:
Talk to the FY1 colleague
Advise him about GMC medical practice
Advise him about to remove the comments
Not to write further about any patient or colleagues
Advise him to change his private setting on Twitter (to be for only friends)

4143 Video not available

DKA in 16 year old

Question
You are the FY2 in Accidents and Emergency.
A 16 year old girl Amie has been sent by her mother due to some concerns.
Talk to her and address her concerns.

D- Hello Ms. Amie…. (Introduction)

How can I help you today?
P- I am fine. My mother has actually sent me to the hospital.
D- Well, Amie that’s so nice that you have such a caring mother. Is there any particular
reason that was concerning her? P-I am not sure.
D- How are you doing now Amie? P- I am fine
D-Do you have any symptoms at all? P- I think I am alright
D-Any fever? P-no Any rash? P-no D-Any headache? P-no
D-Any dizziness/confusion ? P-no
D- Any pain anywhere in your body? P-no D-Any nausea/vomiting? P-no
D-Any cough? P-no. D-Any shortness of breath? P-no D-Any palpitations? P-no
D- How is your urine? P-It is alright
Any burning? P-no /increased frequency? P- yes I use the loo more often these days.
(POLYURIA)
D-Do you drink more water / feel thirsty? P-yes (POLYDIPSIA)
D-Is your diet okay? P- yes, but I feel more hungry these days and eat more often.
(POLYPHAGIA)
D-How is your stools? P-It is alright
D-Any tiredness? P-Sometimes I am very lethargic.
D-How is your mood? P-It is alright
D-Any recent illness? P-no
D-Do you have any tingling /numbness? P-no (Diabetic neuropathy)
D-Is your vision alright? P-no (Diabetic Retinopathy)
Menstrual history
D-Are your periods regular? P-yes
D -When was your last period? P- 2 weeks ago
MAFTOSA
D- Are you previously diagnosed with any medical conditions/long term conditions? P-no
D- Have been diagnosed with Diabetes? P - No
D-Are you on any medications including over the counter supplements or steroids? P-no
D-Any allergy to food or medications? P-no
D-Anyone in the family with any medical or serious illness including Diabetes? P-no
D-Are you a student? P-yes
D-How is everything with your studies? P-fine
D -Any stress or worries? P - I am stressed because of the exam coming by.
D-How is your diet to be? P-….
D-Do you exercise? P-no
D-Is there anything else you want to tell me? P-no
D-Thank you for answering all my questions.
Examination
D-I would now like to examine you if that’s alright? P-yes
I would like to first check your vitals including your PR, BP, RR, SpO2, Temperature.
I would also do an examination of your tummy, your chest and your palms if that’s alright?
I would also be doing some bloods like a random blood sugar, CBC, RFT, LFT, Infection
and Inflammatory markers, Serum Electrolytes, CXR, ABG.
And also a Urine dipstick if that’s alright?
Investigations given:
CBG-22mmol/l, Urine dipstick- Glucose - +++, Ketones +++ Albumin ++
ABG-in process ( may show metabolic acidosis)
Management
D-Do you have any idea what might be going on? P-no
D-Well you have a condition called Diabetic Keto Acidosis. Have you heard about it ?P-no
D-Well, I am sorry to say that you are having early onset Diabetes most likely Type 1.
One of the complications of very high blood sugars is Diabetic keto acidosis which means
that a harmful chemical substances called Ketones build up in your body and your blood
becomes acidic. Do you follow me? P-Yes
P-Why does it happen?
D-Type 1 Diabetes occurs when organs called Pancreas located in our tummy doesn’t
produce enough Insulin which controls blood glucose. It can be due to a number of factors
including a family history, exposure to viruses and other environmental factors. DKA
happens sometimes if the sugar becomes very high which can happen if you have infection
or if you have stress. You told me you are stressed about your exam. May the stress
triggered this condition.
P-What happens now?
D- Diabetic Keto Acidosis can sometimes be life threatening so we need to admit you first.
Would you like me to call your mother or someone for you? P-No I will do that.
D- In this condition you have severe dehydration. We will be rehydrating you by giving
you fluids through your veins, we would decrease the blood sugars by giving you a
medicine called Insulin through your veins and constantly monitoring you and also check
for any source of infection.
Hopefully you will get better in about 3 to 4 days. Do you follow me so far? - P- Yes.
D -Do you have any questions? P – Will be fine after the treatment?
D -What we are treating now is for DKA and you can recover from this condition in the
next few days. However, as I mentioned previously this is a complication of another
condition which is diabetes. Unfortunately, diabetes is a lifelong condition because there
 is no cure. It can cause lot of complications like it can affect your eyes, heart, kidneys and
nerves. You may need to take treatment like Insulin for the whole of life to keep sugar
under control. Also you need to make life style modification especially on your diet and
exercise. You have eat at regular timings, keep some sweets with you all the time to eat in
case if you develop low sugar. You will need to wear diabetes bracelet all the time. If you
have to start driving in the future, you need to inform the DVLA.
I will be informing my seniors of my plan and see if they would have anything to add on. Is
that okay?
I will be informing about you to my seniors and we will refer you to diabetic specialist
(Endocrinologist). They will assess you further and explain in detail of managing your
diabetes. P-fine
D-I will be here in case you need anything or have any doubts.
If you are feeling uneasy, sick, having severe tummy pain, feeling dizzy or anything at all
please press the buzzer and one of us will be with you shortly.
P-Okay
D-Okay Amie see you shortly. Hope you feel better soon.

4144 Video not available

FIT NOTE – CHICKENPOX

Question
You are the FY2 in GP Clinic.
Mrs. Lilly Martin has some concerns.
Talk to her and address her concerns.

D- Hello Mrs. Lilly Martin…. (Introduction)

Telephonic GRIPS
D- How can I help you?
M (Mother)-Hello I am here to get a fit note as my son is having chickenpox.
D-Can you please confirm your son’s name and age. M – My son’s name Danny. He is 3
years old.
D-Before we can proceed further on your fit note can I actually ask you a few questions so
that I can have a background of what is going on? M – Sure
D- How is Danny doing now? M- He is little better doctor.
D-So when was Danny diagnosed to have chickenpox? M- P-2 days ago
D- Is he having any fever /rash/Itching/Bleeding/Pain? Since when?
D-Any shyness to light? M- no
D-Is he eating well, peeing, pooing well/playful?
P- yeah doctor I am taking care of all that I am here for my fit note.
D-Sure I will address that. Just to let you know that in case you need any help we are here
for you.
D -Have you ever had chickenpox? M- yes when I was a kid.
D-Can you briefly describe that episode for me how many days it lasted /what
symptoms/any other problem? M-…..
D-Okay. Do you have any symptoms now? M-No doctor
M-But I have been home for the last week since I just had a flu and recovered.
D-How are you doing now?
M-I am fine now, all better to take care of Danny.
D-Any fever/rash/itching? M-no
D-Any aches and pains anywhere in your body? M-no
D-That’s great to hear.
D- Have you ever been vaccinated against chickenpox? M-yes/no
D-Was Danny or you exposed to anyone who is pregnant, babies or elderly? (contact)
M-No doctor we have been home all the time.
D-That’s really good. Just that exposure to someone who is having decreased immunity as
them might have a serious infection.
M-okay doctor. I will keep that in mind
D-Does Danny have any other medical conditions? M-no
D-Was everything alright during Danny’s birth? M-yes all normal
D-Is he up to date with vaccination? M-yes
D-Any problem with red book/development? M-yes
D-Does Danny have any other siblings? M-no
Questions for low immunity:
D-Do you have any medical conditions including DM? M-no
D-Do you take any medications including immunosuppressant medications? M-no
D-Anyone in the family with any medical or serious illness? M-no
D – Are pregnant by any chance? M– No
D-Apart from Danny and you, does anyone else live with you?
M-No my partner has gone on a work trip.
D-What is your job? M-I work as a professor in the University.
D-How is everything at work?
M-Good. Just because of Danny’s chickenpox I need a fit note.
D-Definitely. How long had you been off due to your previous flu? M-1 week.
D-Did you go back to work after that or was Danny chickenpox immediately following?
M-No I didn’t go back.
D-Do you know that people can self-certify for any illness up to 7 days?
M-Yes doctor but I am over my seven days.
D- Sure I can understand that.
D -When would your partner be back? M-not anytime soon doctor.
D-Would it be possible for you to come back earlier to look after Danny? M-no
D-Is there anyone else who can take care of Danny apart from you? M-no doctor
D-Any family members/carers you can arrange? M-no doctor.
D-Thank you for answering all my questions.
M-Will I get chicken pox?
D-Well from my assessment since you have had chickenpox in your childhood you should
have lifelong immunity against chickenpox.
If you do develop any symptoms, please do not hesitate to contact us. M-Sure.
D-Well, I can see that you are the only person available to take care of your son. Have you
spoken to your employer for some time off due to the same reason?
M-Yes doctor and they wanted me to provide a FIT note since it has been more than 7days.
D-Do you have any days of annual leave left?
M-No doctor I have exhausted all of them.
D-Does your employer have any parental leave allowance/dependants allowance in your
contract? M-no doctor.
D-Well in that case I can definitely write a FIT note for you to take once your back at
work. M-Thank you so much doctor.
P-Will I transmit chickenpox to the children at university?
D-Since chickenpox usually transmits 2 days before to 5 days after the start of the rash and
you would be home till then you wouldn’t be transmitting the illness to your students do
 not worry. M-Great.
D-Make sure Danny stays hydrated and cool. Keep Danny home till 5 days after his rashes
or till his lesions have completely crusted.
I will print out some reading material for you on chickenpox it will help you with Danny as
well as make you understand the condition better.
M-That’s lovely doctor. Thank you so much.

Fill up the sick note (Fit note) if it is kept on the table.

When not to give sick (fit) note

1. If she can get someone to look after the child
2. If she has gone back to work after taking 7 days of self-certified sick leave – then she is
entitled to take 7 more days of sick leave by self-certifying
[If the mother has gone back to work after 7 days of self-certified sick leave even for one
day then she can take sick leave again for another 7 days by self-certifying].

4145 Video not available

Teaching Cancer Referral Pathway

Question
You are the FY2 in GP.
A final year medical student Adam wants to learn about cancer referral pathway.

D- Hello Adam (pause) …. (Introduction – use your first name)

S- Hello.
D- So how’s final year of med school treating you?
S- …… (Build Rapport – future plans, sports, holidays, weather, pets-)
D- So Adam, I was told that you wanted to learn about cancer referral pathway? S- Yes…
D- So just to know is there any particular reason you want to learn about the pathway?
S- Yeah, so I can know when and whom to refer and how the system works.
D- That’s great. I really appreciate you coming and approaching to learn stuff.
I will walk you through it. At any point if you have any doubts you can stop me and I can
explain better. S-Perfect.
D- So as the name suggests the cancer referral pathway is for suspected cancers.
-A Cancer Pathway is the patient's journey from the initial suspicion of cancer through
Clinical Investigations, diagnosis and treatment.
Patients should be referred to the specialist team within 2 weeks from the time of suspicion
of the cancer. If the patients referred within 2 weeks that is called urgent referral. Some
of the cancers may need to be referred within the two days.
Do you have any idea as to why we refer urgently?
S-Yes so they can be diagnosed early.
D- Yes, your absolutely right. Cancer that is diagnosed early can be treated more
successfully which increases the survival rate.
Also the cancer referral pathway has some benefits for the doctors – because there is a
written clear guidance about for which symptoms when the patients should be referred, it is
easier for the doctors to follow the guidelines.
D- A GP doctor or a nurse can refer the patient with suspected cancer who will then be
seen by a specialist (Ex-Urologist for prostate cancer, Gynaecologist for cervical or ovarian
cancer etc) anytime within the next 2 weeks. Do you follow me?
S-Yes. So in those 2 weeks can something happen?
D- Sometimes the patient can be called for a test/investigation before being seen by a
doctor. GPs themselves can do some investigations very urgently (within 48 hours) what is
called - direct access investigations – eg; chest X ray for lung cancer, Full Blood count
for suspected Leukemia, MRI if brain cancer is suspected, OGD for suspected oesophageal
cancer.
S-Can you tell me some common symptoms where we can do urgent referral.
D-Certainly. That is an amazing question.
So some of the most common symptoms which might arise a cancer suspicion can be
*cough >3 weeks/hoarseness (lung cancer, laryngeal cancer)
*lump/swelling (lymphomas)
*blood in urine/stool (urinary bladder or kidney cancer)
*altered bowel habits (bowel cancer)
*losing a lot of weight without dieting/exercise
*unexplained fever, loss of appetite
*new/changing mole (Melanoma)
*constant heartburn or indigestion particularly if painful (stomach cancer)
*feeling bloated all the time
*bleeding in between periods/after sex/after menopause (cervical cancer)

*investigations like high/low blood cell, high tumour markers, abnormal immune markers,
etc.
D- Can you repeat a few?
S- ……So what is usually done in that 2weeks appointment.
D-The doctor will again do a thorough assessment (history / examination) of the patient
and request the required investigation (if not already done) and take it further.
S-So when will the results be available?
D- Usually the investigations should to be done and the patient should be told whether
he/she has cancer or not within 28 days from the referral time.
S-That’s good. So what if they actually have cancer.
D- In that unfortunate situation the case will be dealt with by a multidisciplinary team of
speciality doctors, oncologist, radiotherapist, Macmillan nurses and a treatment plan will
be created. The patient will be involved in any treatment decision and advised on any
queries and further support given.
S-It is amazing how this pathway works. So then when will treatment start?
D-The treatment should commence at the earliest preferably within 62 days of initial
referral.
S-Well thank you so much.
D- Most of the people (9 in 10 people) referred will not have cancer. But we do all these to
pick up those rare cases and to diagnose if any cancer at the earliest. S-Got it.
D-I hope you could learn and understand something from today’s session. I also wanted to
let you know that you could always approach me if you have any doubts and I would be
happy to explain. S-Sure. It was great have this conversation.
D-Same here. See you later.

How long should you keep your child off school

Yes Until
Chickenpox at least 5 days from the onset of the rash and until all blisters
have crusted over
Diarrhoea and Vomiting 48 hours after their last episode
Cold and flu-like illness they no longer have a high temperature and feel well enough to
(including COVID-19) attend. Follow the national guidance if they’ve tested positive
for COVID-19
Impetigo their sores have crusted and healed, or 48 hours after they
started antibiotics
Measles 4 days after the rash first appeared
Mumps 5 days after the swelling started
Scabies they’ve had their first treatment
Scarlet fever 24 hours after they started taking antibiotics
Whooping cough 48 hours after they started taking antibiotics

No But make sure you let their school or nursery know about
Hand, foot and mouth Glandular fever
Head lice Tonsillitis
Threadworms Slapped cheek
4146 Video not available

Molluscum contagiosum (tel)

Question
You are in the GP clinic.
Father is concerned about his 2year old son having rash.
Talk to him and address his concerns.

How can I help you? F (Father) - My son has some rashes in his arm pit.
Can you please confirm your son’s name and age? F – He is John and he is 2 years old.
D – Since when did you notice it? F – since about a week.
D- Any Fever, pain, itching, Discharge, bleeding? F – No
(R/O – chicken pox, Measles, Mums)
D – Has he got rash anywhere else? F – No
D – Has he got cough, chest pain? F – No
D- Any problem in the wee or poo? F – No
D _ Is he eating or sleeping well? F- Yes
D – Is he well otherwise? F - Yes Is he playful? F -Yes
Anyone else who is in close contact with him has similar lesions? F – No
Has he had any skin illness previously like chicken pox, measles? F -No
Any insect bite you know of (D/D)? F -No

BIRD - Normal
Has been diagnosed with any medical conditions previously? F -No
Is he known to have any allergies (D/D)? F -No
Has he got any other siblings? F -Yes /No Are they are well? F -Yes/No
Any of his family members – like you or his mom or siblings diagnosed with any medical
conditions? No

Examination
I need to check his vital signs like Pulse, BP, temperature.
I need to have a look at his skin lesions- do you have any pictures of that? Yes

Diagnosis
This is a condition what we call as Molluscum contagiosum. This is a virus type of bug
infection. The virus causes the rash after it enters a small break in the skin. Bumps usually
appear 2–6 weeks after that.
How did he get it?

The molluscum virus spreads easily from skin touching skin that has bumps. Kids also can
get it by touching things that have the virus on them, such as toys, clothing, towels, and
bedding.

[Sexually active teens and adults with bumps in the groin or inner thighs can spread them
to partners].

How do you treat it?

Most of the time, molluscum clears up on its own without treatment.

Each bump goes away in about 2–3 months. New bumps can appear as old ones go away,
so it can take 6-12 months (and sometimes longer) for molluscum to fully go away.

Sometimes, we can remove the bumps or help them go away more quickly by:

 Freeze the bumps off.

 Scrape or cut the bumps off.
 Put a chemical on the bumps to make the body fight them away faster.
 Put medicine on the bumps or give medicine to swallow.

However, we don't recommend these treatments for kids. That's because they can be
painful and burn, blister, stain, or scar the skin.

Is it a serious problem? - No it does not cause any serious problem. The rash usually
doesn't cause long-term problems or leave scars. Often, the best way to handle it is to be
patient, as hard as that might be.

Can he go to nursery (school) ?

Kids with molluscum can still go to daycare, school, and sports. To prevent the spread of
molluscum to other places on their body and to other people, they should:

 Wash their hands well and often with soap and water.
 Cover the bumps with clothing or a bandage.
 Cover the bumps with a watertight bandage before swimming or doing activities
with close contact (like wrestling) or shared equipment (like gymnastics).
 Not share towels or toys or pool toys.
 Not touch, scratch, or rub the bumps.
 Not shave over areas that have bumps.

How Can Parents Help?

To avoid molluscum and other skin infections, have your kids follow these tips:

 Wash hands well and often with soap and water.

  Do not share towels or clothing.
 Do not share kickboards and other water toys

Who Gets Molluscum?

Molluscum most often happens in healthy kids between 1 and 12 years old. But it also
happens in:
 athletes who have close contact, such as wrestlers, or athletes who share equipment,
such as gymnasts
 people with health problems treated with long-term steroid medicine use

4147 Video not availble

Head lice
Question
You are in the GP clinic
Mother concerned about her 6year old child.
Talk to her and address her concerns.
D -How can I help you? M -My child has head lice.
D - Can you please confirm the name and age of your child? M -Sarah 6 years old.
D -Thank you. Can you please tell me in detail what is the problem?
M- My child has head lice since about 3 weeks now. I tried all types of shampoo but it is
not going.
D – How do you know it is head lice? I saw that on her head
D- Does she complain of any pain?
D –Does she keep scratching the head (head lice can be itchy)? - Yes
D - Anyone else has similar problem at home or school who is close contact with your
child?
D -What type of shampoo did you try? I used Dimethicone, which I got from the
pharmacy.

Child
Apply once weekly for 2 doses, rub into dry hair and scalp,
allow to dry naturally, shampoo after minimum 8 hours (or
overnight).

If you use this as a lice treatment, it suffocates them

immediately. Obviously you have to comb out the eggs etc,
and after 10 days (gives the eggs you may have missed time
to hatch, but they aren’t old enough to lay more eggs) do
another dimethicone pour on your scalp and you’re good!!

Step by step for treating head lice with 4 percent (4%) dimethicone lotion
 put the lotion on to dry hair
 work it in around the head and cover the hair right to the ends
 use enough lotion to completely moisten the hair and scalp
 comb the hair with an ordinary comb to make sure the lotion covers all the hair
evenly
 leave the lotion to dry naturally
  wait at least 8 hours before washing the hair with your normal shampoo
 there's no need to cover the hair with a wrap
 head lice can't move within a minute of being covered with 4 percent (4%)
dimethicone lotion
 you can use a fine-tooth head lice comb to remove remaining eggs after treatment
and any dead lice which were not washed out - this step is not essential
 repeat in 7 days

D -Did you use it as per the instructions written on the pack?

D -How long this problem going on? 2 weeks
D -How many times did you use this shampoo? (Supposed to be used twice at least one
week apart.
D – Did you try wet combing?
D -Any sores around the head, neck or shoulder areas (infected skin due to scratching)

Management
First of all, you need to make sure that it is head lice and nothing else is causing your child
to scratch head.
Things often mistaken for nits include:
 Dandruff
 Residue from hair products
 Beads of dead hair tissue on a hair shaft
 Scabs, dirt or other debris
 Other small insects found in the hair

There are lot of pictures of head lice on the internet you can check how it looks like.
Head lice are tiny wingless insects. They live among human hairs and feed on blood from
the scalp.

Head lice are a common problem, especially for kids. They spread easily from person to
person, and sometimes are tough to get rid of.

There are many reasons why the treatment with Dimethicone may not work.

1. No medicine is 100% effective.

2. If it is not used as per the instructions. - So make sure you use it as per the
instructions.
3. If it is not repeated again after about a week, because the eggs hatch in about a
week time. – I advise you to try again using it twice with one week gap.
4. If your child is in close contact with someone else who has head lice because it can
spread from one person to other person through head to head contact. It takes a
mere 30 seconds for a single louse to transfer from one scalp to another.
They can remain alive for 2 days outside the human body.
– Make sure your child is not in contact with other children who has head lice. If
that is not possible, advise your child to avoid head to head contact with other
children at least for the next 2 to 3 weeks.

5. If your child is sharing clothing, bed linens, combs, brushes, and hats with others
who has head lice. Make sure your child does not share these things with others.

6. If the clothing – not washed in very hot water to kill the head lice. – Wash all the
clothing in very hot water.
7. If the old combs or hats not thrown away after the treatment. – Throw away all the
old combs or hats.
8. It is better to do wet combing also along with using Dimethicone. There are special
combs available to remove the head lice.
Nit comb method

Follow the steps below:

1. Cover the infected hair in conditioner to loosen the lice and make combing easier.
2. Start pulling the comb from the roots all the way to the tips of the hair.
3. After each stroke, check the comb and clean it on a tissue to see if there are any lice
on it.
4. Repeat this over a period of at least 30 minutes.
5. Do the same process four more times over the following two weeks to ensure all
lice (including newly hatched ones) are removed.

You can watch some youtube videos about how to do this.

[Youtube: - https://www.youtube.com/watch?v=YXVYlDB7pAg]

Follow up: If nothing works please do come back and we will see what else we can do.

Safety Netting; If there are any signs of skin infection (swelling, redness, pus discharge)
please bring your child.

Are Head Lice Contagious?

Head lice spread quickly from person to person, especially in group settings like schools,
childcare centers, slumber parties, sports activities, and camps.
They can't fly or jump, but they have claws that let them crawl and cling to hair. They
spread through head-to-head contact, and sharing clothing, bed linens, combs, brushes, and
hats.
Can she attend school?
She can attend the school. While at school, she should avoid head-to-head contact with
other kids.
Can you get head lice from pets?
Pets can't catch head lice and pass them on to people or the other way around.

Can We Prevent Head Lice?

To get rid of head lice and their eggs, and to help prevent them from coming back:
 Wash all bed linens, stuffed animals, and clothing used during the 2 days before
treatment (any lice that fell off before that will not be alive). Wash in very hot
water (130°F [54.4°C]), then put them in the hot cycle of the dryer for at least 20
 minutes.
 Dry clean items that can't be washed. Or put them in airtight bags for 2 weeks.
 Vacuum carpets and any upholstered furniture (in your home or car), and throw
away the vacuum cleaner bag.
 Soak hair-care items like combs, barrettes, hair ties or bands, headbands, and
brushes in hot water or throw them away. Tell kids not to share these items.
 Because lice easily pass from person to person in the same house, check all family
members. Treat everyone who has lice so they won't pass it back and forth.
 Tell kids to try to avoid head-to-head contact at school (in gym, on the playground,
or during sports) and while playing at home with other children.
 Every 3 or 4 days, check kids who had close contact with a person who has lice.
Then, treat any who have lice or nits close to the scalp.

There's no need to buy electronic combs that claim to kill lice or make nits easier to
remove. No studies have been done to back up these claims. You also don't need to buy
special vinegar solutions to apply to the scalp before picking nits. Water and conditioner
works fine.
Though petroleum jelly, mayonnaise, or olive oil are sometimes used to try to suffocate
head lice, these treatments may not work. If medicine doesn't work and you want to try
these methods, talk to your doctor first.
A few important things to NOT do: Don't use a hairdryer after applying scalp
treatments. Some treatments for lice use flammable ingredients and can catch on
fire. Don't use pesticide sprays or hire a pest control company to try to get rid of the lice;
these can be harmful. Don't use essential oils (such as ylang ylang oil or tea tree oil) to
treat lice on the scalp. They can cause allergic skin reactions and aren't approved by the
U.S. Food and Drug Administration (FDA). Don't ever use highly flammable chemicals
such as gasoline or kerosene on anyone.

4149 Video not available

Gout Tophi – Hand swelling

Question
60year old woman came to GP
Swelling in the both hands for past 5years
Assess and manage the patient.

GRIPS
How can I help you? My fingers are swollen.
Since when? Last five years.
Did you see doctors for this before? I went to the Wellman clinic. Nurse told me to see the doctor
for that.
Any pain? No Any stiffness? No
Are they red colour? No Any fever (septic arthritis)? No
Did you have any injuries? No
Are all the fingers swollen? What about other hand?
Do you have any swelling anywhere else? Like feet, other joints?

Have been diagnosed with any medical condition? Yes, Gout and high blood pressure
When was high blood pressure diagnosed? More than 10 years ago.
Are you taking medicine for high blood pressure? Yes, Amlodipine
Have been taking any other medication before amlodipine? Yes, Bendroflumethiazide but doctor
changed it to Amlodipine.
Why? Because I developed gout
When did you develop gout? 5 years ago.
Are you taking any medication for Gout? I was taking Colchicine but I stopped because I
developed reaction to that.
Did you stop taking the medicine on your own or did the doctor advise you to stop it?
Have been prescribed any other medicines for gout (allopurinol or probenecid)
Are you taking any other medication for Gout now? No
Did you have gout attacks (painful fingers)

Rest of the history similar to the other station of Gout

Rule out - Rheumatoid arthritis (morning stiffness), septic ( severe pain, fever), osteoarthritis
( other big joints involved – pain worse in the evening)

Previous heart disease, DM, Kidney disease (Risk factors). Kidney stones ( complication of gout)
Family history of gout?
Diet? - Red meat, sea food, beans
Alcohol? - Yes, beer
Sugary drinks?
Exercise? - No
Overweight?
Stress?
Loin to groin pain (kidney stones)?

Does it affect your life in anyway (daily activities, job, depression)

Examination
Shows picture of the hand

Investigation: Blood test – uric acid may be increased.

Diagnosis
These swellings of your fingers are due to Gout. This happens when the Gout last for long time
(chronic gout)– many years. This problem does happen to some people with gout.

Do you know what is gout?

Explain as in the previous station of gout.

Explain that in chronic gout - where urate large crystals deposits in

the joints and produce thick nodules on the fingers, hands, elbows called tophi.

We will refer you to Rheumatologist who are the specialist to treat this condition.
They may prescribe medicines Allopurinol which will help limit the amount of uric acid your body
make or Probenecid which will help improve your kidneys' ability to remove uric acid from your
 body, but it should be started after several weeks of an acute attack.

Sometimes you can get attacks of gout where you can get sudden pain over the fingers.
If it happens we will prescribe NSAIDS/ Naproxen/ Steroids.
Other advice same as previous station:
Diet (refer to dietician), alcohol, exercise, stress, Take medicines properly always as prescribed.
Don’t stop on your own.
Drink plenty of fluid.
Gout society

4148 Video not available

Gout - Big toe

Differential diagnosis for Gout

 Bursitis, tenosynovitis, cellulitis

 Haemochromatosis. - joint pain, and possibly joint swelling. This occurs most
commonly in the joints of the fingers and hands. The wrists, elbows, hips, knees,
ankles and joints in the feet can also be affected.
 Non-urate crystal-induced arthropathy, such as pseudogout.
 Osteoarthritis – pain worse by the end of the day.
 Psoriatic arthritis – Any skin lesions
 Reactive arthritis – soreness in the eye (uveitis), burning micturition (Urithritis)
 Rheumatoid arthritis. (small joints of toes and fingers can be affected.
 Septic arthritis:
o Septic arthritis must be considered in any person who is systemically unwell
(with or without a temperature) and an acutely painful, hot, swollen joint. It is
important to diagnose septic arthritis promptly, as late recognition can be fatal. If
suspected, refer for emergency joint aspiration and culture.
 Trauma.
 Bunions - Persistent or intermittent pain in the metatarsophalangeal joint is a symptom
of bunions. Likewise, an elevated bump on the outside of the base of your big toe,
calluses (or corns), and stiffness result from bunions. When not managed early, it can
also lead to deformity and itchy swelling.
 Gout - While bunion pain comes and goes, gout pain is localized. Also, the pain is often
intense and most common at night. However, its effect is usually widespread
systemically, meaning pain may not be restricted to the toes. It is also associated with
the classic signs of inflammation like swelling around the joint, redness, tenderness, and
warmth. Lastly, it also causes stiffness in the metatarsophalangeal joint.

What is the difference between pseudogout and gout? Pseudogout and gout are both types of
arthritis, and they're both caused by the accumulation of crystals in the joints. While pseudogout
is caused by calcium pyrophosphate crystals, gout is caused by urate (uric acid) crystals.

Triggers for Gout

 Food and drinks Drugs Others
Purine-rich foods Aspirin Dehydration
Red meat Diuretic drugs include: Arsenic
Sea food  chlorothiazide This chemical is found in
Sugary beverages  chlorthalidone some pesticides and
such as:  hydrochlorothiazide fertilizers.
 soda  indapamide Diabetes and prediabetes
 sugary-flavored drinks  metolazone
 orange juice  spironolactone Injury and inflammation
 energy drinks Other medications may also Obesity
 fruit juice from trigger symptoms: Other factors
concentrate  ACE inhibitors Other factors can cause
 freshly squeezed fruit  beta blockers your uric levels to spike,
juice  angiotensin II receptor leading to a gout attack:
 sweetened lemonade blockers  stress
 sweetened ice tea  cyclosporine  infections
 chemotherapy drugs  sudden illness
Cytotoxics  hospitalization
Ethambutol  surgery
 extreme weather
changes
Alcohol
When you drink alcohol, your kidneys must work to get rid of the alcohol rather than uric
acid. This may cause uric acid to build up in the body, triggering gout.
Some types of alcohol — such as beer — also contain purines. If you’re prone to gout, avoid
all types of alcoholic beverages including:
 beer
 wine
 cider
 liquor

Question
You are in the GP clinic.
40year man presents with swelling on the foot.
History and management.

GRIPS
How can I help you? I have a swelling on my foot.
Anything more you can tell me about it? It is there for about 2 months.
Where exactly on your foot? Near the base of my big toe.
Do you know how did it start? On its own.
Did you have any injury? No
Any change in the size since it started? Yes, it is slowly becoming bigger.

Do you have any other symptoms other than the swelling on the foot? Like what?
Any pain? Yes, slightly painful.
Since when it has become painful?
Is the pain worse in the morning (rheumatoid arthritis) or evening (osteo arthritis), night (pain
worse at night in gout) or same throughout the day?
Is the skin red over the swelling? Yes
Do you have any fever (cellulitis, septic arthritis)? No

Do you have any swelling anywhere else? No

Do you have similar swelling on the other big toe? No
Like in your toes, knees, fingers, Wrists, elbows? No
(Small joints of toes and fingers involved in Rheumatoid arthritis, Big joints in osteo-arthritis).
Any itchy skin lesions (Psoriatic arthritis)? – No
Loin pain, loin to groin pain (Kidney stones – complication of gout)?

PMHx -Have been diagnosed with medical conditions? - Yes HTN and Hay fever.
Do you have HTN, diabetes, Heart problems or kidney disease (risk factors)
Are you taking any medications? – Bendroflumethiazide(trigger) for HTN and anti-histaminic
for hay fever.
Any recent surgery (risk factor)

Are you allergic to any medicines?

Any of your family members have similar problems or diagnosed with gout (Risk factor)
Do you eat lot of red meat or sea food (trigger)? Yes
Do you drink lot of sugary drinks (like fruit juice, soda, sweetened ice tea)
(triggers)?
Do you drink alcohol (Trigger)? Yes
What type of alcohol do you drink? - Beer, Wine (Triggers)
Do you do exercise ( no exercise – risk factor)?
What do you think of your body weight – do you think normal or over weight (trigger)?
Do you have any kind of stress? [If yes what kind of stress (trigger)?
Is there anything else you want to tell me?

Examination (Rule out septic arthritis)

I need to check your vitals (pulse, BP, temperature (septic arthritis)).
I need to examine your both feet and other joints
Pt shows picture

Gout Gout Vs Bunion

Gout Bunion
 Gout tophi on pinna Tophi on fingers

Diagnosis:
Dr- Do you have any idea what is causing you condition? P - No
D - You seem to have a condition what we call as Gout. It is a condition which affects joints and
is caused by too much uric acid in your blood. When this happens tiny crystals form and collect
in the joints causing pain and swelling. It usually affects big toe but it can occur in any joint.

Investigations
However, we need to do some blood tests to confirm this. We can check the level of uric acid
in the blood. We will do joint (foot) X-rays to rule out other causes of joint inflammation.

We will refer you to specialist called Rheumatologists. They may do further tests like
joint fluid test by drawing some fluid from your affected joint. Urate crystals may be visible
when the fluid is examined under a microscope.

D - Do you have any questions? P - Why I am having this condition?

D - There are some substances in our body called purines. Our body breaks down purines and
forms uric acid. Normally, uric acid dissolves in our blood and passes through our kidneys into
the urine. But sometimes either our body produces too much uric acid or our kidneys excrete too
little uric acid. When this happens, uric acid can build up, forming sharp, needle like crystals in
a joint or surrounding tissue that cause pain, inflammation and swelling.

This type of purines is found in some types of food like red meat, sea food, sugary drinks,
alcohol especially beer. If we consume these types of food or beverages uric acid accumulates
in the blood. Since you mentioned you consumes these on a regular basis, that could be one of
the reason. Also sometimes this condition can run in the family.
Certain types of medication like the one you are taking Bendroflumethiazide for you high
blood pressure also can cause increase in the uric acid.
 Also if there are any problems in the kidney then this uric acid does not get excreted and
accumulates in the body.

Management:
P -How will you treat me?
D -In this condition sometimes you can have attacks of severe pain and swelling. When you
have this type of attacks - we can prescribe you NSAIDS type of medicines called Ibuprofen or
Naproxen, these are painkillers to ease your pain, but if you cannot tolerate this (due to any side
effects) then you might be given colchicine. You might also be given some proton pump
inhibitor [PPI] to protect your stomach. Other medicines which can help is Corticosteroids,
such as prednisone.

To reduce the recurrent attacks, we can give some other type of medication called Allopurinol
which will help limit the amount of uric acid your body make or Probenecid which will help
improve your kidneys' ability to remove uric acid from your body, but it should be started after
several weeks of an acute attack.

Pt – Can it happen again?

Dr – Unfortunately, it comes in attacks, which can develop rapidly over a few hours, and last for
several days if left untreated. It is possible to have one attack of gout and never experience it
again, however for many people it does return.
There certain things need to be done to reduce the attacks and it coming back again:
We will change the Bendroflumethiazide medicine which can cause recurrent attacks to some
other type of medicine for your blood pressure. Antihistamines that you are taking for hay fever
do not cause gout. Do not take Aspirin which is available over the counter as it can flare up
gout.

If you consume too much of red meat, alcohol, sugary drinks it can come back again and
again.
To reduce the recurrent attacks, you should cut down on consuming these type of food and
beverages. It is better to consumes more of vegetables and dairy products because they do not
have that much of purines.
Also you should drink plenty of fluid which will help in excreting this uric acid from the blood.
Caffeine found in coffee can also cause flare up of this condition - so drink less tea, coffee even
be careful when you are taking cough and cold remedies as they have caffeine.
Cherry have proven beneficial to patients with gout - so eat lot of cherries.
Cut down on drinking alcohol especially avoid beer. Wine has less of purine.
We will refer you to dietician who will give you a detail diet plan.

Other things which can cause flare up of this condition is having too much stress, not doing
exercise, being overweight. I would advise you to reduce your stress, do regular exercise and
reduce your body weight (if he is overweight).

I will give you the address of the UK Gout Society, and some other support groups, some
leaflets and useful websites.
Thank You
4150 Video not avialble

8 weeks Vaccination advice

Question
You are the FY2 in GP Clinic.
Mrs.Nichola Paterson has called in regards of her 5 week old son Andrew .
Talk to her and address her concerns.
(Vaccination chart kept inside cubicle)

D- Hello Mrs. Nicola Paterson…. (Introduction)

Telephonic GRIPS
D -Can you please confirm your son’s name and age?
D -How can I help you today?
M(Mother)- I was told that I should vaccinate my baby. Doctor I am not sure whether I
should actually vaccinate my son and wanted your advice on it.
D- Well first of all Congratulations on having a beautiful baby boy. I really appreciate you
approaching us for advice on vaccination and il be more than happy to explain everything in
detail. So in order to explain better can we have a quick chat before discussing vaccination?
M-Sure.
History
D -Is your son currently unwell? M-no
D -Any fever? Any rash? M - No
BIRD
D-Was everything alright during his birth? M-yes
D-Was it a normal vaginal delivery or caesarean section? M-Normal delivery
D-Are you happy with the red book so far? M-yes
D-Have you noticed any concerns with his development till now? M-no
D-Any siblings? M-No he is my firstborn.
D-Just to be sure has he had any jabs before this? M-no
MAFTOSA
D-Is Andrew diagnosed with any medical conditions? M-no
D-Is he on medications? M-no
D-Any allergy to food or medications you have noticed? M-no
D-Anyone in the family with any medical or serious illness? M-no
D –Anyone at home has any type of infections? M - No
Counselling
D-Thank you for answering all my questions. Now coming back to your concerns, can I
know why are you hesitant about vaccination?
M-My partner and I both of us were not vaccinated and we are doing absolutely fine. Also,
my friends told there might be complications due to vaccination and that it is better to not
vaccinate.
D-I can imagine why your concerned.
Vaccinations are the most effective way to prevent serious infectious (contagious) diseases.
Anti-vaccine stories are often spread online through social media which are not based on
scientific evidence and can put your child at risk of a serious illness.
M-Then why did we not get any?
D-Well, you’ve been lucky and also vaccinating the majority of the population means that the
lesser minority of the non-vaccinated people can also be covered due to herd immunity by
helping to stopping the spread.
If people stop having vaccines, it is possible for infectious diseases to quickly spread again.
M-If those diseases are rare in UK, then why do we need vaccines?
D-That’s a brilliant question. So those diseases are very rarely seen in the UK due to
effective vaccination programs. The diseases are still present at the rarest possibility
especially in the developing countries and we might contract them when we are exposed to
travellers who may have these infections especially when one is not vaccinated.
M-How do they actually work?
D-Vaccinations contain either live inactivated or killed organisms that cause the disease
process. Vaccines makes our immune system to develop antibodies that protect us from
disease. Once antibodies are formed your body, it can fight a disease for many years.
M-Okay doctor. When do we give the vaccination?
D- The first jabs in UK are given at around 8 weeks after birth and then when they are 12 and
16 weeks old.
They need 3 doses to make sure they develop strong immunity to the conditions the vaccine
protects against. Every time another dose of the vaccine is given, your baby's immune
response increases.
D -Do you want to know about the vaccines?
M-Sure doctor. We vaccinate the children so that they don’t get any of the preventable
serious infections. We give vaccines against 6 infections when the baby is 8 weeks old. The 6
infections are
1. Diphtheria – which affects the nose and throat, and sometimes the skin. Diphtheria
 can be a serious illness and sometimes it can cause death, especially in children, if it’s
not treated quickly. Vaccination can prevent it.
2. Hepatitis B – which can cause liver damage (cirrhosis) and increase the risk of
getting liver cancer.
3. Hib (Haemophilus influenzae type b) - can cause serious infections of the brain,
lungs, heart, blood and bones.
4. Polio - can cause permanent paralysis.
5. Tetanus – can cause painful muscle spasms, which can make it difficult to breathe
and swallow. If not treated it can cause death.
6. whooping cough (pertussis) - Whooping cough (also called pertussis) is a bacterial
infection of the lungs and breathing tubes.
We give one vaccine to prevent these 6 infections (1 in 6 vaccine) which is given as an
injection into the muscle at the outer aspect of the thigh.
We also give two more vaccines which are given separately to prevent 1. “meningitis type
b” which prevents brain infection this is given to the muscle in the thigh and the other one 2.
“rota virus infection” which causes diarrhoea. This vaccine is given by mouth.
D -Do you follow me so far? M- Yes
D -Any concerns? M- Why should we give these vaccines when we know that it can cause
side effects?
D – That is a good question. Can I ask you do you know what are the side effects of giving
these vaccines? M – No
D - Let me explain. These vaccines has very few side effects like -pain, redness and
swelling where the injection was given. High temperature (more common after the 2nd and
3rd doses), being sick, irritability, loss of appetite. Unusual high-pitched crying and fits or
seizures are rare side effects of the 6-in-1 vaccine.
Very rarely, a baby may have a severe allergic reaction (anaphylaxis) after the 6-in-1
vaccine. However, that can be managed.
These side effects are rare and they are not serious as well as they can be managed well.
Whereas if the children are not given vaccines they can get serious and sometimes deadly
infections as I mentioned before. So the benefits are far higher than the risks. That is why
we suggest that children should be given vaccines. Do you follow me? - M- Yes
D - Do you agree to vaccine to your child? M - Yes doctor.
D –That is a good decision.
There certain reason when we should not give vaccines for example if the child had severe
allergic reaction to the previous dose of vaccine.
As you know your child should have vaccine at 8 weeks. If your child has high temperature
at the time of the vaccination appointment – wait until they've recovered or
have a neurological problem that’s getting worse, including poorly controlled epilepsy – wait
until they’ve been seen by a specialist
There's no need to postpone vaccination if your baby has a minor illness, such as a cough
or a cold with no temperature.
If your baby has a history of fits (febrile convulsions) or has had a fit within 72 hours of a
dose of the vaccine, please let us know.
D-Is there anything else I can help with today?
M-No doctor. Thank you so much.
D-That’s great to know. I can also provide you with some leaflets regarding vaccination for
you to read and understand better. If by any chance you have any other doubts, please contact
us and we would be more than happy to address them.
D-Hope you enjoy time with your little one until then.
M-Thank you doctor.

(National Immunisation Schedule UK)

4151 Video not available

Parkinson’s disease
Question
You are in the GP clinic.
70year old man presents with difficulty walking and tremors in fingers.
History, examination and management.

What is differential diagnosis for Parkinsons?

What is the gold standard for diagnosing Parkinson's disease?

The clinical diagnosis of Parkinson's disease (PD) is based on the presence of characteristic motor
symptoms: bradykinesia, rigidity, postural instability, and resting tremor but neuropathology is
still considered the gold standard for definite diagnosis.

What medications can mimic Parkinson's?

Amiodarone, used to treat heart problems, causes tremor and some people have been reported to
develop Parkinson's-like symptoms. Sodium valproate, used to treat epilepsy, and lithium, used
in depression, both commonly cause tremor which may be mistaken for Parkinson's.
-----------------------------------------------------------------------------------
Other causes of parkinsonism include:
 Drug-induced parkinsonism — note: it is often not possible to distinguish between
Parkinson's disease and drug-induced parkinsonism on the basis of clinical symptoms and
signs alone. It typically presents with motor symptoms that are rapid in onset and bilateral;
there is often no rigidity or resting tremor, and there may be an action tremor. Possible
causative drugs include:
o Antipsychotics (parkinsonism symptoms usually appear within 10 weeks of
starting the drug):
 In general, second-generation antipsychotics (such as amisulpride,
aripiprazole, clozapine, olanzapine, quetiapine, risperidone, sertindole, and
zotepine) are less likely to cause parkinsonism than first-generation
antipsychotics (such as fluphenazine, trifluorophenazine, haloperidol,
chlorpromazine, flupentixol, and zuclopenthixol).
o Anti-emetics:
 Prochlorperazine.
 Metoclopramide.
 o Other drugs (more rarely):
 Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs).
 Calcium-channel blockers.
 Cinnarizine.
 Amiodarone.
 Lithium.
 Cholinesterase inhibitors, such as donepezil or memantine.
 Sodium valproate.
 Methyldopa.
 Pethidine.
 Medical conditions
o Cerebrovascular disease — such as repeated strokes with stepwise progression.
o Non-Parkinson's dementia (including dementia with Lewy bodies and Alzheimer's
disease).
o Other neurodegenerative parkinsonian syndromes, which involve a wider area of
the nervous system than idiopathic Parkinson's disease, such as:
 Progressive supranuclear palsy (suggested by early dysphagia, gaze palsy,
or recurrent falls).
 Multiple system atrophy (suggested by severe early autonomic
involvement such as postural hypotension, or cerebellar ataxia).
 Corticobasal degeneration (suggested by asymmetric rigidity and dystonia,
with apraxia and cognitive impairment).
o Wilson's disease (suggested by Kayser-Fleischer rings caused by deposition of
copper in the membrane of the cornea; variable neurological signs including
tremor, ataxia, and dystonia; and non-specific liver disease).
o Repeated head injury.

Other causes of tremor include:

 Postural and action tremor

o Essential tremor
 Note: essential tremor and Parkinson's disease may co-exist, and
differentiating between the two conditions can be difficult clinically.
 Essential tremor is common; onset is at any age, and often there is a family
history.
 Typically tremor is bilateral and symmetrical; may worsen with stress,
caffeine, sleep deprivation; typically involves the head, neck, or voice as
well as the limbs; and often improves with alcohol and beta-blockers.
o Exaggerated physiological tremor.
 o Dystonic tremor
 May affect the head and usually presents in young adults.
o Hyperthyroidism.
o Drugs, such as beta-2 agonists.
 Intention tremor
o Cerebellar disorders.

History-
Presents with tremors (shaking) on hand even at rest. Imbalance on walking.

Movements are very slow and walking with short steps.

Stiffness of muscles.
Monotone and slow Slurred speech. Difficulty in writing.
Though the symptoms can be bilateral - Usually symptoms are worse on one side.

Symptoms
 Tremor. A tremor, or rhythmic shaking, usually begins in a limb, often your hand or
fingers. You may rub your thumb and forefinger back and forth. This is known as a pill-
rolling tremor. Your hand may tremble when it's at rest. The shaking may decrease when
you are performing tasks.
 Slowed movement (bradykinesia). Over time, Parkinson's disease may slow your
movement, making simple tasks difficult and time-consuming. Your steps may become
shorter when you walk. It may be difficult to get out of a chair. You may drag or shuffle
 your feet as you try to walk.
 Rigid muscles. Muscle stiffness may occur in any part of your body. The stiff muscles
can be painful and limit your range of motion.
 Impaired posture and balance. Your posture may become stooped. Or you may fall or
have balance problems as a result of Parkinson's disease.
 Loss of automatic movements. You may have a decreased ability to perform
unconscious movements, including blinking, smiling or swinging your arms when you
walk.
 Speech changes. You may speak softly, quickly, slur or hesitate before talking. Your
speech may be more of a monotone rather than have the usual speech patterns.
 Writing changes. It may become hard to write, and your writing may appear small.

Rule out secondary causes like due to drugs – Antipsychotics, Lithium, Anti-epileptics, Anti-
emetics, Anti-depressants. [ no rigidity(stiffness) if drug induced]
Previous stroke can cause Parkinson’s like symptoms.
Rule out essential and intention tremor – tremor while writing (essential) and reaching to a coffee
mug ( intentional).
Any reduction in memory (Alzheimer's disease)
Dysphagia (Progressive supranuclear palsy) (dysphagia can happen in Parkinson’s too)
Previous head injuries.
Family history (sometimes can run in family).
Exposure to toxins. Ongoing exposure to herbicides and pesticides may slightly increase your risk
of Parkinson's disease.
Ask for other complications of Parkinson’s – Depression, Anxiety, sleep problem, Bladder
problem, Constipation, memory problems and difficulty in thinking. Fatigue, sexual dysfunction,
Examination : Mask face ( expressionless face)
I need to do neurological examination.
Resting tremors ( pill rolling movements)
Imbalance. Muscle stiffness( rigidity).
Investigation
No tests are confirmatory. Diagnosis mainly by clinical signs and symptoms.
Single-photon emission computerized tomography (SPECT) scan called a dopamine transporter
(DAT) scan – may suggest that you have this condition.
MRI, USG and PET scans to rule out other conditions.
Diagnosis
You seem to have a condition called Parkinson’s disease.
Parkinson's disease is a that affects the nervous system and the parts of the body controlled by the
nerves. It is a progressive disorder.
In Parkinson's disease, certain nerve cells (neurons) in the brain gradually break down or die. Many
of the symptoms are due to a loss of neurons that produce a chemical messenger in your brain
called dopamine. When dopamine levels decrease, it causes atypical brain activity, leading to
impaired movement and other symptoms of Parkinson's disease.
What is the cause ?
The cause of Parkinson's disease is unknown, but several factors appear to play a role, including:
Genetics
 Heredity. Having a close relative with Parkinson's disease increases the chances that you'll
develop the disease. However, your risks are still small unless you have many relatives in
your family with Parkinson's disease.
 Age. Young adults rarely experience Parkinson's disease. It ordinarily begins in middle or
late life, and the risk increases with age. People usually develop the disease around age 60
 or older.
 Sex. Men are more likely to develop Parkinson's disease than women.
 Exposure to toxins. Ongoing exposure to herbicides and pesticides may slightly increase
your risk of Parkinson's disease.
Treatment:
Unfortunately, Parkinson's disease can't be cured, but medications can help control the symptoms,
often dramatically. In some more advanced cases, surgery may be advised.
Lifestyle changes, especially ongoing aerobic exercise. In some cases, physical therapy that focuses
on balance and stretching is important. A speech-therapist may help improve speech problems.
We will refer you to a specialist ( Neurologist) who will assess you further and explain in detail
about the medications and surgical procedures which can help your condition.
Medications
Medications may help you manage problems with walking, movement and tremor. These
medications increase or substitute for dopamine.
You may have significant improvement of your symptoms after beginning Parkinson's disease
treatment. Over time, however, the benefits of drugs frequently diminish or become less consistent.
You can usually still control your symptoms well.
Medications include:
 Carbidopa-levodopa. the most effective Parkinson's disease medication, is a natural
chemical that passes into your brain and is converted to dopamine.
After years, as your disease progresses, the benefit from levodopa may lessen, with a tendency to
wax and wane ("wearing off").
 Dopamine agonists. Unlike levodopa, dopamine agonists don't change into dopamine.
Instead, they mimic dopamine effects in your brain.
Dopamine agonists aren't as effective as levodopa in treating symptoms. However, they last longer
and may be used with levodopa to smooth the sometimes off-and-on effect of levodopa.
Dopamine agonists include pramipexole, and rotigotine (Neupro, given as a patch). Apomorphine
is a short-acting injectable dopamine agonist used for quick relief.
 MAO B inhibitors. These medications include selegiline, rasagiline and safinamide. They
help prevent the breakdown of brain dopamine by inhibiting the brain enzyme monoamine
oxidase B (MAO B). This enzyme metabolizes brain dopamine. Selegiline given with
levodopa may help prevent wearing-off.
 Catechol O-methyltransferase (COMT) inhibitors. Entacapone and opicapone are the
primary medications from this class. This medication mildly prolongs the effect of
levodopa therapy by blocking an enzyme that breaks down dopamine.
 Amantadine alone provide short-term relief of symptoms of mild, early-stage Parkinson's
disease.
 Adenosine receptor antagonists (A2A receptor antagonist). These drugs target areas in
the brain that regulate the response to dopamine and allow more dopamine to be released.
Istradefylline is one of the A2A antagonist drugs.

Surgical procedures
Deep brain stimulation
 Deep brain stimulation. In deep brain stimulation (DBS), surgeons implant electrodes into
a specific part of the brain. The electrodes are connected to a generator implanted in your
chest near your collarbone that sends electrical pulses to your brain and may reduce your
Parkinson's disease symptoms.
Deep brain stimulation is most often offered to people with advanced Parkinson's disease who have
unstable medication (levodopa) responses. DBS can stabilize medication fluctuations, reduce or
halt involuntary movements (dyskinesia), reduce tremor, reduce rigidity, and improve movements.
DBS is effective in controlling changing responses to levodopa or for controlling dyskinesia that
doesn't improve with medication adjustments.
Advanced treatments
MRI-guided focused ultrasound (MRgFUS) is a minimally invasive treatment that has helped some
people with Parkinson's disease manage tremors. Ultrasound is guided by an MRI to the area in the
brain where the tremors start. The ultrasound waves are at a very high temperature and burn areas
that are contributing to the tremors.
Lifestyle and home remedies
Certain lifestyle changes may also help make living with Parkinson's disease easier.
Healthy eating
Eating foods high in fiber and drinking plenty of fluids can help prevent constipation that is
common in Parkinson's disease.
A balanced diet also provides nutrients, such as omega-3 fatty acids, that might be beneficial for
people with Parkinson's disease.
Exercise
Exercising may increase your muscle strength, flexibility and balance. Exercise can also improve
your well-being and reduce depression or anxiety.
We will refer you to a physical therapist to learn an exercise program that works for you. You
may also try exercises such as walking, swimming, gardening, dancing, water aerobics or
stretching.
Exercise may improve your balance.
Avoiding falls
In the later stages of the disease, you may fall more easily. In fact, you may be thrown off balance
by just a small push or bump. The following suggestions may help:
Daily living activities
Daily living activities — such as dressing, eating, bathing and writing — can be difficult for people
with Parkinson's disease. We will refer you to an occupational therapist who can show you
techniques that make daily life easier.
If you are having trouble talking, a speech therapist may help. Many patients with Parkinson's
disease have speech difficulties such as a slow, weak voice, trouble with consonants, slurred
speech, a low voice that has a monotone with little expression, and inappropriate silences. A speech
therapist may be able to help with these problems.
Alternative medicine
  Massage. Massage therapy can reduce muscle tension and promote relaxation.
 Tai chi. An ancient form of Chinese exercise, tai chi employs slow, flowing motions that
may improve flexibility, balance and muscle strength.
 Yoga. In yoga, gentle stretching movements and poses may increase your flexibility and
balance. You may modify most poses to fit your physical abilities.
 Meditation. In meditation, you quietly reflect and focus your mind on an idea or image.
Meditation may reduce stress and pain and improve your sense of well-being.
 Pet therapy. Having a dog or cat may increase your flexibility and movement and improve
your emotional health.
 Relaxation techniques. These practices help lower your blood pressure, reduce your heart
rate and improve muscle tone.
Coping and support
We will refer you to a support group where you will meet other people with similar condition
which will help you to cope with this condition.
Prevention
Because the cause of Parkinson's is unknown, there are no proven ways to prevent the disease.

4152 Video not available

Parkinson’s disease - Follow up

Symptoms of Parkinson’s (Pneumonic – TRAP)
Tremor
Rigidity
Akinesia/ bradykinesia (most important feature) - reduction in speed and amplitude of
voluntary movements), hypomimia (loss of facial expression), reduced vocal volume
(hypophonia), slowing of - walking, dressing and turning in bed.
Postural instability stooped posture, small shuffling steps, reduced arm swing, freezing.

Question
65year old man was diagnosed with Parkinson’s 2 months ago and was treated with
Levodopa. He has come for follow up now.
Talk to him and address his concerns.
GRIPS
D – How are you doing?
D -I understand you have been diagnosed with Parkinson’s disease, is that right? Yes
D - When was it diagnosed? P- 2 months ago.
D - I understand that you have come for follow up, is that correct? P - Yes
D - Can you please tell me what symptoms you had when you came to us first time for this
problem?
P - Doctor, - I had tremors in my hand, I had difficulty getting up from chair, I did not have
proper balance, I had problem in initiating any movements.
D – How are these symptoms now?
P – I feel much better now doctor. My tremors have gone.
D – What about difficulty in getting up from chair and imbalance while walking ?
P – much better now.
D – Good to know. Do you know which medications has been prescribed for you?
P – Levodopa. D – Are you taking the medications properly? P – Yes.
D – Have been referred to Physiotherapy and Occupational therapy? P - Yes.
D – Are you attending those regularly? P – Yes.
D – Have you developed any new symptoms? – P - No
D – Any difficulty in swallowing
D – Have noticed any changes in your speech?
D – Do you have any problem in writing?
D – Have you been diagnosed with any other medical conditions?
D – Are you taking any other medications? (lot of medications can cause Parkinson’s type
symptoms including tremors). P – No Any problems with your medicines?
D – Any problems with your memory
D- What is your job? P – I am retired
D- Does anyone else lives with you? P – Yes my wife.
D – Does your symptoms affect your day-to-day activities or your job?
D – Do you smoke? Yes/ No
D - Do you drink alcohol? Yes D - How much? P - only socially
D – Do you exercise? P - No

Examination ( really do the examination – not just mentioning)

[watch Youtube video - https://www.youtube.com/watch?v=cxHpFWKIfGw]
https://www.youtube.com/watch?v=DsmSYb-DEGs

1. Inspection – No spontaneous movements, mask face, fidgeting, Crossing/uncrossing

legs, Tremor.
2. Bradykinesia – Finger tapping (as big and fast as you can) one hand at a time.
3. Rigidity – wrist movements (Lead pipe, cog wheel rigidity)
4. Tremor – rest tremor, postural tremor, action (kinetic) tremor (finger nose test)
5. Gait and balance – stand up from sitting position, walking (turns with no loss of balance,
step length normal not small, Heel strike present), arm swing, pull test

Management

D - Mr … Have you been explained about Parkinsons’s disease? Do you want me to

explain about it now?
[ Explain if patient wants to know:
Parkinson's disease is a medical condition which affects the nervous system and the parts
of the body controlled by the nerves.
In Parkinson's disease, certain nerve cells (neurons) in the brain gradually break down or
die. Many of the symptoms are due to a loss of neurons that produce a chemical messenger
in your brain called dopamine. When dopamine levels decrease, it causes abnormal brain
activity, leading to impaired movement and other symptoms of Parkinson's disease.
It is a progressive and lifelong disorder.

The cause of Parkinson's disease is unknown, sometimes it can run in the family Genetics

Unfortunately, Parkinson's disease can't be cured, but medications can help control the
symptoms.

With the information that you gave me and examination, I can see there is a lot of
improvement in your symptoms.
 We advise you to continue with your medications and physiotherapy.

D - Do you have any other concerns?

P – Do I need to take this medicine anymore because my symptoms have gone?
D- Unfortunately, you have to this medicine life long as there is no cure for this condition.
P - Doctor, is there anything can be done so that these tremors don’t come back.
D – Medicine that was prescribed to you help in reducing the tremors. However, in this
conditions all the symptoms can come and go. Symptoms usually begin gradually and
worsen over time.
There is no permanent cure for the condition as well as the symptoms. However, there are
other things which can help to reduce the tremors are doing proper exercise, eating
healthy food. You need to continue with your physiotherapy.
If they really trouble you a lot, there are surgical methods what we call as deep brain
stimulation can help. It may help control your movement symptoms for a longer period of
time than medication alone. It may improve your ability to perform day-to-day activities.
I will talk to my seniors and let you know about it.
Also there are certain things can aggravate tremors like Anxiety, excitement, and stress.
You should try to avoid these.

What is the best exercise for Parkinson's disease?

Biking, running, Tai Chi, yoga, Pilates, dance, weight training, non-contact boxing, qi gong
— all have positive effects on PD symptoms.
D –We will refer you to Parkinson’s support group where there are other patients with
similar condition you can share information with each other which will help you to cope
with your condition.
D – Any other concerns?
P – Doctor, do I need to come back for follow up again?
D – As I explained to you earlier, this condition is progressive and it is lifelong because
there is no cure. So we need to keep monitoring you and sometimes if the symptoms get
worse we may need to change your medications or we may need to consider surgical
options. That is why we need to keep following you up. I will talk to my senior and let you
know when you need to come back again for the follow up.
Safety netting
If you develop any problems do come back.

Current guidelines from The International Parkinson and Movement Disorder Society state
that deep brain stimulation should only be offered to people after they have been diagnosed
with Parkinson’s for more than five years.

4153 Video not available

Headache due to CO poisoning

Question
You are the FY 2 doctor in GP clinic
18year old lady calls you on the phone complaining of - headache.
Assess and manage.
GRIPS
How can I help you? – I have headache.
Have you taken any pain killer – do you want any pain killer medicine now?
Anything more can you tell me about it? – Since one month
Where exactly in your head – is it all over your head or any particular area of you head? – All over
my head.
How did it start? – I don’t know.
Did it start suddenly or gradually? – Gradually
What type of headache? –
Do you get this headache any particular time of the day like early morning (SOL) or evening or
same throughout the day? – Same throughout the day.
Anything makes it better or worse? – When I am inside the house it is worse and when I go out it is
slightly better.
How severe is your headache in the scale of 1 to 10? -5 out of 10
Did you have headache every day of this one month or only some days? - I always get headache
whenever I am at home.
Do you get headache when looking at near objects or distant objects (refractory errors)? - No

Do you have any other symptoms other than headache? - Like what?
Fever, skin rash, neck stiffness (Meningitis)? – No
Did you have sudden severe headache at the back of the head (SAH)? – No
Did you have any injury to your head? – No
Any vomiting, dizziness, SOB, nausea, vomiting, chest pain, pain in tummy (all symptoms of CO
poisoning)? - Yes
Do you have difficulty concentrating, drowsiness or poor coordination (high exposure to CO)? -
No
Did you have convulsions or lost consciousness anytime in the last one month (high exposure to
CO)? – No
Any weakness of arm or leg, early morning headache, vomiting (SOL)? – No
Do you drink alcohol? (if she drinks alcohol does she get these symptoms after few hours of
drinking and no symptoms other days when she does not drink alcohol) (Alcohol hangover)? - No

You said you get this headache when you are inside the house since about a month. Has anything
changed in this one month – did you change the house? Anything changed at home? – I changed
my home about a month ago, I used live with my parents. I shifted one month ago to live with my
friends.
Were you getting headache before one month when you were living in parent’s home? – No
Do the others at home also have similar symptoms? -Yes
Do you have gas stove, gas boiler, gas heaters at home? Are they working properly? Do you think
there could be some leak?

Do you keep the windows open when you use gas cooker? – No
Do you have CO detector fitted at home?
Have the home appliances checked regularly?
Were you near any Heating systems, including home furnaces, Burning charcoal, kerosene, propane
or wood? - No
Were you exposed to smokes from Car and truck engines? - No
Anything else you want to tell me?

PMHx – Have you been diagnosed with any medical conditions like heart, lung problem or
anaemia (High risk for poisoning)?
Do you smoke (High risk for poisoning)?

Examination
(No examination as it is telephone conversation station)

Diagnosis:
Do you have any idea why you are having this headache? - No
I think it is due to exposure to carbon monoxide causing CO poisoning.
Carbon monoxide (CO) is a gas produced when gasoline and other fuels burn. It is invisible and
colourless. You can’t smell or taste it. CO can build up quickly and is dangerous in high levels.

Since you said you are getting this headache when you are at home and subsides when you go out
and also your friends staying in your home also keep getting headache, there could be some faulty
gas appliances at your home leaking CO or when you use gas cookers if you don’t keep the
windows open CO accumulates inside the house which you may end up inhaling.

There could be leaking of CO from gas appliances like gas boilers, stoves, heaters or other gas
appliances if they are faulty. It can also happen if you don’t keep the windows open when you use
gas stoves.

CO poisoning is a very serious condition if you are exposed to too much of carbon monoxide
sometimes it can even cause sudden death.

Management

Though this is going on for about a month it can still be serious problem. You should stay inside
the home.
You should go to the hospital emergency department now.
They will assess you and they will check how much Carbon monoxide is there in your blood.
If there is too high CO (carboxy-heamoglobin) in your blood they may treat you with high flow
100% Oxygen. If it not too much you may not need treatment.
You should advise your friends staying in your home also to do the same.

You can call the free National Gas Helpline immediately (on 0800 111 999). The service is open
24 hours a day, 7 days a week. They can check if there is any CO leakage at your home.
Do not re-enter your home until emergency responders have said it’s safe to do so.

How can carbon monoxide poisoning be prevented?

Make sure CO Alarm is fitted in every room.

Check all the gas appliances regularly.
Whenever you use any gas stoves keep the windows open.

Levels of CO The symptoms of low levels of CO exposure are

Normal 1-3% similar to flu symptoms or food poisoning:
Smoker 10%  Mild headache.
Toxic effect appears 15-20%  Mild nausea.
CO levels at 30% indicate severe  Shortness of breath.
exposure Moderate CO exposure can cause symptoms such as:
 Chest pain.
 Dizziness and weakness.
 Fainting (loss of consciousness).
 Loss of muscle coordination.
 Mental confusion.
 Severe headache.
 Upset stomach, nausea and vomiting.
4154 Video not available

Colleague posting patient information on social media

Question:
You are the FY 2 doctor in the hospital setting

Your FY 1 colleague want to talk to you about another FY 1 colleague.

Hi, I am (first name) one of the FY 2 doctor.

FY 2 - May I know your name please?

How are you doing? How is the work going on? Do you need any kind of help?
FY 2 - Is there anything you want to tell me?
I want to talk to you about one of my FY 1 colleague, but I am bit concerned talking about
it.
FY 2 - Why are you concerned? I want to talk to you about something what he is doing
which I think is not right. If I tell you about it will you not mention my name to others.
FY 2 - Okay Don’t worry, I will not mention your name to others. You can tell me.

He is posting patients information in his Facebook page.

FY 2 - How do you know about it? I am in his group/ my friend told me about it.
FY 2 - Did he make the patient as his Facebook friend?
FY 2 - How many patients did he make his Facebook friends?
FY 2 - When did this happen?
FY 2 - Is it his personal or professional page?
FY 2 - What information did he put?
FY 2 - Did he put personal or about medical condition information about the patient?
FY 2 - Did he put any derogatory message about the patient or colleagues?
FY 2 - Did you he put patients name or any other identifiable information?
FY 2 - Did he post patient’s photos?
FY 2 - Did he put the hospital or department name?
FY 2 - Did he put any information about the hospital colleagues?
FY 2 – Is he advertising himself if the Facebook for any professional benefits?
FY 2 - Is he giving any medical advice to the patients online?

FY 2 - Was he trying to build any type of improper emotional relationship or sexual

relationship do you think?
FY 2 - Was the patient responding to his postings?

FY 2 - What information he put there which you think is not right?

FY 2 - And why do you think it is not right to do that?

FY 2 – Did you talk to him about this matter? – No

Why didn’t you talk to him about it?
Have you read the GMC good medical practice guidelines?

Counselling:
It is really good that you brought out this issue with me.
Your concern about Dr. (other FY1) absolutely right. It is not right ethically as well as
legally to put patients or colleague’s information on the Facebook or any other social
media.

All the guidelines about using social media is given in the good medical practice guidelines
in the GMC website. It is very important that we all doctors should read about it.

There are advantages as well risks of using social media.

Doctors’ use of social media can benefit patient care by:

a. engaging people in public health and policy discussions
b. establishing national and international professional networks
c. facilitating patients’ access to information about health and services

Risks:
Using social media also creates risks, particularly where social and professional
boundaries become unclear. We must follow the guidance in Maintaining a professional
boundary between us and our patients.
It can be breaching the patient’s confidentiality. We should be careful not to share
identifiable information about patients. Although individual pieces of information may not
breach confidentiality on their own, the sum of published information online could be
enough to identify a patient or someone close to them.
We should not use publicly accessible social media to discuss individual patients or their
care with those patients or anyone else.

It can impact on patients trust on the doctor in particular and the medical profession as a
whole.
It may change the nature of the relationship between a doctor and a patient.

We will lose our personal privacy. We should adopt privacy settings. Do not accept
Facebook friend requests from or former patients.

If a patient contacts us about their care or other professional matters through our private
profile, we should indicate that we cannot mix social and professional relationships and,
where appropriate, direct them to our professional profile.

It is inappropriate to post informal, personal or derogatory comments about patients or

colleagues on the social media.

Do not try to develop any improper relationship including sexual relationship with patients
or their relatives using social media.

Do you know how we normally handle these type of issues? - No

Don’t worry, I will explain.

Normally we should talk to our colleague directly and tell them what is concerning about
them. Sometimes they may be doing these because they may not know that doing these
things are not right. We can talk to them directly and advise them about it, usually they
will understand and appreciate it.
 Do you think you can talk to him yourself? If you are still worried about talking to him
then I will talk to him and I will not bring out your name.

1. We should advise him to delete all the information about the patient and he may need to
apologize to the patient if he has put any inappropriate message about the patient.
2. We should also advise him not to do these things in the future.
3. We should advise him to read about GMC good medical practice guidelines.
4. Also we should advise him all other things which I told you.

Any other concerns?

4155 Video not available

Lyme disease
Question
Lady presents with skin rash after a camping trip.
You should specifically ask for any camping trip, did you go to garden or parks, wooded
areas.
Lyme disease
 the bacteria that cause Lyme disease are transmitted by the bite of an infected tick

ticks are mainly found in grassy and wooded areas, including urban gardens and
parks
 tick bites may not always be noticed
 infected ticks are found throughout the UK and Ireland.
Be aware that most tick bites do not transmit Lyme disease and that prompt, correct
removal of the tick reduces the risk of transmission.
Clinical assessment
Diagnose Lyme disease in people with erythema migrans, a red rash that:
 increases in size and may sometimes have a central clearing
 is not usually itchy, hot or painful
 usually becomes visible from 1 to 4 weeks (but can appear from 3 days to
3 months) after a tick bite and lasts for several weeks
 is usually at the site of a tick bite.
 Arthritis
Consider the possibility of Lyme disease in people presenting with several of the following
symptoms, because Lyme disease is a possible but uncommon cause of:
fever and sweats migratory joint or muscle aches and pain
swollen glands cognitive impairment, such as memory problems and difficulty
concentrating (sometimes described as 'brain fog')
malaise headache
fatigue paraesthesia.
neck pain or stiffness
Consider the possibility of Lyme disease in people presenting with symptoms and signs
relating to 1 or more organ systems (focal symptoms) because Lyme disease is a possible
but uncommon cause of:
 neurological symptoms, such as facial palsy or other unexplained cranial nerve
palsies, meningitis, mononeuritis multiplex or other unexplained radiculopathy; or
rarely encephalitis, neuropsychiatric presentations or unexplained white matter
changes on brain imaging
 inflammatory arthritis affecting 1 or more joints that may be fluctuating and
migratory
 cardiac problems, such as heart block or pericarditis
 eye symptoms, such as uveitis or keratitis
 skin rashes such as acrodermatitis chronica atrophicans or lymphocytoma.
Laboratory investigations to support diagnosis
Management
Emergency referral
For people with symptoms that suggest central nervous system infection, uveitis or
cardiac complications such as complete heart block, even if Lyme disease is suspected.
Specialist advice
If an adult with Lyme disease has focal symptoms, consider a discussion with or referral to
a specialist, without delaying treatment. Choose a specialist appropriate for the person's
symptoms, for example, an adult infection specialist, rheumatologist or neurologist.
Antibiotic treatment
If symptoms worsen during treatment for Lyme disease, assess for an allergic reaction to
the antibiotic. Be aware that a Jarisch–Herxheimer reaction may cause an exacerbation of
symptoms but does not usually warrant stopping treatment.
Symptoms Treatment
Lyme disease without focal Oral doxycycline:
symptoms but with erythema 100 mg twice per day or 200 mg once per day for
migrans and/or non-focal 21 days
symptoms
Lyme disease affecting the Oral doxycycline:
cranial nerves or peripheral 100 mg twice per day or 200 mg once per day for
nervous system 21 days
Lyme disease affecting the Intravenous ceftriaxone:
central nervous system 2 g twice per day or 4 g once per day for 21 days
(when an oral switch is being considered, use
doxycycline)
Lyme disease with arthritis Oral doxycycline:
100 mg twice per day or 200 mg once per day for
28 days
Lyme disease with Oral doxycycline:
acrodermatitis chronica 100 mg twice per day or 200 mg once per day for
 atrophicans 28 days
Lyme disease with Lyme Oral doxycycline:
carditis 100 mg twice per day or 200 mg once per day for
21 days
Lyme disease with Lyme Intravenous ceftriaxone:
carditis and 2 g once per day for 21 days (when an oral switch is
haemodynamically unstable being considered, use doxycycline)

Note: Do not use azithromycin to treat people with cardiac abnormalities associated with
Lyme disease because of its effect on QT interval.
Information for people with Lyme disease
Explain to people diagnosed with Lyme disease that:
Lyme disease is a bacterial infection treated with antibiotics
Most people recover completely
Prompt antibiotic treatment reduces the risk of further symptoms developing and increases
the chance of complete recovery
It may take time to get better, but their symptoms should continue to improve in the
months after antibiotic treatment
They may need additional treatment for symptom relief.
Preventing Tick Bites on People
Tick exposure can occur year-round, but ticks are most active during warmer months
(April-September).
Before You Go Outdoors
Know where to expect ticks. Ticks live in grassy, brushy, or wooded areas, or even on
animals. Spending time outside walking your dog, camping, gardening, or hunting
could bring you in close contact with ticks. Many people get ticks in their own yard or
neighbourhood.
Treat clothing and gear with products containing 0.5% permethrin. Permethrin can be
used to treat boots, clothing and camping gear and remain protective through several
washings. Alternatively, you can buy permethrin-treated clothing and gear.
Use Environmental Protection Agency (EPA)-registered insect repellents external
icon containing DEET
Avoid Contact with Ticks
Avoid wooded and brushy areas with high grass and leaf litter.
Walk in the center of trails.
After You Come Indoors:
Check your clothing for ticks.. Any ticks that are found should be removed. Tumble dry
clothes in a dryer on high heat for 10 minutes to kill ticks on dry clothing after you come
indoors.
Examine gear and pets.
Shower soon after being outdoors.
Check your body for ticks after being outdoors.

4156 video not available

Allergic conjunctivitis
Question
Patient presents with itching in both eyes.
Patient has hay fever.
Rule out infectious conjunctivitis – discharge, pain,
R/O glaucoma ( halos around the light, blurred vision), ankylosing spondylitis ( back pain),
Reiter’s syndrome ( sexual history, urethritis – urethral discharge /vaginal discharge,
arthritis - joint pain, conjunctivitis)
Allergic conjunctivitis
Aetiology
Allergic conjunctivitis is the most common cause of non-infectious conjunctivitis and
occurs secondary to a type I hypersensitivity reaction to a particular trigger.
Risk factors
A personal or family history of atopic conditions, such as asthma and hay fever, increases
the risk of allergic conjunctivitis.
Clinical features
The distinguishing feature of allergic conjunctivitis is the presence of itching. As it is
driven by a systemic process, both eyes are usually affected with diffuse redness and
watery discharge.
Examination of the eyelid will reveal papillae, which if large can give a ‘cobblestone’
appearance .

cobblestone’ appearance . Conjunctivitis caused by allergies like hay

fever makes eyes red and watery but is not
contagious

There are multiple subtypes of allergic conjunctivitis:

 Seasonal allergic conjunctivitis: secondary to hay fever, therefore most common in
summer months due to the presence of pollen
 Perennial allergic conjunctivitis: caused by allergens such as house dust mite
 Vernal keratoconjunctivitis: most common in young males living in hot dry
climates
 Atopic keratoconjunctivitis: most common in middle-aged men
Investigations
A history of atopy or recurring conjunctivitis in response to a trigger or changes to the
weather is strongly suggestive of allergy conjunctivitis.
Conjunctival scrapes may be performed and will reveal the presence of eosinophils, typical
of a type I hypersensitivity reaction.

Management
 There are things you can do to help ease your symptoms.
 Boil water and let it cool down before you gently wipe your eyelashes to clean off
crusts with a clean cotton wool pad (1 piece for each eye).
 Hold a cold flannel on your eyes for a few minutes to cool them down.
Do not wear contact lenses until your eyes are better.

Treatment includes allergen avoidance, topical and oral antihistamine as well as

topical mast-cell stabilisers and occasionally, mild steroids.
Complications
Allergic conjunctivitis does not result in complications. However, the use of steroids in
managing flares can increase the risk of herpes infection, glaucoma and cataracts.
Key points
 Allergic conjunctivitis is a common condition with a predominating feature being
itching
 Individuals affected by allergic conjunctivitis tend to have strong histories of atopy
 The mainstay of management includes allergen avoidance and antihistamines for
symptomatic relief

4166 Video not available

Alopecia
Question
50 year old lady with hair loss. Talk to her and address her concerns.
Patient is receiving tacrolimus after kidney transplant ( immunouprressant). Tacrolimus can
cause hair loss. Treatment – Reduce the dose if possible, Reassure. Wigs.
Causes of alopecia
2 types of hair loss
1) Non-scarring – reversible ( alopecia areata, Telogen effluvium ( hair loss due to stress –
child birth, surgery, severe illness)

2) Scarring – irreversible (lichen planus, discoid lupus, tumours, trauma)

Some types of hair loss are permanent, like male and female pattern baldness. This type of hair
loss usually runs in the family.
Other types of hair loss may be temporary. They can be caused by:
 an illness

 stress

 cancer treatment

 weight loss

 iron deficiency

Treatment for hair loss

Most hair loss does not need treatment and is either:
  temporary and it'll grow back

 a normal part of getting older

Hair loss caused by a medical condition usually stops or grows back once you've recovered.
There are things you can try if your hair loss is causing you distress. But most treatments are not
available on the NHS, so you'll have to pay for them.
No treatment is 100% effective.
Finasteride and minoxidil
Finasteride and minoxidil are the main treatments for male pattern baldness.
Minoxidil can also be used to treat female pattern baldness. Women should not use finasteride.
These treatments:
 do not work for everyone

 only work for as long as they're used

 are not available on the NHS

 can be expensive

Wigs
Some wigs are available on the NHS, but you may have to pay unless you qualify for financial help.
Synthetic wigs:
 last 6 to 9 months

 are easier to look after than real-hair wigs

 can be itchy and hot

 cost less than real-hair wigs

Real-hair wigs:
 last 3 to 4 years

 are harder to look after than synthetic wigs

 look more natural than synthetic wigs

 cost more than synthetic wigs

Find out more about NHS wigs and costs

Other hair loss treatments

Other treatments for hair loss

Treatment Description

Steroid injection Injections given into bald patches

Steroid creams Cream applied to bald patches

Immunotherapy Chemical applied to bald patches

Light treatment Shining ultraviolet light on bald patches

Tattooing Tattoo used to look like short hair and eyebrows

Hair transplant Hair is removed from the back of the head and moved to thinning patches

Scalp reduction surgery Sections of scalp with hair are stretched and stitched together

Artificial hair transplant Surgery to implant artificial hairs

Some of these treatments may not be available on the NHS.

Emotional help
Losing hair can be upsetting. For many people, their hair is an important part of who they are.
If your hair loss is causing you distress, your GP may be able to help you get some counselling.
You may also benefit from joining a support group, or speaking to other people in the same
situation on online forums.

Tacrolimus appears to be associated with alopecia totalis in patients who have received a
kidney and/or pancreas transplant and the increased risk for hair loss seems to be dose related.

Why do transplant patients take tacrolimus?

Tacrolimus is used together with other medicines to prevent the body from rejecting a
transplanted organ (eg, kidney, liver, heart, or lung). This medicine may be used with steroids,
azathioprine, basiliximab, or mycophenolate mofetil. Tacrolimus belongs to a group of medicines
known as immunosuppressive agents.

How long should you take tacrolimus?

How long will I have to take tacrolimus? You will likely be on this immunosuppressant or one
similar to it for as long as your transplanted organ is functioning. Over time, there may be some
changes to the types of immunosuppressants you will take.

Alopecia has generally been a reversible phenomenon with tacrolimus dosage reduction, although
there may be a lag time.

Will biotin help with hair loss from medication?

Biotin is a water-soluble B vitamin found naturally in some foods and also in supplements
While biotin is added to some shampoos that claim to reduce hair loss, there is no evidence that
this works. Consuming foods rich in healthy vitamins and minerals will help with overall hair
health. The best natural sources of biotin are meat, eggs, fish, seeds, nuts, and vegetables.
Causes of hair loss

 Hereditary hair loss. Both men and women develop this type of hair loss that happens
with aging, which is the most common cause of hair loss worldwide. ...

 Age. ...

 Alopecia areata. ...

 Childbirth, illness, or other stressors. ...

 Medications and supplements

 Radiation therapy to the head.

 A very stressful event

 Hair care. ...

 Hairstyle pulls on your scalp. ...

 Hormonal imbalance. ...

 Scalp infection.

Hereditary hair loss

Both men and women develop this type of hair loss, which is the most common cause of hair loss
worldwide. In men, it’s called male pattern hair loss. Women get female pattern hair loss.
Regardless of whether it develops in a man or women, the medical term is androgenic alopecia.
No matter which term you use, it means that you’ve inherited genes that cause your hair follicles
(what each hair grows out of) to shrink and eventually stop growing hair. Shrinking can begin as
early as your teens, but it usually starts later in life.
In women, the first noticeable sign of hereditary hair loss is usually overall thinning or a widening
part.
When a man has hereditary hair loss, the first sign is often a receding hairline or bald spot at the
top of his head.
Is regrowth possible?
Yes, treatment can help stop or slow hair loss. It may also help regrow hair. The earlier treatment
is started, the better it works. Without treatment, you will continue to lose hair.
Hereditary hair loss
Both men and women develop this type of hair loss, which is the most common cause of hair loss
worldwide. In men, it’s called male pattern hair loss. Women get female pattern hair loss.

--------------------------------------------------------------------------------
Age
With age, most people notice some hair loss because hair growth slows. At some point, hair
follicles stop growing hair, which causes the hair on our scalp to thin. Hair also starts to lose its
color. A woman’s hairline naturally starts to recede.
Is regrowth possible?
Caught early, treatment helps some people regrow their hair.
--------------------------------------------------------------------------------
Alopecia areata
Alopecia areata is a disease that develops when the body’s immune system attacks hair follicles
(what holds the hair in place), causing hair loss. You can lose hair anywhere on your body,
including your scalp, inside your nose, and in your ears. Some people lose their eyelashes or
eyebrows.
Is regrowth possible?
Yes. If your hair fails to grow back on its own, treatment may help stimulate regrowth.

---------------------------------------------------------------------------------
Cancer treatment
If you receive chemotherapy or have radiation treatment to your head or neck, you may lose all
(or most of) your hair within a few weeks of starting treatment.
Is regrowth possible?
Hair usually starts to regrow within months of finishing chemotherapy or radiation treatments to
the head or neck. Dermatologists can offer medication to help hair grow back more quickly.
Is it preventable?
Wearing a cooling cap before, during, and after each chemotherapy session may help prevent hair
loss.
------------------------------------------------------------------------------------------
Childbirth, illness, or other stressors
A few months after giving birth, recovering from an illness, or having an operation, you may notice
a lot more hairs in your brush or on your pillow. This can also happen after a stressful time in your
life, such as a divorce or death of a loved one.
Is regrowth possible?
If the stress stops, your body will readjust and the excessive shedding will stop. When the
shedding stops, most people see their hair regain its normal fullness within 6 to 9 months.
------------------------------------------------------------------------------------------
Hair care
If you colour, perm, or relax your hair, you could be damaging your hair. Over time, this damage
can lead to hair loss.
Is regrowth possible?
You can change how you care for your hair, which can prevent hair loss. Once you damage a hair
follicle, hair cannot grow from that follicle. Having many damaged hair follicles creates permanent
bald spots.

Hairstyle pulls on your scalp

If you often wear your hair tightly pulled back, the continual pulling can lead to permanent hair
loss. The medical name for this condition is traction alopecia.
Is regrowth possible?
No. You can prevent hair loss by making some changes.
Hairstyle pulls on your scalp
If you often wear your hair tightly pulled back, the continual pulling can lead to permanent hair
loss.
-----------------------------------------------------------------------------------------------
Hormonal imbalance
A common cause of this imbalance is polycystic ovary syndrome (PCOS). It leads to cysts on a
woman’s ovaries, along with other signs and symptoms, which can include hair loss. Stopping
some types of birth control pills can cause a temporary hormonal imbalance. Women who
develop a hormonal imbalance can develop thinning hair (or hair loss) on their scalp.
Is regrowth possible?
Treatment may help.
--------------------------------------------------------------------------------------
Scalp infection
A scalp infection can lead to scaly and sometimes inflamed areas on your scalp. You may see what
look like small black dots on your scalp. These are actually stubs of hair. Some people develop a
bald spot.
Is regrowth possible?
Yes, treatment can get rid of the infection. Once the infection clears, hair tends to grow.

---------------------------------------------------------------------------------------
Medication
A possible side effect of some medications is hair loss. If you think a medication is causing your
hair loss, ask the doctor who prescribed it if hair loss is a possible side effect. It’s essential that you
do not stop taking the medication before talking with your doctor. Abruptly stopping some
medications can cause serious health problems.
Is regrowth possible? Yes.
----------------------------------------------------------------------------------------------
Scalp psoriasis
Many people who have plaque psoriasis develop psoriasis on their scalp at some point. This can
lead to hair loss.
Is regrowth possible?
Hair tends to regrow once the scalp psoriasis clears, but this takes time. By following these
dermatologists’ tips, you may be able to prevent hair loss.

----------------------------------------------------------------------------------------------
Pulling your hair
Some people pull on their hair, often to relieve stress. They may be unaware that they’re pulling
their hair. The medical term for this is trichotillomania.
Is regrowth possible?
If you haven’t destroyed the hair follicles, yes. For your hair to regrow, you have to stop pulling it.
---------------------------------------------------------------------------------
Scarring alopecia
This condition develops when inflammation destroys hair follicles. Once destroyed, a hair follicle
cannot grow hair. Diverse conditions can cause this. The medical name for this group of conditions
is cicatricial alopecia.
Is regrowth possible?
Once a hair follicle is destroyed, it cannot regrow a hair. Catching this condition early can prevent
further hair loss.

----------------------------------------------------------------------------------------------
Sexually transmitted infection
Left untreated, a sexually transmitted infection (STI) can lead to hair loss. Syphilis is such an STI.
Left untreated, syphilis can cause patchy hair loss on the scalp, eyebrows, beard, and elsewhere.
Other STIs can also cause hair loss.
Is regrowth possible?
After treating the STI, hair often starts to regrow.
---------------------------------------------------------------------------------------------------
Thyroid disease
If you have a problem with your thyroid, you may see thinning hair. Some people notice that their
hair comes out in clumps when they brush it.
Is regrowth possible?
Yes, treating the thyroid disease can reverse the hair loss.
-------------------------------------------------------------------------------------------------
Too little biotin, iron, protein, or zinc
If you’re not getting enough of one or more of these, you can have noticeable hair loss.
Is regrowth possible?
Yes. When your body gets enough of the missing nutrients, hair can regrow.
--------------------------------------------------
Friction
People can develop hair loss where boots, socks, or tight clothing frequently rubs against their
skin. The medical term for this is frictional alopecia.
Is regrowth possible?
Hair tends to regrow on its own when the rubbing stops.
---------------------------------------------------------------------------------------------
Poison
Being slowly poisoned can lead to hair loss. Poisons that can cause hair loss include arsenic,
thallium, mercury, and lithium. If you ingest a large amount of warfarin, which is found in rat
poisons, it can also cause hair loss. Taking large amounts of vitamin A or selenium is also toxic and
can cause hair loss.
Is regrowth possible?
Yes, hair tends to regrow when you are no longer exposed to the poison.
------------------------------------------------------------------------------------------------
While many causes of hair loss can be treated successfully, the key to effective treatment is to find
out what’s causing the hair loss. Without an accurate diagnosis, treatment is often ineffective.
Dermatologist examining a patient with hair loss
To find out what's causing your hair loss, a dermatologist may use a tool called a dermascope to
get a closer look.

Effective treatment for hair loss begins with finding the cause. To get an accurate diagnosis, it
helps to see a board-certified dermatologist. These doctors have in-depth knowledge about the
many causes of hair loss and experience treating the diverse causes.
How do dermatologists find out what’s causing hair loss?
To pinpoint the cause of your hair loss, a dermatologist begins by gathering information. Your
dermatologist will:
 Ask questions. It’s important to know how long you’ve had hair loss and whether it came
on quickly.

 Look closely at your scalp, nails, any other area with hair loss. This exam provides vital
clues about what’s happening.

 Test the health of your hair. Gently pulling on your hair tells your dermatologist a lot
about how your hair is growing and whether it’s prone to breaking.

If your dermatologist suspects that the cause of your hair loss could be a disease, vitamin
deficiency, hormone imbalance, or infection, you may need a blood test or scalp biopsy. These
tests can be done in your dermatologist’s office.
Once your dermatologist has this information, it’s often possible to tell you what’s causing your
hair loss.
Sometimes, your dermatologist needs more information. This might be the case if someone has
more than one cause. For example, a woman may have had a baby a few months ago, and this
may be causing obvious hair shedding. She may also have early hereditary loss, which isn’t so
obvious.
No one hair loss treatment works for everyone
Once your dermatologist finds the cause(s), your dermatologist will tell you whether treatment is
recommended. Sometimes, your hair will regrow on its own, making treatment unnecessary.

When hair may regrow on its own

Yes, your hair may regrow on its own. This can happen if you recently:
 Had a baby

 Recovered from a major illness or had surgery

 Underwent cancer treatment

 Lost 20 pounds or more

 Developed a mild case of a disease called alopecia areata, which causes your immune
system to attack your hair follicles

 Got rid of psoriasis on your scalp

Your dermatologist can tell you whether your hair may start to grow again on its own.
Sometimes to see regrowth, you need to make some changes.
Changing your hair care (or hairstyle) may help
Some hairstyles and hair care habits can damage hair, leading to hair loss. If your dermatologist
finds that this may be causing your hair loss, your dermatologist can recommend changes that will
help you stop damaging your hair.

When do dermatologists recommend treatment for hair loss?

While your hair may regrow on its own, your dermatologist may recommend treatment to help it
grow more quickly. Sometimes, treatment is essential to prevent further hair loss.
A treatment plan for hair loss may include one or more of the following.
At-home treatments for hair loss
At-home treatments offer convenience, and you can buy many of them without a prescription.
Because studies show that the following can help, your dermatologist may include one (or more)
in your at-home treatment plan.
Minoxidil (Rogaine®): To use minoxidil, you apply it to the scalp as directed, usually once or twice
a day.
When used as directed, minoxidil can:
 Stimulate hair growth

 Prevent further hair loss

Minoxidil tends to be more effective when used along with another treatment for hair loss. Many
people see some regrowth when using minoxidil, but it takes time to see results, usually about 3
to 6 months.
Should you see regrowth, you will need to keep using it every day. Once you stop applying it, hair
loss returns.
Minoxidil can help early hair loss; it cannot regrow an entire head of hair.

Laser for at-home use: You can buy laser caps and combs to treat hair loss at home. While only a
few studies have looked at these devices, the results are promising.
In one study, more than 200 men and women who had hereditary hair loss were given either a
laser hair comb or a sham device that looked like a laser comb. The patients used the device that
they were given 3 times per week for 26 weeks.
The researchers found that some patients using the laser rather than the sham device saw overall
thicker and fuller hair.
It’s important to understand that not everyone who used a laser saw regrowth.

Microneedling: A microneedling device contains hundreds of tiny needles. A few studies have
shown that it can help stimulate hair growth. In one study, men between the ages of 20 and 35
years old who had mild or moderate hereditary hair loss were treated with either:
 5% minoxidil twice a day

 5% minoxidil twice a day plus weekly microneedling

After 12 weeks of treatment, the patients treated with minoxidil and microneedling had
significantly more hair growth.
Other studies have shown that using microneedling along with another treatment, including
platelet-rich plasma or a corticosteroid that you apply to the thinning area, helps improve hair
growth.
While you can buy a microneedling device without a prescription, it’s best to check with your
dermatologist first. Microneedling can worsen some conditions. It’s also important to get the right
microneedling device.
The devices used for hair loss contain longer needles than the those used to treat the skin.
Procedures to help regrow hair
While at-home treatments offer convenience, a procedure performed by a board-certified
dermatologist tends to be more effective. For this reason, your dermatologist may include one of
the following in your treatment plan.
Injections of corticosteroids: To help your hair regrow, your dermatologist injects this medication
into the bald (or thinning) areas. These injections are usually given every 4 to 8 weeks as needed,
so you will need to return to your dermatologist’s office for treatment.
This is considered the most effective treatment for people who have a few patches of alopecia
areata, a condition that causes hair loss. In one study of 127 patients with patchy alopecia areata,
more than 80% who were treated with these injections had at least half of their hair regrow
within 12 weeks.
Hair transplant: If you have an area of thinning or balding due to male (or female) pattern
baldness, your dermatologist may mention a hair transplant as an option. This can be an effective
and permanent solution.
To learn more, go to: A hair transplant can give you permanent, natural-looking results.
Laser therapy: If using minoxidil every day or taking medication to treat hair loss seems
unappealing to you, laser therapy may be an option. Also called low-level laser therapy, a few
studies suggest that this may help:
 Hereditary hair loss

 Alopecia areata

 Hair loss due to chemotherapy

 Stimulate healing and hair growth after a hair transplant

Studies indicate that laser therapy is safe and painless but requires many treatment sessions. To
see a bit of hair growth, you may need several treatments a week for many months.
Platelet-rich plasma (PRP): Studies show that this can be a safe and effective hair loss treatment.
PRP involves drawing a small amount of your blood, placing your blood into a machine that
separates it into parts, and then injecting one part of your blood (the plasma) into the area with
hair loss.
The entire procedure takes about 10 minutes and usually doesn’t require any downtime.
You will need to return for repeat injections. Most patients return once a month for 3 months and
then once every 3 to 6 months.
Within the first few months of treatment, you may notice that you are losing less or minimal
amounts of hair.
Prescription medication that can regrow hair
Another treatment option is to take prescription medication. The type of medication prescribed
will depend on your:
 Hair loss cause

 Overall health

 Age

 Expected results

 Plans for getting pregnant

With any medication, side effects are possible. Ask your dermatologist about possible side effects
that you might experience while taking one of these medications to treat hair loss. The
medications include:
Finasteride (Propecia®): The U.S. Food and Drug Administration (FDA) approved this medication
to treat male pattern hair loss. When taken as directed, finasteride can:
 Slow down hair loss

 Stimulate new hair growth

Finasteride is a pill that you take once a day. Taking it at the same time each day seems to
produce the best results.
Finasteride: Before and after
This man took finasteride to treat his male pattern hair loss, and within 1 year (B), he had
noticeable improvement. After 2 years (C), he had regrown most of his hair.
Like other treatments for hair loss, this, too, takes time to work. It usually takes about 4 months to
notice any improvement.
Finasteride tends to be more effective if you begin taking it when you first notice hair loss. A
dermatologist may also prescribe this medication to treat a woman who has hereditary hair loss
and cannot get pregnant.
If finasteride works for you, you will need to keep taking it to continue getting results. Once you
stop, you’ll start losing hair again. Before taking this medication, be sure to discuss possible side
effects with your dermatologist.
Spironolactone: For women who have female pattern hair loss, this medication may be an option.
It can:
 Stop further hair loss

 Increase hair thickness

Studies indicate that this medication is effective in about 40% for women who have female
pattern hair loss. In one study of 166 women taking spironolactone, 42% said they had mild
improvement, and 31% reported increased thickness.
It’s essential that you not become pregnant while taking spironolactone. This medication can
cause birth defects. To prevent pregnancy, your dermatologist will also prescribe a birth control
pill if it’s possible for you to get pregnant.
Other medications: If you have an infection or painful inflammation, your dermatologist can
prescribe medication to treat these.
For example, if you have a type of hair loss called frontal fibrosing alopecia (FFA), which can cause
painful inflammation, your dermatologist may prescribe an antibiotic and antimalarial medication.
Scalp ringworm, which is caused by a fungus, requires antifungal medication.
Vitamins, minerals, and other supplements
If your blood test reveals that you’re not getting enough biotin, iron, or zinc, your dermatologist
may recommend taking a supplement. If you’re not getting enough protein, your dermatologist
can tell you how to boost your intake.
You should only take biotin, iron, or zinc when your blood test shows that you have a deficiency. If
your levels are normal, taking a supplement can be harmful. For example, if you take too much
iron, you can develop iron poisoning. Early signs of this include stomach pain and vomiting.
Other supplements meant to help with hair loss tend to contain a lot of one nutrient. Because this
can cause you to get too much of the nutrient, many dermatologists recommend taking a
multivitamin instead.
Wigs and concealers
Do you feel uncomfortable taking medication? Does your schedule limit the amount of time you
have for treatment? Is the cost of treatment, which insurance generally will not cover, too
expensive?
If you answered yes to any of these questions, your dermatologist may recommend a wig or
concealer.
While these cannot slow hair loss or help you regrow hair, they can boost your self-esteem.
Another advantage is that a wig or concealer offers immediate results.
Many types of wigs, including ones that can be custom-made for you, are available. If you’re
looking for a concealer, such as a spray or powder that can hide hair loss, you’ll find many
products available online. With endless choices, it can be helpful to have a dermatologist guide
you in selecting one.
What is the outcome for someone who has hair loss?
With an accurate diagnosis, many people who have hair loss can see hair regrowth. If you need
treatment for regrowth, the earlier you start, the more likely you are to see regrowth.
It’s important to understand that:
 Not every type of hair loss can be treated, but a dermatologist may be able to prevent
further hair loss.

 It can take months before you see results from treatment.

 No one treatment works for everyone, even two people with the same type of hair loss.

 Sometimes, hair loss is stubborn and requires trying different treatments before finding
one that works.

Self-care also plays an essential role in preventing and treating hair loss. To find out what
dermatologists recommend, go to Hair loss: Self-care.

Tacrolimus appears to be associated with alopecia totalis in patients who have received a
kidney and/or pancreas transplant and the increased risk for hair loss seems to be dose related.
alopecia has been seen occasionally with tacrolimus, but it has generally responded to a reduction
in dosage. It may be necessary to wait some period of months before regrowth of hair takes place.

what is an unlicensed medicine uk

You might have been prescribed a medicine that is 'unlicensed'. An unlicensed medicine
is not officially approved ('licensed') for treating your health condition at present.
This could be because: the number of people with the same condition is too small for a
clinical trial to take place. Can unlicensed drugs be prescribed?
You can prescribe unlicensed drugs or use drugs for unlicensed indications. You should
usually prescribe licensed medication in accordance with the terms of their license. But
remember, you're legally responsible for the decision to prescribe.
What is the difference between licensed and unlicensed drugs?
Unlicensed medicines

In other words, the medicine has not undergone clinical trials to see if it is effective and
safe in treating your condition. However, the medicine will have a licence to treat
another condition and will have undergone clinical trials for this

BNF information
When the BNF suggests a use that is outside the terms defined by the licence (‘off-label’
use), this too is indicated. Unlicensed or off-label use may be necessary if the clinical
need cannot be met by licensed medicines; such use should be supported by appropriate
evidence and experience.
The doses stated in the BNF are intended for general guidance and represent, unless
otherwise stated, the usual range of doses that are generally regarded as being suitable
for adults.
Prescribing unlicensed medicines
 Prescribing medicines outside the recommendations of their marketing authorisation
alters (and probably increases) the prescriber’s professional responsibility and potential
liability. The prescriber should be able to justify and feel competent in using such
medicines, and also inform the patient or the patient’s carer that the prescribed medicine
is unlicensed.

New stations
1)LRTI prescription – 1 year child diagnosed with LRTI. Weight 9kg. Prescribe Cefuroxime
and maintenance IV fluid. Also prescribe Chlorphenamine maleate PRN.
2) Simman chest infection ( sepsis)
3) Weakness ? Parkinsons
4) Cauda equina syndrome
5) Paralytic ileus ( Patient did not open bowel for 5 days)

4157 Video not available

Idiopathic intracranial hypertension [ IIHTN]

Question
30year old lady presents with headache.
History, examination and management.

How can I help you? – I have been having headache

Since when? - Last few weeks
Which part of head? – All over my head.
Do you know how did it start? – No
Is the headache worse at any particular time of the day? (early morning headache in brain
tumour) – No
Anything makes it worse or better? – No
Any injuries to your head? – Nothing
How severe is your headache? - 7 out of 10
Do you have headache only one side? (migraine) – No
Do you get headache while combing hair or chewing? – No
Any fever? (Meningitis) – No
Any sudden onset severe headache at the back of your head ? ( SAH) - No
Any injuries to your head? – No
Any other symptoms other than headache? – Like what?
Any problems in hearing? – No
Do you hear any abnormal sound inside your ears (Tinnitus)? ( IIHTN) – Yes/ No
Any problems with your vision? – Sometimes when I bend forward I lose my vision.
Any coloured halos in your vision? (Glaucoma) – No
Any nausea or vomiting (early morning nausea vomiting in brain tumour)- Yes I feel
nauseas sometimes in the morning.
Do you get headaches while reading books or looking at distant objects? (refractory error) -
No

Have been diagnosed with any medical conditions previously? – No

Have been diagnosed with any brain conditions like infectionsof the brain, brain tumours, ?
– No
Any head injuries in the past? - No
Have been diagnosed with anaemia? No
Any kidney or thyroid problems? – No
Any problems passing urine? (Kidney disease) –No

Are you taking any medications? - No

Are you taking any contraceptive pills? – Yes
Are you allergic to any medicines? – No
Any of your family members has similar problems? – No
Any of your family members been diagnosed to have any brain tumours? - no
Have gained or lost weight recently (brain tumour, Thyroid problem)? – No
Any weakness of arms or legs? (Brain tumour) – No

What do you think of your weight? Do you think your weight is normal, overweight or
underweight? (idiopathic intracranial hypertension) - I am overweight.
Do you know what is your BMI? – High

What do you do for living? – I am a teacher

Does it affect your job? - Sometimes I have to take off from my work because of headache.

Thank you for the information.

Examination
I need to do full neurological examination – Examiner may say normal
I need to do eye examination
Mannequin kept in the cubicle
Eye – inspection – normal ( no squint)
Visual acuity – Normal (6/6)
Red reflex – Normal
Fundoscopy – shows papilloedema
Optic Nerve Head Appearance
Blurred disc margins
Absence of physiological cup
Vessels Obscuration- Swollen/Elevated RNFL
Flame haemorrhages
Absence of spontaneous venous pulsation (SVP)

Diagnosis

I can see some abnormality inside your eye what we call as papilloedema which usually
happens if the pressure inside your head increases.
With my examination so far I could not find out what exact is the cause for your increased
pressure inside your head. Sometimes it can happen due to some reasons like brain
tumour or some other reason but sometimes it can happen without any know reason what
we call as Idiopathic intracranial hypertension ( old term - pseudo tumour cerebri).

Is it serious?
It can be serious sometimes because if not treated immediately there is a risk of losing
vision permanently.

Why did I get this condition?

This condition ( IIHTN) is common in women than men and it is common between the
ages of 20 to 50 ( child bearing age group). More common who are overweight.
Sometimes some other conditions can cause this – like problems in the kidney, thyroid, or
hormone problems or anaemia. Sometimes it can happen in those who had brain infections
or injuries to the brain in the past.

Management

You need to be seen immediately by the Eye specialists. We will call the ambulance to take
you to the A&E and they may refer you to the eye specialists.
What will the specialists do ?

They will assess you further and may do CT and MRI scans of your head what exactly is
 causing the increased pressure inside your head.
If they also find that your eye is affected they may give you some medications what is
called acetazolamide to reduce the pressure inside your eye.
Further treatment may depend on if you have any other cause like brain tumour or other
cause causes then they need to be treated.

It is very important that you need to reduce your body weight.

Surgery: In severe cases, you may need surgery for IIH.

[Papilloedema is bilateral optic disc swelling that is secondary to elevated intra-cranial

pressure (ICP). Can be unilateral. May be asymmetric. All patients presenting with
papilloedema should be suspected of having an intra-cranial mass until there is proof to the
contrary. Not a Primary condition.]
The most common sign of intracranial hypertension is a sudden, severe headache.
Sometimes the headache is so painful that it wakes you from sleep. People with IIH may
also have a change in vision. You might see double or have sudden blind spots. Several
conditions can cause these symptoms, so check with your provider to find out if symptoms
are related to IIH or another condition.
Intracranial hypertension symptoms can also include:
 Fatigue.
 Headaches.
 Loss of peripheral (side) vision.
 Nausea and vomiting.
 Shoulder and neck pain.
 Temporary blindness.
 Tinnitus (ringing in your ears).

Symptoms Headaches Pulsatile Tinnitus/ ‘Whooshing’ Sound (‘Ringing’) Nausea &

Vomiting – usually 1st thing in the morning Enough to wake you from your sleep Worse
upon physical exertion coughing/sneezing Worse when moving from seated to standing.

4158 Video not available

Opioid Overdose [ simman ]

Middle aged man had injured his lumbar vertebra few days ago. Conservative treatment
was decided. He was treated with Morphine and was sent home. Patient presented to the
A&E with some concerns. Talk to him and address his concerns.
History

How can I help you? - I am not feeling well.

[ Check the monitor – Oxygen saturation – 91%, heart rate – 80, BP – 90/70, RR – 10 ]
What you mean by not feeling well what exactly is happening to you? – I don’t know I am
just not feeling well.
Since when? - Last few hours and it is getting worse.
Have you been diagnosed with any medical conditions? - I had injured my back few days
ago and doctors told me I have fractures on my back bones.
What was done for that? They told me that I don’t need any operation it will heal on its
own and gave me some pain killer medication.
Which medications? – Morphine
Since when are you taking this medication (How many days)? –
Have been taking the medications as prescribed? – Yes
Have you taken more medicine than prescribed? – No
Can you please tell me the strength of the tablets and how many times a day you have been
taking this Morphine? Check the dose of morphine prescribed given in the question?)

Have you been taking any other medications along with Morphine? (Any other sedatives) –
No

Have you been taking any recreational drugs? – No

Have you been diagnosed with any other medical conditionals apart from this injury to
your back?
Are you allergic to any medicines?
Patient may stop talking.

Check the response – AVPU

Patient un-responsive
DO ABCDE

Airway - Since the patient has been talking airway is patent however tongue may be
obstructing the airway. I will insert oropharyngeal airway. Give high flow oxygen.
Saturation increases.

Check Breathing and Circulation together for 10 seconds – Lungs are working carotid
plse felt. Patient not in cardiac arrest.
Breathing problems – Resp. Rate -10
Chest –Inspection, Deep breaths, Expansion – symmetrical, No rashes on the skin,
Palpation, trachea – central, Expansion equal.
Percussion – Normal
Auscultation – Normal
Circulation – Heart rate – 80, BP – 90/70, ECG appears normal rhythm on the monitor.
Periphery – cap – refill – normal, No cyanosis, Not warm or cold.
No signs of bleeding
Heart auscultation – Normal
I will insert IV cannula and take blood for FBC, U&Es, Toxicology screen,
(Give IV fluids - NS 500ml within 15 minutes since the BP is very low)

Disability – I will check the sugar level (examiner gives the level as 5 mmols – normal)
Check the GCS
Check the pupils – Examiner says – Pin point pupils.

I suspect he has opioid poisoning because he has been taking Morphine and his resp. rate is
very low, Oxygen sat is low and has pin point pupils.
I want to give him Naloxone 0.4mg in 1ml ( 400 micrograms) – [check the trolley and
pick up the Naloxone]

Reassess for improvement – check improvement in Oxygen saturation, RR, BP, Pupils
dilating, and patient regaining consciousness. Ask patient is he feeling better.

[ If no improvement – repeat Naloxone every 2 to 3 minutes same dose (4 mg dose may be

required in seriously poisoned patients)

Patient recovered.

Exposure – I want to completely expose the patient for any rashes, any rec. drug abuse
needle marks.

We need to review his medication as he had overdose effect with the prescribed dose. We
may need to consider giving him home Naloxone.
I will talk to my seniors.

1.1 Opiate overdose or intoxication is characterised by:

Mild intoxication:
“Spaced out”, glazed response, pinpoint pupils (miosis), sweating
Moderate intoxication:
Nodding with efforts to hold up head
Severe intoxication:
Respiratory depression (<12 breaths/min with no signs of distress, may be unable to talk),
sedated, bradycardia (slow heart rate<60 beats/min), hypothermia, hypotension, cyanosis.
Stupor or impaired levels of consciousness. May progress to loss of consciousness

Teach breaking bad news to the medical student

Develop rapport
Is there anything I can help you with?

Student- How can I tell the patient that he has cancer?

As you know cancer is a bad news. There is a way to break the bad news to the patient.

You need to show sympathy, empathy and that you really care for them while talking.

We should break the news in layers.

Usually we follow a format (Pneumonic) what we call as SPIKES

S stands for = setting up the scene

You should take the patient to a quiet, comfortable private room, taking account of the
need for confidentiality, where there is no one to disturb you while speaking to the patient.
You should hand over you bleep to your colleague so that you will not be bleeped while
you are talking to the patient.
Close the door.
May be you can take another colleague or nurse for your and patient’s comfort.

Develop a good rapport before you talk of their diagnosis – like you can ask them how
they are doing currently, any symptoms troubling them currently.
Tell them the purpose of your consultation – You had done tests previously and you got
the results and you are there to tell them their results.
Ask them whether they want to know the results.
P stands for patient’s perception
Before you tell the bad news you need to check whether they are mentally prepared to hear
the bad news. You can ask them what do they think the result may show?
If they mention some simple condition means they are not mentally prepared to hear the
bad news.

If they are not mentally prepared to hear the bad news, then you need to prepare them by
giving 2 warning shots.
First warning shot – You can say you don’t have a good news about the result – do you
want to know? They may say yes. Then second warning shot is asking them if they want
any of their family members or friends to be with them when you talk.

‘I’ stands for inviting = inviting them to know the diagnosis or asking them whether they
want any of their family members (inviting family members) or friends to be with them
when you talk.
You can also ask how much they want to know if they want to know. Some patients just
want to know the diagnosis but they don’t want to know how long they may live.

Once they are prepared to hear the news – break the news [ K = giving knowledge means
breaking the news and addressing their concerns] saying that they have a cancer and
give a pause so that the information sinks into them.
Patients usually go into 5 stages of grief or emotions when you break the bad news
1. Denial, 2. Angry, 3. Bargaining, 4. Depression and 5. Acceptance.

Bargaining means they may request the doctors to do something so that they can live long.
When they understand that they may not be able to live long - initially they will be very
depressed and finally they will accept it.

You need to deal with their emotions showing lot of sympathy and empathy and being
very sensitive about their feelings.
Once they accept their conditions then you can start talking about the management of their
condition which S= strategy in the pneumonic.
4159 Video not available

Teaching cancer pathway to the medical student

Urgent =2 weeks
Very urgent = 48hours
Immediate = within the next few hours.

GRIPS – Develop rapport.

Is there anything you are interested in learning from me?

Student - I want to know about cancer pathway.

-A Cancer Pathway is the patient's journey from the initial suspicion of cancer through
Clinical Investigations, diagnosis and treatment.
This could be by: Initial referral to a hospital specialist by the patient's general practitioner
or from the A&E.

Why do we have this pathway?

This pathway has a time frame from the suspicion of cancer to the diagnosis and treatment
-means GP’s need to refer the patients to the cancer specialists as soon as possible.
In most of the suspected cancers the referral time is urgent means 2 weeks. However, in
some other type of cancers it could be very urgent means within the 48 hours.
Usually the investigations should to be done and the patient should be told whether he/she
has cancer or not within 28 days from the referral time.
Sometimes GPs themselves can do some investigations very urgently ( within 48 hours)
( direct access investigations – eg; chest X ray for lung cancer, Full Blood count for
Leukemia) if they suspect the patient has cancer.

Benefits of pathway

Benefits for patients and carers:

• Reduces anxiety and uncertainty of a possible cancer diagnosis, with less
time between referral and receiving the outcome of diagnostic tests.
• Lesser visits to the hospital, particularly to specialist centres, and avoiding emergency
admission.
• Potential for earlier recognition and initiation of pre-optimisation for
treatment that could reduce complications and adverse outcomes.

For systems:
• Reduced demand in outpatient clinics with increased straight to test
provision and use of pathway navigators.
• Resources can be targeted at patients with cancer by removing non-cancer
patients earlier in the pathway.

For clinicians
• Using a nationally agreed and clinically endorsed pathway to support
quality improvement.
• The use of predetermined diagnostic algorithms and standards of care to
 help clinical decision-making and reduce delays for multidisciplinary
team (MDT) discussion.

This pathway includes recommendations on the symptoms and signs that warrant
investigation and referral for suspected cancer.

The recommendations are organised by:

1. the site of the suspected cancer : eg - Refer people using a suspected cancer
pathway referral (for an appointment within 2 weeks) for lung cancer if they:
a) have chest X-ray findings that suggest lung cancer or
b) are aged 40 and over with unexplained haemoptysis.

2. the symptom ; eg-

a) Lung cancer: Offer an urgent chest X-ray (to be done within 2 weeks) to assess for
lung cancer in people aged 40 and over if they have 2 or more of the following
unexplained symptoms, or if they have ever smoked and have 1 or more of the
following unexplained symptoms:
Cough, fatigue, shortness of breath, chest pain, weight loss, appetite loss.

b) Leukaemia in adults
Consider a very urgent full blood count (within 48 hours) to assess for leukaemia in adults
with any of the following:
Pallor, persistent fatigue, unexplained fever, nexplained persistent or recurrent infection,
generalised lymphadenopathy, unexplained bruising, unexplained bleeding, unexplained
petechiae, hepatosplenomegaly.

3. the findings of primary care investigations

a) If the GP finds Anaemia (iron deficiency) in patients aged 60 and over suspect
Colorectal cancer and refer the patient using a suspected cancer pathway
referral (for an appointment within 2 weeks)

b) Bone sarcoma in children and young people

Consider a very urgent referral (for an appointment within 48 hours) for specialist
assessment for children and young people if an X-ray suggests the possibility of bone
sarcoma.
Who is it for?
1. Healthcare professionals
2. People involved in clinical governance in both primary and secondary care
3. People with suspected cancer and their families and/or carers

4161 Video not available

LYMPHOMA
Question
You are the FY2 in GP surgery.
40 year old Mr…… had presented with some concerns.
Talk to him and address his concerns.

D-Hello Louise … (Introduction)

D-How can I help you today ?
P-Doctor I have noticed this swelling on my neck for the past 2 weeks and just thought I
will get it checked.
D-Well Louise you did an amazing job by coming to us. Don’t worry I just need to know
some information and then we can help you better. Is that okay? P-Sure.
D- Can you tell me more about your swelling ?
P- Well I noticed it about 2 weeks ago, it is on the right side, it didn’t cause me any
problems .
D-what size was it? P- about a size of a pound coin.
D- is it single or multiple ? P- I have noticed only one.
D- By any chance did you notice swelling anywhere else in your body ? P- no
D- how does it feel to touch ? P- well I am not sure … ?firm
D- is it warm ? P- no (infection)
D- any redness ? no/ any pain? No /any discharge ? no /any itching ? no

D- do you have any difficulty swallowing?- no

D-does it move on tongue protrusion (thyroglossal cyst)? P- No
D- any fever? no / weight loss? No / loss of appetite ? no / night sweats ? no (lymphoma)
D- any cough? Breathlessness? no (TB) any sore throat (tonsil), tooth prob ? ear infection?
- no
D- any tiredness? heart racing? no
D- bowel and bladder normal? yes (HIV)
D- Have you been diagnosed with medical conditions in the past ? No

MAFTOSA
D- any medical conditions ? no
D- any medications (any immunosuppressant medications? ? no
D- allergy ? no
D- family history of any medical condition or serious illnesses?
P-yes my father died of blood cancer
D-I am so sorry about your loss. Are you okay ? yes
D- travel ? (TB) no , contact with anyone ? no
D- do you smoke ? P- no
D- do you consume alcohol ? P- socially
D- are you sexually active ? yes /do you have a stable partner ? yes /do you practise safe
sex (HIV)? yes
D- is there anything else you want to tell me ? P- no
Thank you for answering all my questions .
Do you have any idea what might have caused this ? no

Examination:
I would now like to examine you if that’s okay ? P- yes
I would be checking your Vital signs like your PR,BP,O2,RR,Temperature
I would also be examining your neck, your oral cavity including tonsils, your armpits and
your groin area for other lumps.
I need to examine your tummy to check your organs like liver and spleen.

Provisional Diagnosis:

D- I suspect you may have a condition what we call as Lymphoma. Have you heard of it ?
no
Lymphoma is a cancer of the lymphatic system, which is part of the body's germ-fighting
network. The lymphatic system includes the lymph nodes (lymph glands), spleen, thymus
gland and bone marrow. Lymphoma can affect all those areas as well as other organs
throughout the body.

Many types of lymphoma exist. The main subtypes are:

 Hodgkin's lymphoma (formerly called Hodgkin's disease)

 Non-Hodgkin's lymphoma

D- Do you have any concerns? P –why did I get this cancer?

D- There could be many reasons why one can get this type of cancer.

What exactly causes of lymphoma is not known. But it begins when a disease-fighting
white blood cell called a lymphocyte develops a genetic mutation (change). The
mutation tells the cell to multiply rapidly

Some types of lymphoma are more common in young adults, while others are most often
diagnosed in people over 55.

Males are slightly more likely to develop lymphoma than are females.

Lymphoma is more common in people with immune system diseases or in people who
take drugs that suppress their immune system.

Developing certain infections. Some infections are associated with an increased risk of
lymphoma,[ including the Epstein-Barr virus and Helicobacter pylori infection].

D- Do you have concerns? P- what will do now for me?

Investigations
We will do some basic blood tests.

We will refer you to the specialist called Heamatologist urgently through what we call
as cancer pathway. They will see you within the next 2 weeks.

To confirm whether you have this condition or not, they may do some investigations what
we call as biopsy where they take out the lump or some tissue from the lump and look
under the microscope. They may also do other tests like removing sample from the bone
marrow to test and scans like CT scan, MRI scans and PET scans.
D- do you have any more concerns ?
P- What if it is a lymphoma, how will you treat me ?

Treatment

D - Specialist doctor will tell you how they are going to treat you.
Which treatments are right for you depends on the type and stage of your disease, your
overall health, and your preferences. The goal of treatment is to destroy as many cancer
cells as possible and bring the disease into remission.
There will be a Multidisciplinary team who will sit and discuss the best treatment options
for you.

Lymphoma treatment may involve

chemotherapy,
radiation therapy,
a bone marrow transplant.

P- is there anything I should look out for ?

D- yes definitely in this meanwhile if you develop any fever, night sweats, swelling is
getting bigger, painful, harder, swelling anywhere else in the body please don’t hesitate to
contact us and we will take it from there.
P- thank you so much doctor.

--------------------------------------------------------------------------------------------------------------

 Chemotherapy. [Chemotherapy uses drugs to destroy cancer cells].

 Radiation therapy. [Radiation therapy uses high-powered beams of energy,

such as X-rays and protons, to kill cancer cells].

 Bone marrow transplant. [A bone marrow transplant, also known as a stem

cell transplant, involves using high doses of chemotherapy and radiation to
suppress the bone marrow. Then healthy bone marrow stem cells from the
patient’s own body or from a donor are infused into the blood where they
travel to the bones and rebuild the bone marrow].
 Sickle Cell Disease
Question
You are the FY 2 in GP clinic.

32 year old man came with some concerns.

He was tested for sickle cell disease twice which was normal.
Talk to the patient and address his concerns.

History
Dr - How can I help you?
Pt - I want to know about the test result.
Dr - Do you know what test we did for you?
Pt – Yes, I was worried whether I have sickle cell disease. That is why you did some blood
tests. I want to know the result of that.
Dr - Yes, we have received your results of your blood test for sickle cell disease and other
blood disorders. Surely, I will discuss the results with you. Before that can I ask you few
question regarding your health? Pt - Yes
Dr - Can you please tell me why were you worried that you may have sickle cell disease?
Pt - My brother has sickle cell disease. I was told it can run in the family. That is why I
came here to do the tests.
Dr - Okay. You have done a good thing by coming to us and having the test done.
Dr - Can I ask you whether you have any symptoms of sickle cell disease? Pt - No
Dr - For example – Any pain over your chest, tummy, legs, Any vision problems,
Tiredness (anaemia), Frequent infections? SOB (due to pulmonary hypertension)? Pt - No
Dr - Did you ever have any strokes (complication of Sickle cell disease)? - No
Dr - Have been diagnosed with any other medical conditions? – Pt - No

Dr - Have your parents been diagnosed with any medical conditions?

Dr - Have your parents been diagnosed with sickle cell disease or carrier of sickle cell
disease?

Dr - Do you have any other siblings?

If so, do they have sickle cell disease or are they carrier of this disease?
Dr - Are you married?
Dr - Do you have children? If he has children, do they have any medical conditions?

Thank you for all the information.

Counselling
Dr - Mr. Do you know what exactly is sickle cell disease?
Pt - I know that it is some problem in the blood.
Dr - Yes, you are right. Let me explain that in detail.

Blood has different types of cells called red cells and white cells.
Red cells have some iron-rich compound called haemoglobin which enables red blood
cells to carry oxygen from the lungs throughout the body. In this condition because of
genetic problem haemoglobin becomes abnormal which causes the red cells to become
rigid, sticky and misshapen.
Normally, the red cells round and flexible, so they move easily through blood vessels. In sickle
cell anaemia, some red blood cells are shaped like sickles or crescent moons. These sickle cells also
become rigid and sticky, which can slow or block blood flow to the tissues and organs in the body.
This causes anaemia because the abnormally shaped red cells die sooner. Also because it can slow
down and block the blood flow to the tissues it can cause severe pain in the chest, tummy legs and
also can cause vision problems. Sometimes it can cause stroke too.
If the person has this condition they need pain killers whenever they get pain and blood
transfusion or sometimes we have to do bone marrow transplant.

Dr - Are you following me so far? Yes

This condition is genetically inherited means it can run in the family.

There are two types of genetically inherited conditions what we call as Autosomal
dominant and autosomal recessive.
Sickle cell disease is inherited as autosomal recessive.
For someone to get sickle cell disease both the parents should either have sickle cell
disease or they should be carriers of this disease.
Each parent will have one normal haemoglobin gene and one abnormal haemoglobin
gene.
Child inherits one gene from each parent.

Let me explain this with a diagram. (ask for pen and paper)
If the child inherits two normal genes (one normal gene from each parent) then the child
will be normal means that child will not have sickle cell disease or the child will not be a
carrier of the disease otherwise called sickle cell trait. There is 25% chance that the child
can be normal.

If the child inherits two abnormal genes (one abnormal gene from each parent) from each
parent) then the child will have the disease. There is 25% chance that the child can be
born with the disease.

If the child inherits one normal gene from one parent and one abnormal gene from the
other parent, then the child will not have the disease but the child will be a carrier of the
disease called sickle cell trait means that child can pass on the disease to their children.
There is 50% chance the child can be born as a carrier.

You mentioned that your brother has been diagnosed with sickle cell disease that means
both your parents may be carriers of this disease. There was 25% chance of you having this
disease, 25% of not having the disease and 50% chance of you being a carrier of this
disease. Do you follow me so far? Pt - Yes

Reassure:
However, good news for you is that we have done blood tests twice to check whether you
have this disease or whether you are a carrier of this disease – and the test shows that you
are normal means that you do not have the disease nor you are a carrier of this
disease.

You do not need any treatment. Also you do not inherit this disease to your children.
Even if your partner is a carrier of the disease or even if your partner has this disease your
children will not get this condition or they will not be a carrier of this condition.

Dr - Do you have any other concerns?

Thank you.

If the parents are carriers of this condition they will need genetic counselling.

What You Should Know About Sickle Cell Disease and Pregnancy

What Causes Sickle Cell Disease And Sickle Cell Trait?

Sickle cell disease (SCD) is a genetic condition that is present at birth. It
is inherited when a child receives two sickle cell genes—one from each
parent. A person with SCD can pass the disease on to his or her children.
Sickle cell trait (SCT) is not a disease, but means that a person has inherited
the sickle cell gene from one of his or her parents. People with SCT usually
do not have any of the symptoms of SCD and live a normal life, but they can
pass the sickle cell gene on to their children.
• When both parents have SCT, they have a 25% chance of having a child
with SCD with every pregnancy.
• When both parents have SCT, they have a 50% chance of having a child
with SCT with every pregnancy

Does Someone With Sickle Cell Disease Or Sickle Cell

Trait Need To See A Genetic Counselor?
The best way to find out if and how SCD runs in someone’s family is for that
person to see a genetic counselor. These professionals have experience with
genetic blood disorders. They also specialize in prenatal genetic counseling.
The genetic counselor will look at the person’s family history and discuss
with him or her what is known about SCD in the person’s family. It is best
for a person with SCD or SCT to learn all he or she can about SCD before
deciding to have children.

What Should Someone With Sickle Cell Trait Or

Sickle Cell Disease Do If He Or She Is Planning To
Have A Baby?
A woman and her partner should get tested for SCT if they are
planning to have a baby.
• Testing is available at most hospitals or medical centers,
from SCD community-based organizations, or at local health
departments.
• If a woman or her partner has SCT, a genetic counselor can
provide additional information and further discuss the risks to
their children.
Will Someone With Sickle Cell Trait Or Sickle Cell
Disease Have A Baby With Sickle Cell Disease Or
Sickle Cell Trait?
During pregnancy, prenatal testing can be done to find out if a
baby will have SCD, SCT, or neither one.
• The prenatal tests chorionic villus sampling (CVS) and
 amniocentesis often are used to find out if the baby will
have the disease or carry the trait. These tests usually are
conducted after the second month of pregnancy.
Can Women With Sickle Cell Disease Have A
Healthy Pregnancy?
Yes, with early prenatal care and careful monitoring throughout
the pregnancy, a woman with SCD can have a healthy pregnancy.
However, women with SCD are more likely to have problems
during pregnancy that can affect their health and that of their
unborn baby. Therefore, they should be seen often by their
obstetrician, hematologist, or primary care provider.
• During pregnancy, SCD can become more severe and pain
episodes can occur more frequently.
• A pregnant woman with SCD is at a higher risk of preterm
labor and of having a low birth weight baby.
Can Women With Sickle Cell Trait Have A Healthy
Pregnancy?
• Women who have SCT also can have a healthy pregnancy.
• Pregnant women with SCT also should be monitored by their
obstetrician or primary care provider for the same health
complications as for all pregnant women.

4163 Video not available

Herpetic Whitlow
Question
You are the FY2 in GP Surgery
30 year old man has some concerns and made an appointment to see you.
Talk to the patient and address his concerns.

What are the stages of herpetic whitlow?

Contagious skin condition caused by herpes simplex virus.

Herpetic whitlow causes painful blisters on your fingers around your nails. The early stages
of the condition include pain and a tingling sensation on your finger. Then, blisters form
near your fingernail, which causes your skin to be tender and sensitive. Within a few days,
a crust will form, along with drying and healing. Most cases of herpetic whitlow affect one
finger, but it can spread to other fingers, too.

SYMPTOMS AND CAUSES

What are the signs and symptoms of herpetic whitlow?

Signs and symptoms of herpetic whitlow include:

  Blisters or fluid-filled bumps on the skin near your fingernail.
 Colour changes to the skin around your nail, usually darker than your normal skin
tone, or red to purple.
 Swollen finger.

Who does herpetic whitlow affect?

Herpetic whitlow can affect anyone at any age, but the condition is most common in:

 Children who suck their thumbs.

 Healthcare workers, like dental hygienists and respiratory therapists with exposure
to peoples’ mouths (oral mucosa).
 People exposed to genital herpes.
 Athletes, like wrestlers, who have close contact with others.
 People with a weakened immune system.

[Has a bandage on his finger and holding his finger due to severe pain].

Dr - How can I help you?

Doctor, I have blisters on my finger. They are very painful. Can you please “pop” it for
me?
Dr - How long you had it for? Pt- 2 days
Dr - How did it start? Pt - Initially I had pain and tingling sensation on my finger then I
started to have these blisters.
Dr - Do you have it anywhere else? Any such blisters or skin lesions on your toes, mouth
or genital area (genital herpes – STI)? – Pt - No
Dr - Any swelling of the fingers? Any redness of the fingers?
Was there any clear fluid or pus discharge ( Paronychia, Felon)?
Did you have fever before these symptoms on your finger (usually herpetic whitlow there
is fever before the symptoms on the finger)?
Contact history:
Did you anyone else close to you had such symptoms (contagious)?
Have you had this problem before? Any such lesions on your mouth or genital area
before?
[You're more likely to get herpetic whitlow if you've had cold sores or genital herpes].
Sexual history:
Are you married? Do you have stable partner? ( Patient may be divorced).
Do you have unprotected sex?

Differentials for herpetic whitlow

1.Felon (Staphylococcal whitlow) - is a closed-space infection of the distal finger pulp. It

presents with a rapid onset of very severe, throbbing pain, with redness and swelling of the
distal pulp of the fingertip. There is usually a history of a penetrating injury or untreated
paronychia. Fluctuation and pointing of an abscess may be present.
Any injury?
2. Cellulitis - fever
3. Paronychia – pus discharge
4. Cancer (for example melanoma or squamous cell carcinoma) – Bleeding, Weight loss

Have you had it before? (herpetic whitlow can be recurrent)

Did you have any other medical condition recently? Yes, I had cold sore (painful blisters)
(caused by herpes simplex) on my face 2 weeks ago. [ Herpetic whitlow can happen after
cold sore].

[High risk if the patient is Immunocompromised]

Have been diagnosed with any medical conditions? Diabetes
Are you on any medications? Chemotherapy?

Examination
Vital signs – Normal
Examination of the finger – Shows picture

 swelling
 blisters or sores on the finger
 skin becoming red or darker than the usual skin tone

Investigation
We need to take swab from the lesion and send for a test called culture to check for any
bacterial kind of bugs. PCR test for the virus.

DIAGNOSIS

What is herpetic whitlow?

Dr - Herpetic whitlow is an infection of the skin around your fingernail. It is caused by a

virus type of bug called herpes simplex virus (type 1 or type 2). It happens when the virus
penetrates your skin through a break in your skin near your nail.

Pt - Why did I get it?

Dr - It can spread from one place to another place and also it can spread from one person
to another person through physical contact. The condition is most contagious when you
have blisters on your skin. When blisters begin to crust, the virus is no longer contagious.

Since you told me you had a cold sore on your face which is also caused by the same virus
few weeks ago may be this has spread from the face to the finger now if you have touched
the cold sores on your face with the finger.

There is higher chance of getting this if the person has low immunity like if someone has
diabetes and receiving chemotherapy.

You're more likely to get herpetic whitlow if you've had cold sores or genital herpes.

This condition is not that common.

Treatment
Unfortunately, there is no cure for this condition. It usually resolves by itself in about 2 to
3 weeks. It's easily treated but can come back. Once you have the virus, it stays in your
body for the rest of your life.

We do not “pop” as you requested because the blister as it can spread. [ Incision and
drainage not recommended)

We can treat your symptoms.

An antiviral medication (acyclovir) may be prescribed if the patient presented within 48
hours of start of the symptoms. Antiviral tablets can help your finger to heal more quickly.

We can also prescribe Paracetamol or Ibuprofen for the pain.

Herpetic whitlow deserves good wound care. Use compresses and protection with
bandages to prevent secondary infection.

Covering your blisters also prevents the spread of the virus to others.

How to prevent herpetic whitlow?

Prevention may be difficult, but the following measures can help:

 Frequent hand washing with soap and water.

 Wearing gloves in a healthcare setting, especially with close contact with people’s
mouths.
 [If it is a child affected -Stopping your child from sucking their fingers, especially
their thumb].

Occasionally, scars may develop if an infection is persistent or extensive.

Is herpetic whitlow an STD?

Herpetic whitlow isn’t a sexually transmitted infection (STI or STD). Herpes simplex, the
virus that causes the herpetic whitlow, can cause genital herpes (HSV-2), which is a
sexually transmitted infection.

What you should not do:

 do not touch the infected finger

 do not touch other people with your infected finger to avoid spreading the infection
 do not try to drain the fluid by squeezing the affected area
 do not touch other areas of your body with the infected finger, particularly your
eyes – if you wear contact lenses, use the hand that’s not affected to put them in and
take them out, or wear glasses until the infection has healed

Man Rape
Question
You are in the GP clinic.
19year old man presented to the GP clinic with some concerns.
Talk to him and address his concerns.
Dr - How can I help you? Pt- Can you please give me a sick note?
Dr - Why do you need a sick note?
[ Look anxious and worried. May not maintain eye con tact].
Pt- I am raped at a birthday party.
Dr - I am very sorry to her that. It must be very traumatic to you. We will help you as
much as we can. Please tell me the whole incident.
Pt- I was at a birthday party at my brother’s house last night. One of my brother’s friend
raped me last night.
About the incident:
Dr - You mean to say he did this your consent? Pt- Yes
Dr - Is this the first time? Pt- Yes
Dr - Was your brother there at that time? Does he know about this?
Dr - Did he have anal sex? Oral sex? Did he force you to have anal or oral sex?
Did he use any condoms?
Dr - Did you sustain any injuries?
Dr - Was he or were under the influence of alcohol or recreational drugs?
Dr - Has he ever had sex with you before? Pt-No
Dr - Who else was there?
After the incidence:
Dr - What happened afterwards?
Dr - Did you tell anyone?
Dr - Did you go to the A&E department (hospital)? - No
Dr - Did you inform the police? – No Dr - Why did not inform?
Dr - Did you tell your parents? – No Dr - Why you did not inform?
Dr - Has he threatened you not to tell anyone?

Dr - Did you wash yourself after this incident?

Dr - Did you use toilet after the incident? (may not be able to take any samples for tests if
he has already washed himself or used toilet after the incident)

Dr - Are you upset or worried about it? Are you scared that he might hurt you or do it
again?
Past history:
Dr - Have been diagnosed with any medical or mental health conditions?
Dr - Have you been diagnosed with any sexually transmitted infections before?
Dr - Are you on any medications?
Dr - Are you allergic to any medications?

Relationship:
Dr - Do you have any sexual partners? Male or female?
Dr - Did you have sex with your partner after the incident? (may transmit any STI to his
partner)
Dr - Do you think the person who sexually assaulted you has any medical conditions or
sexually transmitted infections?
Social history:
Dr - What do you do? Pt- I go to the college.
Dr - Where are your parents?
Dr - Do you have any friends to support you?
Dr - Where do you live?
Dr – Do you have a safe place to stay now after this incident
Impact on life:
Dr - Has this affected you in anyway?

What does he want to do now:

Dr - Do you want to complain this incident to the police?
Dr - Would you like to inform your brother or your parents or friends?
Dr - You asked for the sick note. Is it to give it to the college? Why do feel like not going
to the college? How long you think you want to stay away from college?

Examination
We need to examine you. I will talk to my seniors. (Let the seniors examine the patient)
We need to examine your genital area and the back passage to check for any injuries.
Also we need to examine you whole body for any injuries. Is that Okay? (consent is very
important).
[If he wants to put a police complain do not examine. Leave it to the specialist (forensic
team) who is trained in such sexual assault cases to examine].
If the patient not washed himself or changed clothes or used the toilet – advise him to not
to do any of these until the forensic team examines him.

Counselling
Dr - Do you have any concerns? Is there anything in particular you are expecting from us
other than the sick note?
I can imagine this is very difficult and stressful time for you.
We are here to help you.

These type of sexual abuse is illegal and it is important to report this to the police.
We suggest you to report it to the police. However, it is your decision. We cannot force
you to do that. If you do not report it to the police you may not be entitled for any
criminal injury. [If he does not want to report to the police ask him why he doesn’t want
to report it]
If the patient does not to report the matter to the police suggest him to attend sexual
assault referral centre [SARC] for forensic and medical examination and specialist advice
and support.

[If there is no SARC or patient is unwilling to attend the SARC]

Make note of the injuries and take photographs with patient’s consent.
If he does not want to attend SARC he can attend SARC even later for help.

We may need to test you for sexually transmitted infections as this incident can
transmit STIs if that person has any STIs. We advise you to attend the GUM (Genito -
urinary medicine) clinic. They may do some blood tests for syphilis (at 3 months) and
HIV (3 to 6 months for seroconversion).
We advise you to talk to your parents and your brother or friends as you need help and
support.
If you are worried or depressed, we can refer you to Psychiatrist for counselling.
If you do not have any safe place to stay we can talk to the social service to arrange a
safe place for you to stay.

About the sick note:

You asked for the sick note and asked me what we will write on that? What do you want
us to write? Is there anything you don’t want us to write in that?
You can self-certify for 7 days of sick leave. We do not need to give sick note for 7 days.
You can simply mention that you have some injuries and you are not fit to attend the
college. We can give sick note after one week if you still can’t go to the college? What do
you say?
 We will have a Follow up at 2 weeks.

4162 Video not available

Sickle Cell Disease

Question
You are the FY 2 in GP clinic.

32 year old man came with some concerns.

He was tested for sickle cell disease twice which was normal.
Talk to the patient and address his concerns.

History
Dr - How can I help you?
Pt - I want to know about the test result.
Dr - Do you know what test we did for you?
Pt – Yes, I was worried whether I have sickle cell disease. That is why you did some blood
tests. I want to know the result of that.
Dr - Yes, we have received your results of your blood test for sickle cell disease and other
blood disorders. Surely, I will discuss the results with you. Before that can I ask you few
question regarding your health? Pt - Yes
Dr - Can you please tell me why were you worried that you may have sickle cell disease?
Pt - My brother has sickle cell disease. I was told it can run in the family. That is why I
came here to do the tests.
Dr - Okay. You have done a good thing by coming to us and having the test done.
Dr - Can I ask you whether you have any symptoms of sickle cell disease? Pt - No
Dr - For example – Any pain over your chest, tummy, legs, Any vision problems,
Tiredness (anaemia), Frequent infections? SOB (due to pulmonary hypertension)? Pt - No
Dr - Did you ever have any strokes (complication of Sickle cell disease)? - No
Dr - Have been diagnosed with any other medical conditions? – Pt - No

Dr - Have your parents been diagnosed with any medical conditions?

Dr - Have your parents been diagnosed with sickle cell disease or carrier of sickle cell
disease?

Dr - Do you have any other siblings?

If so, do they have sickle cell disease or are they carrier of this disease?
Dr - Are you married?
Dr - Do you have children? If he has children, do they have any medical conditions?

Thank you for all the information.

Counselling
Dr - Mr. Do you know what exactly is sickle cell disease?
Pt - I know that it is some problem in the blood.
Dr - Yes, you are right. Let me explain that in detail.
Blood has different types of cells called red cells and white cells.
Red cells have some iron-rich compound called haemoglobin which enables red blood
cells to carry oxygen from the lungs throughout the body. In this condition because of
genetic problem haemoglobin becomes abnormal which causes the red cells to become
rigid, sticky and misshapen.
Normally, the red cells round and flexible, so they move easily through blood vessels. In sickle
cell anaemia, some red blood cells are shaped like sickles or crescent moons. These sickle cells also
become rigid and sticky, which can slow or block blood flow to the tissues and organs in the body.
This causes anaemia because the abnormally shaped red cells die sooner. Also because it can slow
down and block the blood flow to the tissues it can cause severe pain in the chest, tummy legs and
also can cause vision problems. Sometimes it can cause stroke too.
If the person has this condition they need pain killers whenever they get pain and blood
transfusion or sometimes we have to do bone marrow transplant.

Dr - Are you following me so far? Yes

This condition is genetically inherited means it can run in the family.

There are two types of genetically inherited conditions what we call as Autosomal
dominant and autosomal recessive.
Sickle cell disease is inherited as autosomal recessive.
For someone to get sickle cell disease both the parents should either have sickle cell
disease or they should be carriers of this disease.
Each parent will have one normal haemoglobin gene and one abnormal haemoglobin
gene.
Child inherits one gene from each parent.

Let me explain this with a diagram. (ask for pen and paper)
If the child inherits two normal genes (one normal gene from each parent) then the child
will be normal means that child will not have sickle cell disease or the child will not be a
carrier of the disease otherwise called sickle cell trait. There is 25% chance that the child
can be normal.

If the child inherits two abnormal genes (one abnormal gene from each parent) from each
parent) then the child will have the disease. There is 25% chance that the child can be
born with the disease.

If the child inherits one normal gene from one parent and one abnormal gene from the
other parent, then the child will not have the disease but the child will be a carrier of the
disease called sickle cell trait means that child can pass on the disease to their children.
There is 50% chance the child can be born as a carrier.

You mentioned that your brother has been diagnosed with sickle cell disease that means
both your parents may be carriers of this disease. There was 25% chance of you having this
disease, 25% of not having the disease and 50% chance of you being a carrier of this
disease. Do you follow me so far? Pt - Yes

Reassure:
However, good news for you is that we have done blood tests twice to check whether you
have this disease or whether you are a carrier of this disease – and the test shows that you
are normal means that you do not have the disease nor you are a carrier of this
disease.

You do not need any treatment. Also you do not inherit this disease to your children.
Even if your partner is a carrier of the disease or even if your partner has this disease your
children will not get this condition or they will not be a carrier of this condition.

Dr - Do you have any other concerns?

Thank you.

If the parents are carriers of this condition they will need genetic counselling.

What You Should Know About Sickle Cell Disease and Pregnancy

What Causes Sickle Cell Disease And Sickle Cell Trait?

Sickle cell disease (SCD) is a genetic condition that is present at birth. It
is inherited when a child receives two sickle cell genes—one from each
parent. A person with SCD can pass the disease on to his or her children.
Sickle cell trait (SCT) is not a disease, but means that a person has inherited
the sickle cell gene from one of his or her parents. People with SCT usually
do not have any of the symptoms of SCD and live a normal life, but they can
pass the sickle cell gene on to their children.
• When both parents have SCT, they have a 25% chance of having a child
with SCD with every pregnancy.
• When both parents have SCT, they have a 50% chance of having a child
with SCT with every pregnancy

Does Someone With Sickle Cell Disease Or Sickle Cell

Trait Need To See A Genetic Counselor?
The best way to find out if and how SCD runs in someone’s family is for that
person to see a genetic counselor. These professionals have experience with
genetic blood disorders. They also specialize in prenatal genetic counseling.
The genetic counselor will look at the person’s family history and discuss
with him or her what is known about SCD in the person’s family. It is best
for a person with SCD or SCT to learn all he or she can about SCD before
deciding to have children.

What Should Someone With Sickle Cell Trait Or

Sickle Cell Disease Do If He Or She Is Planning To
Have A Baby?
A woman and her partner should get tested for SCT if they are
planning to have a baby.
• Testing is available at most hospitals or medical centers,
from SCD community-based organizations, or at local health
departments.
• If a woman or her partner has SCT, a genetic counselor can
provide additional information and further discuss the risks to
their children.
Will Someone With Sickle Cell Trait Or Sickle Cell
Disease Have A Baby With Sickle Cell Disease Or
Sickle Cell Trait?
During pregnancy, prenatal testing can be done to find out if a
baby will have SCD, SCT, or neither one.
• The prenatal tests chorionic villus sampling (CVS) and
amniocentesis often are used to find out if the baby will
have the disease or carry the trait. These tests usually are
conducted after the second month of pregnancy.
Can Women With Sickle Cell Disease Have A
Healthy Pregnancy?
Yes, with early prenatal care and careful monitoring throughout
the pregnancy, a woman with SCD can have a healthy pregnancy.
However, women with SCD are more likely to have problems
during pregnancy that can affect their health and that of their
unborn baby. Therefore, they should be seen often by their
obstetrician, hematologist, or primary care provider.
• During pregnancy, SCD can become more severe and pain
episodes can occur more frequently.
• A pregnant woman with SCD is at a higher risk of preterm
labor and of having a low birth weight baby.
Can Women With Sickle Cell Trait Have A Healthy
Pregnancy?
• Women who have SCT also can have a healthy pregnancy.
• Pregnant women with SCT also should be monitored by their
obstetrician or primary care provider for the same health
complications as for all pregnant women.

Herpetic Whitlow
Question
You are the FY2 in GP Surgery
30 year old man has some concerns and made an appointment to see you.
Talk to the patient and address his concerns.

What are the stages of herpetic whitlow?

Contagious skin condition caused by herpes simplex virus.

Herpetic whitlow causes painful blisters on your fingers around your nails. The early stages
of the condition include pain and a tingling sensation on your finger. Then, blisters form
near your fingernail, which causes your skin to be tender and sensitive. Within a few days,
a crust will form, along with drying and healing. Most cases of herpetic whitlow affect one
finger, but it can spread to other fingers, too.

SYMPTOMS AND CAUSES

What are the signs and symptoms of herpetic whitlow?

Signs and symptoms of herpetic whitlow include:

 Blisters or fluid-filled bumps on the skin near your fingernail.

 Colour changes to the skin around your nail, usually darker than your normal skin
tone, or red to purple.
  Swollen finger.

Who does herpetic whitlow affect?

Herpetic whitlow can affect anyone at any age, but the condition is most common in:

 Children who suck their thumbs.

 Healthcare workers, like dental hygienists and respiratory therapists with exposure
to peoples’ mouths (oral mucosa).
 People exposed to genital herpes.
 Athletes, like wrestlers, who have close contact with others.
 People with a weakened immune system.

[Has a bandage on his finger and holding his finger due to severe pain].

Dr - How can I help you?

Doctor, I have blisters on my finger. They are very painful. Can you please “pop” it for
me?
Dr - How long you had it for? Pt- 2 days
Dr - How did it start? Pt - Initially I had pain and tingling sensation on my finger then I
started to have these blisters.
Dr - Do you have it anywhere else? Any such blisters or skin lesions on your toes, mouth
or genital area (genital herpes – STI)? – Pt - No
Dr - Any swelling of the fingers? Any redness of the fingers?
Was there any clear fluid or pus discharge ( Paronychia, Felon)?
Did you have fever before these symptoms on your finger (usually herpetic whitlow there
is fever before the symptoms on the finger)?
Contact history:
Did you anyone else close to you had such symptoms (contagious)?
Have you had this problem before? Any such lesions on your mouth or genital area
before?
[You're more likely to get herpetic whitlow if you've had cold sores or genital herpes].
Sexual history:
Are you married? Do you have stable partner? ( Patient may be divorced).
Do you have unprotected sex?

Differentials for herpetic whitlow

1.Felon (Staphylococcal whitlow) - is a closed-space infection of the distal finger pulp. It

presents with a rapid onset of very severe, throbbing pain, with redness and swelling of the
distal pulp of the fingertip. There is usually a history of a penetrating injury or untreated
paronychia. Fluctuation and pointing of an abscess may be present.
Any injury?
2. Cellulitis - fever
3. Paronychia – pus discharge
4. Cancer (for example melanoma or squamous cell carcinoma) – Bleeding, Weight loss

Have you had it before? (herpetic whitlow can be recurrent)

Did you have any other medical condition recently? Yes, I had cold sore (painful blisters)
(caused by herpes simplex) on my face 2 weeks ago. [ Herpetic whitlow can happen after
cold sore].

[High risk if the patient is Immunocompromised]

Have been diagnosed with any medical conditions? Diabetes
Are you on any medications? Chemotherapy?

Examination
Vital signs – Normal
Examination of the finger – Shows picture

 swelling
 blisters or sores on the finger
 skin becoming red or darker than the usual skin tone

Investigation
We need to take swab from the lesion and send for a test called culture to check for any
bacterial kind of bugs. PCR test for the virus.

DIAGNOSIS

What is herpetic whitlow?

Dr - Herpetic whitlow is an infection of the skin around your fingernail. It is caused by a

virus type of bug called herpes simplex virus (type 1 or type 2). It happens when the virus
penetrates your skin through a break in your skin near your nail.

Pt - Why did I get it?

Dr - It can spread from one place to another place and also it can spread from one person
to another person through physical contact. The condition is most contagious when you
have blisters on your skin. When blisters begin to crust, the virus is no longer contagious.
Since you told me you had a cold sore on your face which is also caused by the same virus
few weeks ago may be this has spread from the face to the finger now if you have touched
the cold sores on your face with the finger.

There is higher chance of getting this if the person has low immunity like if someone has
diabetes and receiving chemotherapy.

You're more likely to get herpetic whitlow if you've had cold sores or genital herpes.

This condition is not that common.

Treatment
Unfortunately, there is no cure for this condition. It usually resolves by itself in about 2 to
3 weeks. It's easily treated but can come back. Once you have the virus, it stays in your
body for the rest of your life.

We do not “pop” as you requested because the blister as it can spread. [ Incision and
drainage not recommended)

We can treat your symptoms.

An antiviral medication (acyclovir) may be prescribed if the patient presented within 48
hours of start of the symptoms. Antiviral tablets can help your finger to heal more quickly.

We can also prescribe Paracetamol or Ibuprofen for the pain.

Herpetic whitlow deserves good wound care. Use compresses and protection with
bandages to prevent secondary infection.

Covering your blisters also prevents the spread of the virus to others.

How to prevent herpetic whitlow?

Prevention may be difficult, but the following measures can help:

 Frequent hand washing with soap and water.

 Wearing gloves in a healthcare setting, especially with close contact with people’s
mouths.
 [If it is a child affected -Stopping your child from sucking their fingers, especially
their thumb].

Occasionally, scars may develop if an infection is persistent or extensive.

Is herpetic whitlow an STD?

Herpetic whitlow isn’t a sexually transmitted infection (STI or STD). Herpes simplex, the
virus that causes the herpetic whitlow, can cause genital herpes (HSV-2), which is a
sexually transmitted infection.
 What you should not do:

 do not touch the infected finger

 do not touch other people with your infected finger to avoid spreading the infection
 do not try to drain the fluid by squeezing the affected area
 do not touch other areas of your body with the infected finger, particularly your
eyes – if you wear contact lenses, use the hand that’s not affected to put them in and
take them out, or wear glasses until the infection has healed

4164 Video not availale

Man Rape
Question
You are in the GP clinic.
19year old man presented to the GP clinic with some concerns.
Talk to him and address his concerns.
Dr - How can I help you? Pt- Can you please give me a sick note?
Dr - Why do you need a sick note?
[ Look anxious and worried. May not maintain eye con tact].
Pt- I am raped at a birthday party.
Dr - I am very sorry to her that. It must be very traumatic to you. We will help you as
much as we can. Please tell me the whole incident.
Pt- I was at a birthday party at my brother’s house last night. One of my brother’s friend
raped me last night.
About the incident:
Dr - You mean to say he did this your consent? Pt- Yes
Dr - Is this the first time? Pt- Yes
Dr - Was your brother there at that time? Does he know about this?
Dr - Did he have anal sex? Oral sex? Did he force you to have anal or oral sex?
Did he use any condoms?
Dr - Did you sustain any injuries?
Dr - Was he or were under the influence of alcohol or recreational drugs?
Dr - Has he ever had sex with you before? Pt-No
Dr - Who else was there?

After the incidence:

Dr - What happened afterwards?
Dr - Did you tell anyone?
Dr - Did you go to the A&E department (hospital)? - No
Dr - Did you inform the police? – No Dr - Why did not inform?
Dr - Did you tell your parents? – No Dr - Why you did not inform?
Dr - Has he threatened you not to tell anyone?

Dr - Did you wash yourself after this incident?

Dr - Did you use toilet after the incident? (may not be able to take any samples for tests if
he has already washed himself or used toilet after the incident)

Dr - Are you upset or worried about it? Are you scared that he might hurt you or do it
again?
Past history:
Dr - Have been diagnosed with any medical or mental health conditions?
Dr - Have you been diagnosed with any sexually transmitted infections before?
Dr - Are you on any medications?
Dr - Are you allergic to any medications?

Relationship:
Dr - Do you have any sexual partners? Male or female?
Dr - Did you have sex with your partner after the incident? (may transmit any STI to his
partner)
Dr - Do you think the person who sexually assaulted you has any medical conditions or
sexually transmitted infections?
Social history:
Dr - What do you do? Pt- I go to the college.
Dr - Where are your parents?
Dr - Do you have any friends to support you?
Dr - Where do you live?
Dr – Do you have a safe place to stay now after this incident
Impact on life:
Dr - Has this affected you in anyway?

What does he want to do now:

Dr - Do you want to complain this incident to the police?
Dr - Would you like to inform your brother or your parents or friends?
Dr - You asked for the sick note. Is it to give it to the college? Why do feel like not going
to the college? How long you think you want to stay away from college?

Examination
We need to examine you. I will talk to my seniors. (Let the seniors examine the patient)
We need to examine your genital area and the back passage to check for any injuries.
Also we need to examine you whole body for any injuries. Is that Okay? (consent is very
important).
[If he wants to put a police complain do not examine. Leave it to the specialist (forensic
team) who is trained in such sexual assault cases to examine].
If the patient not washed himself or changed clothes or used the toilet – advise him to not
to do any of these until the forensic team examines him.

Counselling
Dr - Do you have any concerns? Is there anything in particular you are expecting from us
other than the sick note?
I can imagine this is very difficult and stressful time for you.
We are here to help you.

These type of sexual abuse is illegal and it is important to report this to the police.
We suggest you to report it to the police. However, it is your decision. We cannot force
you to do that. If you do not report it to the police you may not be entitled for any
criminal injury. [If he does not want to report to the police ask him why he doesn’t want
to report it]
If the patient does not to report the matter to the police suggest him to attend sexual
assault referral centre [SARC] for forensic and medical examination and specialist advice
and support.

[If there is no SARC or patient is unwilling to attend the SARC]

Make note of the injuries and take photographs with patient’s consent.
If he does not want to attend SARC he can attend SARC even later for help.

We may need to test you for sexually transmitted infections as this incident can
transmit STIs if that person has any STIs. We advise you to attend the GUM (Genito -
urinary medicine) clinic. They may do some blood tests for syphilis (at 3 months) and
HIV (3 to 6 months for seroconversion).
We advise you to talk to your parents and your brother or friends as you need help and
support.
If you are worried or depressed, we can refer you to Psychiatrist for counselling.
If you do not have any safe place to stay we can talk to the social service to arrange a
safe place for you to stay.

About the sick note:

You asked for the sick note and asked me what we will write on that? What do you want
us to write? Is there anything you don’t want us to write in that?
You can self-certify for 7 days of sick leave. We do not need to give sick note for 7 days.
You can simply mention that you have some injuries and you are not fit to attend the
college. We can give sick note after one week if you still can’t go to the college? What do
you say?
We will have a Follow up at 2 weeks.
4165 Video not available

Informed Consent Station

Scenario: You're an FY2 doctor in the Surgery department, guiding a medical student, Jordan Miller
(fifth year), who's eager to unravel the intricacies of informed consent.

Introduction:

Doctor FY2: "Greetings, I'm Dr. [Your Name], a seasoned FY2 in the surgical unit. Pleasure to meet
you, Jordan. How's your journey through medical academia treating you?"

Jordan: "Every day is a learning experience, Dr. FY2. The medical world is full of wonders."

Establishing Connection:

Doctor FY2: "Indeed, the path to becoming a doctor is an intriguing one. What brings you here
today, Jordan?"

Jordan: "I'm captivated by the notion of informed consent. It's a critical concept, and I'm eager to
grasp its intricacies."

Assessing Prior Knowledge:

Doctor FY2: "Fantastic to hear, Jordan. To start off, how much do you already know about informed
consent?"

Jordan: "I have a basic understanding—it's about getting patient permission before medical
procedures. But the details are still hazy."

Uncovering Motivation:

Doctor FY2: "Great. And why the interest in informed consent?"

Jordan: "I believe it's a cornerstone of patient-doctor trust. I want to comprehend it fully to ensure I
uphold this principle in my practice."

Laying the Foundation:

Doctor FY2: "You've chosen a fundamental topic, Jordan. Informed consent stands as a cornerstone
of ethical medical practice. It's about obtaining a patient's consent before any medical procedure or
test."

Jordan: "So, someone grants permission to another party?"

Delving Deeper:
Doctor FY2: "Precisely. The patient offers consent to healthcare providers, whether it's a surgeon
planning an operation or a nurse arranging a test. But it's not just a simple 'yes'—it's a 'yes' that's
both informed and voluntary.

Jordan: "Informed and voluntary, got it. How do we ensure it's informed, though?"

Understanding Informed Part:

Doctor FY2: "Fantastic question, Jordan. Being informed means the patient has the full picture—
knows about the procedure, its risks, benefits, alternatives, and what might happen if they decide
not to proceed."

Jordan: "And 'voluntary'?"

Clarifying Voluntary Consent:

Doctor FY2: "You're right on the money, Jordan. Voluntary means the patient is making the decision
without any external pressure. No doctor, family, or friend should influence that decision."

Jordan: "Clear. How about determining if someone can make that decision?"

Exploring Capacity:

Doctor FY2: "Great inquiry. That's what we call 'capacity.' The patient should be able to understand
the information provided and use it to make an informed choice. And if they can and are well-
informed, their decision stands—even if it means not going ahead, even if it's a life-and-death
situation."
Jordan: "Interesting. What if someone can't decide for themselves?"

Addressing Incapacity:

Doctor FY2: "You're digging into the details, Jordan. If someone can't decide for themselves and
hasn't designated a decision-maker, we base decisions on what's best for them."

Jordan: "That makes sense. What about minors?"

Consent and Minors:

Doctor FY2: "Good catch. Minors who can grasp the situation can give consent themselves. If not,
someone with parental responsibility usually steps in."

Jordan: "And what's the difference in how consent is given?"

Modes of Consent:

Doctor FY2: "You're getting into the nitty-gritty, Jordan. Consent comes in two flavors—verbal and
written. Verbal for minor stuff, like agreeing to a blood test. Written consent takes the spotlight for
surgeries and significant procedures."

Jordan: "Got it. What about emergencies?"

Navigating Emergencies:
Doctor FY2: "Emergencies shake things up. If a patient can't consent but needs immediate treatment
to survive, we proceed. We explain things once they're stable."

Jordan: "And during surgery, if things change unexpectedly?"

Handling Surgical Changes:

Doctor FY2: "Ah, you're going deep, Jordan. In surgery, surprises can happen. If a new procedure is
needed during surgery, we usually explain afterward, when the patient's out of the woods."

Summarizing and Resources:

Doctor FY2: "So, Jordan, that's informed consent. Remember, it's about respecting patient
autonomy, making sure they understand, and ensuring they're not under pressure. For more
insights, the NHS website's a goldmine. If you're ever up for another round of discussion, feel free to
reach out."

Summarizing Informed Consent:

Informed consent forms the cornerstone of ethical medical practice. It involves a patient's voluntary
agreement to a medical procedure, fully comprehending its details, potential risks, benefits, and
alternatives. A crucial principle, it upholds patient autonomy and fosters trust in healthcare
relationships.
NHS resources

The seven principles of decision making and consent are:

1. Right to be involved and supported.
2. Focus on meaningful dialogue, i.e. specific to the individual.
3. Right to be listened to and given information, time and support.
4. What matters to patients.
5. Presumption that all adults have capacity to make decisions.
6. Those who lack capacity should make decisions with those close
to them.
7. Patients whose right to consent is affected by law are also
supported.

Consent to treatment means a person must give permission before they receive any type of medical
treatment, test or examination.

This must be done on the basis of an explanation by a clinician.

Consent from a patient is needed regardless of the procedure, whether it's a physical examination or something
else.

The principle of consent is an important part of medical ethics and international human rights law.

Defining consent
For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to
make the decision.

The meaning of these terms are:

 voluntary – the decision to either consent or not to consent to treatment must be made by the person,
and must not be influenced by pressure from medical staff, friends or family
 informed – the person must be given all of the information about what the treatment involves, including
the benefits and risks, whether there are reasonable alternative treatments, and what will happen if
treatment does not go ahead
 capacity – the person must be capable of giving consent, which means they understand the information
given to them and can use it to make an informed decision
If an adult has the capacity to make a voluntary and informed decision to consent to or refuse a particular
treatment, their decision must be respected.

This is still the case even if refusing treatment would result in their death, or the death of their unborn child.

If a person does not have the capacity to make a decision about their treatment and they have not appointed
a lasting power of attorney (LPA), the healthcare professionals treating them can go ahead and give treatment if
they believe it's in the person's best interests.
But clinicians must take reasonable steps to discuss the situation with the person's friends or relatives before
making these decisions.

Read more about assessing the capacity to consent, which explains what someone can do if they know their
capacity to consent may be affected in the future.

How consent is given

Consent can be given:

 verbally – for example, a person saying they're happy to have an X-ray

 in writing – for example, signing a consent form for surgery
Someone could also give non-verbal consent, as long as they understand the treatment or examination about to
take place – for example, holding out an arm for a blood test.

Consent should be given to the healthcare professional responsible for the person's treatment.

This could be a:

 nurse arranging a blood test

 GP prescribing new medication
 surgeon planning an operation
If someone's going to have a major procedure, such as an operation, their consent should be secured well in
advance so they have plenty of time to understand the procedure and ask questions.

If they change their mind at any point before the procedure, they're entitled to withdraw their previous consent.

Consent from children and young people

If they're able to, consent is usually given by patients themselves.

But someone with parental responsibility may need to give consent for a child up to the age of 16 to have
treatment.

Find out more about how the rules of consent apply to children and young people

When consent is not needed

There are some exceptions when treatment may be able to go ahead without the person's consent, even if they're
capable of giving their permission.

It may not be necessary to obtain consent if a person:

  needs emergency treatment to save their life, but they're incapacitated (for example, they're
unconscious) – the reasons why treatment was necessary should be fully explained once they have
recovered
 immediately needs an additional emergency procedure during an operation – there has to be a clear
medical reason why it would be unsafe to wait to obtain consent
 with a severe mental health condition, such as schizophrenia, bipolar disorder or dementia, lacks the
capacity to consent to the treatment of their mental health (under the Mental Health Act) – in these
cases, treatment for unrelated physical conditions still requires consent, which the patient may be able
to provide, despite their mental health condition
 needs hospital treatment for a severe mental health condition, but self-harmed or attempted suicide
while competent and is refusing treatment (under the Mental Health Act) – the person's nearest relative
or an approved social worker must make an application for the person to be forcibly kept in hospital,
and 2 doctors must assess the person's condition
 is severely ill and living in unhygienic conditions (under the National Assistance Act 1948) – a person
who's severely ill or infirm and living in unsanitary conditions can be taken to a place of care without
their consent

4166 Video not available

Teaching Station: Ankle Injury Evaluation

You are FY2 in Orthopaedics at an NHS Hospital in the UK.

Patient Information:

Patient: Mr. John Smith

Age: 40 years old
Chief Complaint: Sudden sharp pain and a distinct 'pop' at the back of the ankle while tripped
over a curb
Medication: Attempted to manage with ibuprofen, with limited relief
Concerns: Worried about the impact on his active lifestyle and future planned cruise holiday

Epidemiological Context (for discussion during presentation):

Achilles tendon ruptures are most common in individuals between the ages of 30 and 50.
Men are more prone to Achilles tendon ruptures, often due to higher engagement in physical
activities.
Common causes include sudden, forceful movements or overexertion during activities such
as running, jumping, or pivoting.
Patients often describe hearing a 'pop' or 'snap' sound at the time of injury.

Focused History:
Doctor (D): What brought you to the hospital today, Mr. Smith?
Patient (P): Tripped over curb and suddenly I felt this sharp pain at the back of my ankle. It
was like something snapped.
D: Events. Before, during and after
D: Can you describe the pain you experienced? Was it sharp, throbbing, or constant?
P: It was a very sharp pain, and it hit me suddenly.
D: Did you notice any changes in the appearance of your ankle after the incident?
P: Yes, my ankle swelled up a lot, and there's bruising around the area where I felt the pain.
D: Can you bear weight on your injured foot? Is walking or standing difficult?
P: Walking is really hard due to the pain, and I can't put any weight on it without feeling
unstable.
D: Have you ever had any prior ankle injuries or medical conditions affecting your ankles?
P: No, this is the first time I've had an injury like this.
D: Are you allergic to any medications?
P: No, I'm not allergic to anything.

Examination:
D: Thank you, Mr. Smith. I'll conduct a thorough examination of your ankle. Please let me
know if anything hurts or feels uncomfortable.
P: Alright, go ahead.
D: Let's start by checking your vital signs.

Examine the ankle:

a. Exposure: Ensuring proper visibility of the ankle for examination.
b. Chaperone: A chaperone is present to ensure your privacy during the examination.
c. Being gentle: I'll be as gentle as possible during the examination.
d. Consent: Just confirming your consent to proceed with the examination.
e. Positioning: Let's position you comfortably for the examination.
D: I'll now proceed to examine your ankle. Please let me know if anything feels painful or
uncomfortable.

Examination:
Inspection: Looking for signs of swelling, bruising, and any deformities.
Palpation: Gently feeling the ankle to identify areas of tenderness and swelling.
Range of Motion: Moving the ankle gently to assess its mobility and pain levels.
Stress Tests: Applying controlled pressure to assess stability and ligament integrity.
Neurovascular Examination: Ensuring proper circulation and nerve function in the ankle.

Diagnostic test :-
Simmonds Triad and Thomson test

Interpretation and Management:

D: Based on the examination findings, it appears that you may have experienced an Achilles
tendon rupture. The sharp pain and the 'pop' sound you mentioned are indicative of this
injury.
D: To confirm, we'll proceed with an X-ray, primarily to rule out any associated fractures.
D: We'll provide you with a supportive ankle brace or specialist boots to enhance stability
and manage pain. Please do not drive with these specialist boots.
D: You will have to wear these specialist boots even while sleeping
D: We will give you leaflets on how to exercise in these boots to prevent clots in your leg
D: Given the nature of your injury and your active lifestyle, adhering to the R.I.C.E protocol
(Rest, Ice, Compression, Elevation) is crucial.
D: It's advisable to refrain from physical activities until we have a clearer understanding of
the extent of your injury.
D: Depending on the X-ray results, we might consider a referral to a specialist or recommend
physiotherapy to facilitate recovery.
D: Let's schedule a follow-up appointment in a few days to assess your progress and adapt
the treatment plan accordingly.
P: Can I go on a cruise holiday in 6 weeks
D: Lets make a follow up appointment as we need to determine the diagnosis and if the
treatment will be conservative or surgical. As surgical option has a initial faster recovery
time.

Patient Education:
D: Our priority now is ensuring proper healing to prevent complications.
D: The X-ray will provide us with essential information about the severity of your injury and
guide our treatment.
D: If you notice any increasing pain or any new symptoms, don't hesitate to reach out to us.
D: We'll provide you with comprehensive instructions for home care, including how to use
the ankle brace effectively.

Additional Information: Achilles Tendon Rupture and Differential Diagnosis:

Differential Diagnosis for Ankle Injuries:
Achilles Tendon Rupture: A tear in the Achilles tendon, causing sudden pain, a "pop" sound,
and difficulty with movement. Urgent medical attention is required.
Achilles Tendonitis: Inflammation of the Achilles tendon due to overuse or repetitive strain.
Ankle Ligament Sprains: Injuries to the ligaments around the ankle joint.
Muscle Strains: Injuries to the calf muscles that can cause pain and discomfort in the ankle
area.
Bursitis: Inflammation of the fluid-filled sacs (bursae) around the ankle joint.

Achilles Tendon Rupture Management:

Diagnosis is usually confirmed through physical examination and imaging tests.
Treatment options may include non-surgical approaches (such as immobilization and physical
therapy) or surgical repair.
Early diagnosis and appropriate treatment are essential to optimize outcomes and prevent
long-term complications.

Conclusion:
D: Thank you for your cooperation, Mr. Smith. We're dedicated to helping you recover and
return to your active lifestyle as soon as possible.
D: Please feel free to reach out if you have any questions or concerns. Your well-being
remains our priority.
D: Let's work together to ensure a steady and effective recovery process.

NHS resources

 Suspect Achilles tendon rupture if the person describes:

o A sudden pain in the back of the leg, which may be associated with an audible
snap and occur during sporting activity or running. This may be described as
being kicked or hit by a racquet.
 Note that approximately a third of people with complete tendon rupture
do not complain of pain.
o Aching of the calf, swelling, mild bruising, and weakness when pushing off
with the affected foot.
 Swelling and bruising are not a reliable sign as they may be mild.
o Difficulty with weight bearing.
 In some cases the person may be able to walk because other plantar
flexors may mask the Achilles tendon injury.
 Examine the person using Simmonds triad (angle of declination, palpation, and
the calf squeeze test) to help exclude Achilles tendon rupture:
o Ask the person to lie prone with their feet over the edge of the examination
couch:
 Look for an abnormal angle of declination — rupture of the Achilles
tendon may lead to greater dorsiflexion of the injured ankle and foot
compared with the uninjured limb.
 Feel for a gap in the tendon. No gap may be felt because of local
swelling or bleeding. Bruising may be seen.
 Gently and sequentially squeeze the calf muscles — in acute rupture of
the Achilles tendon the injured foot will typically remain in the neutral
position when the calf is squeezed.
 Be aware that diagnosis of chronic rupture may be difficult, because:
o Pain and swelling have often subsided and the gap may have filled with
fibrous tissue.
o Calf muscles may be wasted.
o Other muscles may facilitate plantar flexion.
 Non-operative management

You may initially be placed in a cast for two weeks before it is replaced with an aircast boot
with four wedges under your heel.

Sometimes, you may go straight into an aircast boot with five wedges inserted under your
heel.

You will be classed as non-weight bearing in the cast. Weight bearing status in the boot is
determined by your consultant. You may be provided with elbow crutches to help reduce the
pressure through your tendon/foot.

You will normally be in a cast/boot for a total of 10 weeks.

The boot should be worn at all times, including in bed, to ensure that your tendon is protected
throughout the healing process. While wearing the specialist boot, you should fully weight
bear on your whole foot.

As you will be less mobile than previously, you will have a risk assessment for bloods clots
(venous thromboembolism (VTE)). If you are felt to be at risk, you will be prescribed blood
thinning injections for six weeks from the date of your injury.

Every two weeks, you will need to remove one of the wedges placed under your heel. When
you remove your foot from the boot, please avoid moving the ankle as this can disrupt the
scar tissue and healing process.

Surgical treatment

This is not usually the preferred treatment option as the risks of complications may outweigh
the benefits. However, surgery may be considered for certain patient presentations, these
being:

 Delayed presentation / treatment (more than 2-3 weeks following injury)

 Re-ruptures of Achilles tendon / avulsion injuries / fat within tendon gap
 Elite athletes (some evidence of slightly increased push off strength)
However, patients have to consider potential complications of surgical intervention (risk
increase of around 16% compared to conservative treatment).

Risks of surgery:
 Risk of re-rupture
 Decreased strength
 Risk of clot in leg veins (deep vein thrombosis): less than 1 in 100
 Risk of clot in lungs (pulmonary emboli): less than 1 in 500
 Risk of infection: 1 in 100
 Risk of delayed wound healing
 Risk of numbness around incision and foot

After the procedure you will have a cast applied. You will be shown how to use crutches as
you should not weight bear on the cast. Most patients should be able to go home the same
day.

Your stitches will be removed at two weeks following surgery in outpatients and you will
then go through functional bracing like conservatively managed patients.

Squeeze test
Gap palpation

Angle of dangle