Year 5 OSCE Notes:

High Cholesterol Counselling:

• WIPER, explain the consultation, obtain permission to discuss
• Explain what high cholesterol is:
• Cholesterol is a type of fat produced in the blood. The two types are HDLs
(good) and LDLs (bad). Your results today show...
• High amounts of cholesterol in the blood lead to blockages in the arteries
and cause stroke, heart attack etc
• Ask about risk factors for cardiovascular disease
• Has your cholesterol been raised before?
• FH
• HTN?
• Smoker? Alcohol?
• Exercise?
• Weight
• Ask about general PMH
• DH and allergies
• Discuss management:
• A large part of the cholesterol in your blood is driven by lifestyle factors...
• Exercise, unsaturated over saturated
• Small measurable changes
• The rest of your cholesterol is driven by the liver and can be treated with medication
• Statins lower the cholesterol produced naturally by the liver. If the
qRISK > 10% then a statin is usually prescribed
• The qRISK score estimates the likelihood of a patient developing
cardiovascular disease over the next ten years
• Offer leaflet and arrange follow up
Palpitations:
• WIPER, explain purpose of the consultation, ask about concerns (before we dive in,
I just want to check if there was anything particularly concerning you that you
wanted to address today?)
• Define palpitations:
o What do you mean by palpitations? Awareness of your own heartbeat?
o Frequency?
o Duration?
o Triggers?
o Can you tap it out?
• General cardiac:
o Chest pain
o SOB
o Dizziness
o Exercise tolerance
• Endocrine questions:
o Tremors
o Headache
o Weight loss
• Address mental health causes:
o Well being
o Anxiety
• Lifestyle:
o Ask specifically about caffeine and nicotine intake
o Alcohol and recreational drugs
• PMH, DH
• FH (looking for sudden death)
• SH
• Examine patient, take a standing lying BP, ECG, consider a Halter monitor and echo,
blood tests for anaemia and TFTs
• Thank, summarise, ask questions
UTI Counselling (follow up after urine test results):

• WIPER, explain purpose of consultation

• Recap history
o HPC: Dysuria, frequency, urgency, loin pain, haematuria, fever
o PMH, DH, allergy, FH, SH
• Explain the results:
o Your test results show you have a urinary tract infection. This is very common
in women and is caused by bacteria in the urinary tract
• Check any UTI risk factors
o Diabetes
o Pregnancy
o Any renal problems in childhood leading to renal scarring
• Explain how it occurs:
o Can be due to the fact that the urethra and the anus are very close to each
other so bacteria transferrance can occur
o Urinary stasis if someone hasn’t been going to the bathroom enough
o Sexual intercourse can also lead to it. Stress this is not an STI
• Lifestyle changes: Urinate more and drink more. Double voiding. Urinate after sex.
Wipe front to back
• Medical management: Trimethoprim or Nitrofurantoin. Increase fluid intake
• Safety net for systemic infection. Offer leaflet
Discuss Smoking Cessation:

• WIPER, explain purpose of the consultation

• Assess current smoking habits:
• Pack year history, cigarettes vs roll ups, just tobacco?
• Find out why they want to quit:
• Establish reason and confidence regarding quitting
• Ask about previous attempts quitting:
o What method?
o How long did you stop for?
o Why did you relapse?
• Talk about the benefits of quitting smoking
• In the short term you’ll have more money, better smell and taste, more energy and
better in yourself
• Long term lower risk of cancer and heart disease, better exercise tolerance
• Reassure that although this is difficult there is support available. Ask whether they
have any ideas about stopping smoking this time
• Explain possible methods:
• Cold turkey
• Nicotine replacement therapy
• Medication:
o Bupropion: Stops the enjoyment of nicotine. However, can cause GI
problems, dry mouth, insomnia
o Varenicline: Blocks nicotine receptors and reduces the feeling of cravings.
Similar side effects
o Neither medication can be used in pregnancy
 • Come to a joint decision and set a goal. Reassess confidence about quitting
• Give advice about support services available
• Any questions? Offer leaflet. Arrange follow up

Sore throat and antibiotics (parent presents with a child with a sore throat):

• WIPER, explain purpose of consultation, ICE – Is there anything you are especially
concerned about or would like for me to do for you today?
• PC:
o Age
o Check coryzal symptoms (cough, runny nose, sore throat)
o Check systemic features (fever, lethargy)
o HPC, DH, FH, SH
• Examination:
o Check temperature (>38C?)
o Palpate neck lymph nodes (tender lymphadenopathy?)
o Look at throat for tonsillar exudate
• More likely bacterial if:
o Fever >38
o Tonsillar exudate
o Tender cervical lymphadenopathy
o No cough
▪ Give phenoxymethylpenicillin
• More likely viral if:
o Rhinorrhoea, conjunctivitis, cough
o Explain viral cause to the parent
 ▪ Based on what you have told me, this looks much more like this is
being caused by a virus. Unfortunately, antibiotics only work for
bacteria. I don’t want to give antibiotics here as they have their own
side effects, for example stomach upset
▪ However, you can do things without antibiotics:
▪ Paracetamol
▪ Fluids and rest
▪ Salt water gargles
• SAFETY NET: If things don’t improve in a week, come back. If things get worse, if
they have any problems breathing, go to A&E

Weight loss history:

• WIPER, explain purpose of consultation, Is there anything you are especially

concerned about or would like for me to do for you today?
• HPC:
o How much weight have you lost
o Over what period
o Did you mean to lose weight
o How is your appetite
o What do you typically eat in a day
o Do you have any ideas about why you might have lost weight?
• Systems review:
o Night sweats, fever, back pain
o Change in bowel habit, blood in stool
o Any change in the waterworks?
o How is your mood at the moment?
• PMH, DH
• FH – Check for diabetes, thyroid, malignancy, TB
• SH:
o Smoking, alcohol, rec drugs
 o Foreign travel
o UPSI
o Job and home life
• Thank patient. Send off FBC, U&Es, LFTs, TFTs, creatinine. Full set of OBs

Headache

• WIPER, explain purpose of consultation, is there anything you are especially

concerned about or would like for me to do for you today?
• HPC:
o SOCRATES: Site, Onset, Character, Radiation, Alleviating factors, Timing,
Exacerbating factors, Severity
o Any associated symptoms?
▪ Photophobia
▪ Neck stiffness
▪ Nausea
▪ Weakness
▪ Scalp tenderness
o Head injury?
• Acknowledge seriousness of symptoms and address concerns
• Systems review
• Night sweats, fever, weight loss
 • Any change in bowel habit or waterworks?
• PMH
• DH – Check how often they are taking analgesia
• FH
• SH: smoking, alcohol, stress. Job
• Thank patient.

Weakness:

• WIPER, explain purpose of consultation, is there anything you are especially

concerned about or would like for me to do for you today?
• HPC:
o Is this your first episode of weakness?
o Onset, progression, duration, relapses, timing
o Which muscles
o Exacerbating factors (exercise, hot baths, posture)
o Recent trauma
o Does it affect function?
o Any falls?
o Change in sensation?
• Acknowledge the difficulties the patient is facing and explore any ideas
 • Systems review:
o Night sweats, fever, weight loss
o Bowel habits
o Autonomic dysfunction
o Headaches, vision, LOC
o Speech problems, swallowing problems
o Mood
• PMH, DH
• FH (Aspirin, warfarin, steroids, statins)
• SH – Smoking, alcohol, stress
• Thank patient, explain what tests you will do, offer further information

Loss of consciousness:

• WIPER, explain purpose of consultation, is there anything you are especially

concerned about or would like for me to do for you today?
• HPC:
o First episode?
o Onset, duration, witnesses?
o Fits, tongue biting, incontinence
o Any injuries?
o Did you trip or lose power in your legs?
• Before the episode:
o Did you notice anything unusual before you passed out?
 o What were you doing at the time?
o Symptoms:
▪ Chest pain?
▪ Dizziness?
▪ Palpitations?
▪ Vertigo?
▪ Any problems with your sight?
• After the episode:
o How did you feel after the LOC?
o How much do you remember?
• Acknowledge the difficulty of the situation and explore ideas
• PMH – Epilepsy, migraines, CVA, TIA, HTN, cholesterol, angina
• FH – Epilepsy or cardiac?
• SH
• Thank patient

Alcohol dependence history:

• WIPER, explain purpose of consultation (I’d like to ask you about your health, in
particular, your drinking habits, is that something you would be happy to discuss?),
is there anything you are especially concerned about or would like for me to do for
you today?
• Alcohol history:
o When did you start drinking? Any triggers?
o How much do you drink per day?
o What do you drink?
 o Where?
o Who with?
o How long have you been drinking for?
• CAGE:
o Have you ever felt you should cut back on your drinking?
o Have you felt annoyed about people commenting on your drinking habits?
o Have you ever felt guilty about your drinking habits?
o Have you ever had an eye opener?
• Dependence:
o Difficulty controlling amount drunk
o Reduction – Have you tried cutting down in the past
o Withdrawal symptoms
o Interests outside of drinking
o Tolerance
o Harms
• Effect on life?
o Love
o Labour
o Law
o Liver
• Ask about mood and depression;
o How is your mood?
o Do you have less energy than normal?
o Have you lost interest in things you used to enjoy?
• Do you think you need help with your drinking?
• Explain the acute management of withdrawal (pabrinex, chlordiazepoxide)
• Provide information about quitting
• Thank patient

Drug dependence history (for a patient asking for methadone):

• WIPER, explain purpose of consultation (before I can prescribe anything I need to

have a full understanding of your medical history and to order some investigations
like a urine sample), is there anything you are especially concerned about or would
like for me to do for you today?
• HPC:
 o Why are drugs used?
o Route of administration?
o Frequency?
o Equipment sharing?
o How long have you been using?
o When did you first take drugs? Have your habits changed?
o Have you ever overdosed?
o Drugs are expensive, how do you afford them?
• Dependence:
o Do you find yourself craving the drug?
o Do you get withdrawal symptoms?
o Have you developed tolerance?
• Effect on life:
o Love
o Labour
o Law
o Liver
• Acknowledge the difficulty of drug addiction and ask about mood and suicide
o Suicide? Self harm? Thoughts of harming others?
• Insight
o Do you think you have a problem?
• PMH, DH, DH, SH
• Thank patient

Paediatric BLS

• Check for danger

 • Check for response – If no response, CALL FOR HELP
• Check the airway. If compromised:
o Remove obvious obstruction if apparent
o Airway manoeuvres:
▪ Small child: “sniffing the morning air”
▪ Older child: Head tilt chin lift
▪ Call the anaesthetist
• Check breathing (10 seconds count breaths):
o No breathing -> 5 rescue breaths
• Check circulation for 10s
o <1yo: brachial pulse
o >1yo: carotid pulse
▪ No pulse: 2222
▪ Give compressions:
• 15:2
• 100-120bpm
• Depth to 1/3 chest depth
• 1 finger above xiphisternum
• <1yo: tips of two fingers
• >1yo: heel of one hand over the lower half of the sternum
o Reassess
• When to stop?
o When help arrives
o When exhausted
o Signs of life

Reversible causes:

4Hs: Hypovolaemia, hypothermia, hypoglycaemia, hypoxia

4Ts: Thrombus, tamponade, tension pneumothorax, toxins

Choking child:

• Check for danger and response, CALL FOR HELP

• Identify choking and check airway
• Assess cough, if effective encourage cough
• 5X back blows
o Child: Heel of hand between shoulders whilst upright.
o Infant: Place thumb + finger around bony part of jaw to support body weight,
lay child forward
o Check if item dislodged
• 5X abdominal thrusts
• Repeat algorithm until airway clear or child is unconscious at which point switch to
BLS
DRABCDE – Acutely unwell child:

• Speak to nurse and ask for a full set of OBs (Thank you for letting me know, I am
going to begin a full ABCDE assessment, could you please take a full set of
observations including RR, O2 sats, HR, BP, CR)
• Check for danger and response
• Continually reassess AVPU whenever intervention made
• CALL FOR HELP
• Check airway:
o Assume patent if talking
o Look for any obstruction or foreign body
o Listen for upper airway noises
o Airway manoeuvres if needed
• Breathing:
o RR and O2 saturations – start high flow oxygen if needed
o Inspect – cyanosis, use of accessory muscles, intercostal recession
o Palpate – Check chest expansion and tracheal position
o Percuss lung fields
o Auscultate – Consider salbutamol nebulisers if wheeze
• Circulation:
o HR, BP, CR – Ask for IV access if needed
o Inspect – Pallor, sweating, signs of dehydration
o Palpate – Pulses, cap refill, temperature
o Auscultate – Heart sounds
o Consider a fluid challenge of 10-20ml/kg saline over 15 mins, ABG, ECG
• Disability
o Check pupils
o Blood glucose
o Check AVPU
• Exposure
o Rash
o Fever
o Bleeding
• Complete reassessment and SBAR to senior
LOOK, FEEL, LISTEN, TREAT, REASSESS

DRABCDE – Anaphylaxis

• Check for danger and response

• Call for help
• Recognise airway compromise
o Swollen lips
o Cyanosis
o Swollen tongue
o Call anaesthetist
o Give adrenaline (1:1000) immediately
▪ <6yo: 150ug
▪ 6-12yo: 300ug
▪ 12 – 18yo: 500ug
• Repeat after 5 mins if no improvement
• Breathing:
o RR and O2 sats – Start high flow oxygen if appropriate
o Inspect – Cyanosis, accessory muscles, recession
o Palpate – Chest expansion
o Percuss – lung fields
o Auscultate – Lung fields, breath sounds
• Circulation:
o HR, BP, CR. Obtain IV access, fluid challenge 10-20ml/kg of saline over 15
minutes
o Inspect – Pallor, sweating, signs of dehydration
o Palpate – Pulses, cap refill, temperature
o Auscultate – Heart sounds
• Disability:
o Check pupils
o Blood sugars
 o Reassess AVPU
• Exposure:
o If rash, give chorphenamine
• Reassess
• Consider IV hydrocortisone
• SBAR to senior

Croup:

• Speak to nurse and ask for a full set of OBs (Thank you for letting me know, I am
going to begin a full ABCDE assessment, could you please take a full set of
observations including RR, O2 sats, HR, BP, CR)
• Check for danger and response
• Continually reassess AVPU whenever intervention made
• CALL FOR HELP
• Check airway:
o Don’t disturb the child, sit them up on mum’s lap
o Give oral dexamethasone
o Call anaesthetist and senior paediatrician
o Mild – moderate: Budesanide 2mg NEB
o Severe: 0.5ml/kg NEB
• Breathing:
o RR and O2 sats – start high flow oxygen if appropriate
o Palpate – Chest expansion
o Percuss – lung fields
o Auscultate – Lung fields, breath sounds
• Circulation:
o HR, BP, CR
o Inspect – Pallor, sweating, signs of dehydration
o Palpate – Pulses, cap refill, temperature
o Auscultate – Heart sounds
• Reassess
• Disability:
 o Check pupils
o Blood sugars
o AVPU
• Exposure top to toe
• Reassess and SBAR to senior

DRABCDE - Seizures

• Speak to nurse and ask for a full set of OBs (Thank you for letting me know, I am
going to begin a full ABCDE assessment, could you please take a full set of
observations including RR, O2 sats, HR, BP, CR)
• Check for danger and response
• Continually reassess AVPU whenever intervention made
• CALL FOR HELP
• START THE CLOCK
• Airway:
o Recognise potential for airway compromise
o Head tilt chin lift
• Breathing
o RR and O2 sats – start high flow oxygen if appropriate
o Inspect – cyanosis, accessory muscles, recession
o Palpate – Chest expansion
o Percuss lung fields, auscultate chest
• Circulation:
o HR, BP, CR. Check if IV access
o Inspect – Pallor, sweating, signs of dehydration
o Palpate – Pulses, cap refill, temperature
o Auscultate – Heart sounds
 • Disability
o Check pupils
o AVPU
o Blood sugars
o Treat seizure:
▪ Lorazepam
▪ Midazolam
▪ Diazepam
▪ Leviracetam
▪ Phenytoin
▪ RSI
• Reassess and SBAR to senior

DRABCDE – Asthma

• Speak to nurse and ask for a full set of OBs (Thank you for letting me know, I am
going to begin a full ABCDE assessment, could you please take a full set of
observations including RR, O2 sats, HR, BP, CR)
• Check for danger and response
• Continually reassess AVPU whenever intervention made
• CALL FOR HELP
• Airway:
o Listen for any stridor
o Any obstructions by upper airway secretions
• Breathing
o RR and O2 sats – start high flow oxygen if appropriate
o Inspect for cyanosis, accessory muscles, intercostal recession, tracheal tug,
nasal flaring
o Feel for equal chest expansion, tracheal deviation, percussion
o Auscultate – lung fields added sounds
o Peak flow?
o Treat:
▪ Simple face mask 10L/min
 ▪ Salbutamol 5mg NEB (2.5mg if <3yo)
▪ Ipratropium bromide 250ug NEB
▪ Back-to-back nebulisers X3
▪ Prednisolone 1-2mg/kg
• Circulation:
o HR, BP, CR. Check if IV access
o Inspect – Pallor, sweating, signs of dehydration
o Palpate – Pulses, cap refill, temperature
o Auscultate – Heart sounds
• Disability
o Check pupils
o AVPU
o Blood sugars
• Exposure top to toe
• Reassess and SBAR to senior

General Paediatric History:

• WIPER, explain purpose of consultation, is there anything you are especially

concerned about or would like for me to do for you today?
• PC
• HPC
o Timeframe/SOCRATES each individual symptom
o Has this happened before?
o Anyone else unwell at home?
o Recent travel
o Systems review:
• General: Fever, behaviour change, rashes, change in
behaviour?
• Cardiorespiratory: Cough, SOB, cyanosis
• GI: Vomiting, abdo pain, number of wet nappies/frequency if
older
• Neuro: Fits, headaches
 • ENT: Sore throat, earache
• Birth history: “Any problems during pregnancy or labour?”
• Feeding history:
o “Are they breast or bottle fed?”
o “Has there been a change in their appetite?”
• Growth and developmental history –
o Check red book
o “Any worries about their development at all?”
• PMH
o Previous illness
o Surgery
o Any time in hospital
• DH
o “Have they had all their vaccinations?”
o Allergies
• FH
o Anything run in the family?
• SH:
o Who is at home?
o “Apologies, I have to ask everyone this, do they have a social worker?”
o Any smoking at home
o Any pets
• Thank the patient

Febrile child:

• WIPER, explain purpose of consultation, is there anything you are especially

concerned about or would like for me to do for you today?
• HPC:
o How long have they had the fever?
o Swinging or constant?
o How high is the fever?
o Any shaking?
o Have you given any medications? Did they help?
o Systems review:
• General: Fever, behaviour change, rashes, change in
behaviour?
 • Cardiorespiratory: Cough, SOB, cyanosis
• GI: Vomiting, abdo pain, number of wet nappies/frequency if
older
• Neuro: Fits, headaches
• ENT: Sore throat, earache
• Birth history: “Any problems during pregnancy or labour?”
• Feeding history:
o “Are they breast or bottle fed?”
o “Has there been a change in their appetite?” “By how much?”
• Growth and developmental history –
o Check red book
o “Any worries about their development at all?”
• PMH
o Previous illness
o Surgery
o Any time in hospital
• DH
o “Have they had all their vaccinations?”
o Allergies
• FH
o Anything run in the family?
• SH:
o Who is at home?
o “Apologies, I have to ask everyone this, do they have a social worker?”
o Any smoking at home
o Any pets
• Thank the patient
Febrile Seizures:

• WIPER, explain purpose of consultation, is there anything you are especially

concerned about or would like for me to do for you today?
• PC – Tell me about these fits?
• HPC
o Timeframe/SOCRATES each individual symptom
o Has this happened before?
o Anyone else unwell at home?
 o Recent travel
o Systems review:
• General: Fever, rashes, change in behaviour?
• Cardiorespiratory: Cough, SOB, cyanosis
• GI: Vomiting, abdo pain, number of wet nappies/frequency if
older
• Neuro: Fits, headaches, any focal neurology?
• ENT: Sore throat, earache
• Birth history: “Any problems during pregnancy or labour?”
• Feeding history:
o “Are they breast or bottle fed?”
o “Has there been a change in their appetite?”
• Growth and developmental history –
o Check red book
o “Any worries about their development at all?”
o Ask about specific milestones for age group
• PMH
o Previous illness
o Surgery
o Any time in hospital
• DH
o “Have they had all their vaccinations?”
o Allergies
o Have you given them anything to treat the fever?
• FH
o Anything run in the family?
o Anyone in the family have epilepsy?
• SH:
o Who is at home?
o “Apologies, I have to ask everyone this, do they have a social worker?”
o Any smoking at home
o Any pets
• “This is probably a case of something called febrile seizures, which are quite
common and happen to about 1 in 30 children. We don’t fully understand why they
happen, but they are essentially a reaction of the developing brain to the body
having a high fever. They can seem frightening, but they are unlikely to cause any
 long-term harm” “It is not epilepsy and doesn’t mean your child will develop
epilepsy”
• What happens in a febrile seizure?
o Children might become stiff or their arms and legs can twitch
o LOC and may wet or soil themselves
o May vomit or foam at the mouth
• Will it happen again?
o There is a 30% chance of it happening again. If they do have a recurrence,
they should grow out of it by age 6
o 3% of these children go on to develop epilepsy, however, this is only slightly
higher than the population generally (0.5%) and it does not mean they cause
epilepsy
• What do I do if it happens again?
o Start the clock
o Put them in the recovery position (roll them onto their side)
o Make sure there is nothing they can choke on
o Call an ambulance if it is longer than five minutes
o If this happens frequently, we may consider giving some diazepam for these
episodes
o If the child has a non-blanching rash with the seizure, seek medical care
• What should I do when my child has a fever?
o Give paracetamol
o Don’t sponge with cold water as that can cause shivering and actually
increase temp
o Don’t underdress or overwrap
o Keep hydrated
• Reassess concerns, thank patient
Vomiting infant:

• WIPER, explain purpose of consultation, is there anything you are especially

concerned about or would like for me to do for you today?
• PC – Why don’t you tell me in your own words what's brought you in today?
• HPC
o Onset
o Character
▪ Are they vomiting after feeding? Every feed?
▪ What colour is the vomit? Blood or mucus?
o Has this happened before?
o Anyone else unwell at home?
o Recent travel
o Systems review:
• General: Fever, behaviour change, rashes, change in
behaviour?
• Cardiorespiratory: Cough, SOB, cyanosis
• GI: Vomiting, abdo pain, number of wet nappies/frequency if
older
• Neuro: Fits, headaches
• ENT: Sore throat, earache
• Birth history: “Any problems during pregnancy or labour?”
• Feeding history:
o “Are they breast or bottle fed?”
o “Has there been a change in their appetite?”
• Growth and developmental history –
o Check red book
o “Any worries about their development at all?”
• PMH
 o Previous illness
o Surgery
o Any time in hospital
• DH
o “Have they had all their vaccinations?”
o Allergies
• FH
o Anything run in the family?
• SH:
o Who is at home?
o “Apologies, I have to ask everyone this, do they have a social worker?”
o Any smoking at home
o Any pets
• Thank the patient. VBG to check acid-base balance, FBC, CRP, U&Es. Consider
abdominal USS. Senior review

Neonatal Jaundice:

• WIPER, explain purpose of consultation, before we dive in is there anything you are
especially concerned about or would like for me to do for you today?
• PC – Why don’t you tell me in your own words what's brought you in today?
• HPC, PMH, Gestational/birth history, Developmental history, DH, FH, SH
• What is neonatal jaundice?
o So neonatal jaundice is very common and happens in up to 60% of children.
It is usually nothing to worry about and is to do with two things
▪ The cells in the baby’s blood are a bit more fragile in the uterus and
are replaced after birth
▪ The baby’s liver and gut are still growing and isn’t as good at dealing
with broken down blood cells as an adults
• When is neonatal jaundice worrying?
o First 24 hours – Haemolysis (ABO incompatibility, G6PD), infection, or
bruising from a difficult delivery
o D2 – D14 – Usually physiological.
 o >D14 – prolonged jaundice (breast milk jaundice, infections, haemolysis,
G6PD, hypothyroidism, galactosaemia, biliary atresia, neonatal
hepatitis
• What can be done to investigate this?
o FBC, blood typing, Coomb’s test, Urine MS&C, TFTs
• What can be done to treat it?
o Establish cause
o Phototherapy
o Exchange transfusion

Bronchiolitis:

• WIPER, explain purpose of consultation, before we dive in is there anything you are
especially concerned about or would like for me to do for you today?
• PC – Why don’t you tell me in your own words what's brought you in today?
• HPC, PMH, Gestational/birth history, Developmental history, DH, FH, SH
• What causes bronchiolitis?
o It’s a viral infection called RSV. It will usually go away on its own in two
weeks but if your baby needs extra support or oxygen we can provide that.
There are usually annual epidemics
• What else could it be?
o Croup
o Pneumonia
• How would you investigate this?
o Clinical diagnosis
o CXR
o Septic screen if worrying signs
Intussusception:

• WIPER, explain purpose of consultation, before we dive in is there anything you are
especially concerned about or would like for me to do for you today?
• PC – Why don’t you tell me in your own words what's brought you in today?
• HPC, PMH, Gestational/birth history, Developmental history, DH, FH, SH
• What causes this doctor?
o Sliding of one portion of bowel into another
• How would you investigate this patient?
o Abdominal US
• How would this be treated?
o Reduction under air inflation
• Will this happen again?
o 5-15% chance
Nocturnal enuresis

• WIPER, explain purpose of consultation, before we dive in is there anything you are
especially concerned about or would like for me to do for you today?
• PC – Why don’t you tell me in your own words what's brought you in today?
• HPC
o Frequency of bed wetting
o Any daytime enuresis?
o Any change in bowel habit?
o UTI – Is the urine smelly? Do they have a fever?
o Diabetes – Polyuria? Polydipsia? Any weight loss?
o Stress – Anything causing them stress at home?
o Access to toilet during the day?
o Systems review:
• General: Fever, behaviour change, rashes, change in
behaviour?
• Cardiorespiratory: Cough, SOB, cyanosis
 • GI: Vomiting, abdo pain, number of wet nappies/frequency if
older
• Neuro: Fits, headaches
• ENT: Sore throat, earache

• PMH, Gestational/birth history, Developmental history, DH, FH,

• SH
o How are they getting on at school?
o Are they sharing a bedroom?
• Is this normal?
o Continence achieved by 3 or 4
o Tends to run in families
• How would you manage this patient?
o Education: Emphasis on positive behaviour and rewards, pre bed routine, no
drinking an hour before bed
o Enuresis alarm can be very effective
o Consider desmopressin
• Test urine to rule out UTI
• Offer information

Paediatric pallor and fatigue

• WIPER, explain purpose of consultation, before we dive in is there anything you are
especially concerned about or would like for me to do for you today?
• PC – Why don’t you tell me in your own words what's brought you in today?
• HPC
o Pallor, low energy, breathlessness, cyanosis
o Change in bowel habit, fever, rash cough
o Diet
▪ Vegetarian?
▪ Dairy products?
o Systems review:
• General: Fever, behaviour change, rashes, change in
behaviour?
 • Cardiorespiratory: Cough, SOB, cyanosis
• GI: Vomiting, abdo pain, number of wet nappies/frequency if
older
• Neuro: Fits, headaches
• ENT: Sore throat, earache
• PMH, Gestational/birth history, Developmental history, DH,
• FH – Any family history of inherited anaemias?
• SH
• How would you investigate this?
o FBC
o Serum iron, ferritin, TIBC
o Coombs test, B12
• Management for iron deficiency anaemia:
o Need 1mg/kg/day of iron
o Eat lots of vitamin C as well to help absorption. Leafy greens, red meat,
pulses, nuts
o Avoid cow's milk and high fibre foods
o Additional medical supplementation of iron for 3 months (expected to rise by
1g/dL/week)
• Offer leaflet

Asthma

• WIPER, explain purpose of consultation, before we dive in is there anything you are
especially concerned about or would like for me to do for you today?
• PC – Why don’t you tell me in your own words what's brought you in today?
• HPC (MAILS-IT)
o Medication: Establish what their regime is and whether they are compliant
with it. Are they using their blue inhaler more?
o Atopy?
o Inpatient admissions?
 o Lifestyle:
▪ How much school has been missed?
▪ Affecting hobbies?
o Symptoms:
▪ Wheeze, SOB, Chest pain, Fever
▪ Cough: Worse at night? Productive? Blood?
o Interval timing: Nocturnal cough, exercise induced
o Triggers: Cold, exercise, pets, smoking
o Systems review:
• General: Fever, behaviour change, rashes, change in
behaviour?
• Cardiorespiratory: Cough, SOB, cyanosis
• GI: Vomiting, abdo pain, number of wet nappies/frequency if
older
• Neuro: Fits, headaches
• ENT: Sore throat, earache
• PMH, Gestational/birth history, Developmental history, DH,
• FH
• SH – Anyone smoking at home?
• What is asthma?
o Very common illness which affects the lungs and airways. Your immune
system in these airways is a bit more defensive than it is for most people, so
it tends to overreact. When your lungs come into contact with something
which irritates the airways, they tighten and narrow. They also can be filled
with phlegm.
• Assess inhaler technique. Discuss current medication and encourage peak flow
diary
• Summarise, check understanding offer leaflet

Developmental delay

• WIPER, explain purpose of consultation, before we dive in is there anything you are
especially concerned about or would like for me to do for you today?
• PC – Why don’t you tell me in your own words what's brought you in today?
 • HPC
o Developmental milestones:
▪ Gross motor
▪ Fine motor + vision
▪ Speech, language, hearing
▪ Social skills
o Any regression?
o Systems review:
• General: Fever, behaviour change, rashes, change in
behaviour?
• Cardiorespiratory: Cough, SOB, cyanosis
• GI: Vomiting, abdo pain, number of wet nappies/frequency if
older
• Neuro: Fits, headaches
• ENT: Sore throat, earache
• PMH, Gestational/birth history (were you ever unwell during the pregnancy?),
Developmental history, DH,
• FH – Any similar problems in siblings
• SH
• Refer to paediatrics and other services if appropriate

Gillick competency and parental responsibility for a 12yo appendectomy:

• Can they consent to this operation?

 o There is a need to assess Gillick competency
o Children over 16 are presumed to have capacity
• How would you assess Gillick competency?
o Need to assess capacity: Understand, weigh up, retain, and communicate
o To test this, ask the patient:
▪ I need to check that you can consent to this operation and part of that
is checking your understanding of the operation.
▪ Why don’t you tell me what you understand so far... (fill in gaps)
▪ Why is this operation being proposed?
▪ What are the risks and benefits of the procedure?
▪ How do you feel about it?
▪ So, in your own words can you tell me what we have discussed
• Can he refuse the operation?
o No, he is under 16 and therefore a minor. N.B. Parents can override the
decision of a competent 16/17yo
• Jack’s parent can’t be reached, can the patient consent?
o No, for an under 16yo, only someone with parental responsibility can
consent
▪ Mother automatically
▪ Dad if on birth certificate, married at time of birth, or legally approved
for parental responsibility
▪ Ward of the court
• What is parental responsibility:
o A specific legal term to define who can consent to medical procedures for an
under 16-year-old
• What happens if this can’t be obtained?
o Best interests' principle applies, and the senior doctor makes the decision
• What happens if a child is a Jehovah’s witness and urgently needs blood
o The responsible consultant is informed, and 2 consultants can agree to give
a transfusion. They then apply to the court after the procedure.
o Alternatively they can apply to the court before the surgery
Fraser guidelines: Starting a 15yo on the Combined Oral Contraceptive

• WIPER, explain purpose of consultation, before we dive in is there anything you are
especially concerned about or would like for me to do for you today?
• Establish confidentiality
• “Why do you want to start the pill?”
o Establish details of the current partner: Age, how long relationship has been
going on
o Have you ever felt pressured into something you didn’t want to do?
• Previous sexual history:
o “Have you had sex before?”
o “Have you used contraception before?”
o “Any chance you could be pregnant?”
o “Any chance you have an STI?”
• Assess using Fraser Guidelines:
o Before I prescribe this, I must ask you a few standard questions if that is
okay:
▪ Do you understand everything we have talked about so far?
▪ Are you willing to discuss this with your parents? Would you be okay if
I discussed it with your parents?
▪ What would you do if I didn’t prescribe the pill?
▪ Would your mental health suffer if you didn’t have the medication?
• “I think having the pill is in your best interest, but before starting anyone on the pill I
need to check your medical history”
o Menstrual history – LMP, cycle length, duration of bleeding, dysmenorrhoea,
IMB, age at menarche
o PMH – Any medical problems? Check BMI. Have you ever had migraine with
aura?
o FH – Anyone in the family have breast cancer, cervical cancer, clotting
problems, migraines, stroke
o DH
o SH – Smoking
• What is the COCP?
o It is combination of two natural hormones that your body produces, and
reduces the risk of you becoming pregnant
 o Advantages: Lighter periods, helps with acne, reduces risk of endometrial
cancer
o Disadvantages: Must take every day at the same time, increased risk of
clotting

Counselling for methylphenidate:

• WIPER, explain purpose of consultation, before we dive in is there anything you are
especially concerned about or would like for me to do for you today?
• What is Ritalin?
o Stimulant, not a cure. Can help with focus and attention
o Works in 70% of patients
o Indications for use:
▪ Impulsivity
▪ Inattention
▪ Hyperactivity
▪ Only if non-pharmacological methods have failed
• Are there any side effects:
o Decreased appetite
o Anxiety, tics
o Hypertension
o Can cause growth suppression
o May need drug holidays
• Baseline monitoring:
o Height and weight, BP, LFTs
o Need 3 monthly check ups
o Needs to be under review by a specialist
• Stopping the drug:
o If there is no response after a month, we will stop gradually
o Not addictive provided correct doses used
o Treatment will be continually reassessed
• Alternatives:
o CBT
o Parental management training
o Family therapy
• Offer leaflet
Communicating suspicion of NIA to parents:

“I understand what you are telling me. A minor fall might cause a fracture like this, but it is
very unlikely”

“It is reassuring your child is otherwise healthy”

“When a child has an injury like this, there are guidelines we must follow to protect the
small number of children who may have suffered an inflicted injury"

“These guidelines state that we have to inform social services, so a social worker will come
to speak with you about your child’s care”
Explaining vaccinations:

• Why does my child need multiple doses?

o To ensure they develop a good response to the disease
o The gap between the doses means each one has time to work
o Each new dose boosts the response
• What are the side effects?
o Fever
o Sickness/diarrhoea
o Swelling at site
o Very rarely they may have an allergic reaction
• When should they not have a vaccine?
o Acutely unwell
o On steroids
o Immunocompromised
• 8 weeks is too early to give my child vaccines. Won’t he be protected by breast
milk?
o Early protection is important as many of these diseases are deadly in babies
o Breast milk is good at helping with GI infections and pneumonia, but
otherwise is not helpful for the diseases we are trying to prevent with
vaccination
• I am worried so many vaccinations at once will overload my baby’s immune system.
Can I have them separately?
o Immune system is continuously being challenged by the environment
o If given separately
▪ More chances to have side effects
 ▪ If you are worried about the additives in vaccines, giving multiple
separate doses ups the total amount of these
▪ The NHS does not offer a staggered dosing system of this kind
▪ The child is less likely to have them than if they are all done at once

Postnatal care

• WIPER
• This consultation is to explain what will happen to the care of your baby in the first 8
weeks. Lots of things will happen in the next 8 weeks so we want to let you know
what to expect
• Establish prior knowledge
• Within the first hour of birth
o You won’t be separated from your baby
o You should be encouraged to have skin-to-skin contact
o You should be offered support to help you start breastfeeding
o Baby will be given an injection of vitamin K to prevent a rare but serious
complication
o Newborn screening
▪ Your baby should be fully examined within the first 72hrs of birth
▪ Review of your family’s medical history, complete physical check
▪ Most babies will be healthy, but it is to catch anything that would
benefit from being treated early
• DDH:
o 1-3% newborns
o In some babies, the top of one of the thigh bones may be out of the hip. This
needs treating ASAP or can cause problems later in life.
o This will be checked after birth and at the 6 week baby check
o If you notice any of the following tell your GP
 ▪ Baby drags a leg
▪ You can hear a click on the hips
▪ A difference in the leg creases between the two legs
• Newborn heel prick test
o Given on day 5-8
o Checks for any rare but serious health problems that can’t be detected at
birth
o Sickle cell, cystic fibrosis, congenital hypothyroidism, PKU, ...
• Routine vaccinations will start at 8 weeks
• All babies have a complete physical examination at 6-8 weeks to check they are
getting on well
• Safe sleeping
o Co-sleeping increases the risk of sudden infant death syndrome
o Smoking in the house also increases this risk
o Back to sleep:
▪ Back on firm mattress
▪ Nothing around head or under
▪ Blanket not needed but if used keep baby’s arms above it
▪ Look at the back to sleep campaign online
• ICE. Check understanding and offer a leaflet

Diagnosing ADHD

• Hyperactivity: Fidgeting, excessive motor activity, inability to play quietly

• Inattention: Decreased attention and easily being distracted
• Impulsivity: Blurting out answers in class, inability to take turns
Autism counselling:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Establish what they already know about autism
• What is autism?
o A disorder that affects development, with problems in social interaction,
communication, repetitive behaviours and interests
▪ Impaired social interaction:
• Little interest in forming friendships
• Difficulty in the use of non-verbal cues
• Solitary
▪ Impaired language and understanding:
• Delayed
• Unusual tone of voice, echolalia, stock phrases
• Difficulties understanding abstract concepts or sarcasm
▪ Restricted interests and resistance to change:
• Repetitive play
• Odd repetitive movements
• Intolerant to change
o N.B. Regression not a feature of autism
o 70% have some degree of learning disability
• What causes it?
o We don’t know
o Evidence from twin studies suggests autism to be highly heritable
o No evidence to support the MMR vaccine as a cause
• What can be done?
o Each child is an individual and should have an individualised plan
o Educational support and family therapy can be useful
o Speech and language therapy can be helpful
o Behaviour therapy and parental training can be helpful to help with
meltdowns
o Medication can be helpful with some of the psychological symptoms
• Prognosis:
o 15% manage independently with little support
 • Confirm understanding, invite questions, signpost

Cerebral palsy counselling:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Establish what they already know about cerebral palsy
• What is it?
o Difficulty with moving a body part owing to a problem with the brain
o Disability depends on the type of cerebral palsy
o May not be able to walk, move, talk, eat, or play in the same way as other
children
• What are the types of cerebral palsy?
o Spastic (most common): Movement is stiff and jerky, affected muscles are
permanently contracted
o Dyskinetic: Slow writing movements of the hands/arms/legs. Stiffness can
vary
o Ataxic: Problems with balance and coordination
• What causes it?
o 80% antenatal – maternal infection
o 10% intrapartum – intraventricular haemorrhage, prematurity, severe
jaundice in the newborn
o 10% antenatal – meningitis
• What can be done?
o Physiotherapy and occupational therapy
o Medication – Botox and baclofen
o Surgery can sometimes be useful
Cystic fibrosis:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Establish what they already know about cystic fibrosis
• What is it?
o Genetic condition caused by a mutation in the CTFR4 protein.
o Incurable lifelong condition, mean survival 40-50 years
o However, some treatments exist for the most common mutation (70%) delta
F508, so prognosis may be much better if your child has that
• How is it passed on?
o It is a genetic disease.
o Approximately 1 in 25 people carry the mutation, but you have to have two
copies to have the disease
• What does it do?
o Airways: Mucus in the lungs is very thick and can’t be shifted easily. This
makes patients more likely to develop infections
o Intestines: Newborn babies can take longer to pass meconium. Much higher
energy needs
o Pancreas: Problems with secreting pancreatic enzymes into the gut. Means
it is difficult to absorb fat and vitamins. Can lead to diabetes
o Liver: Can have intrahepatic cholestasis
• What can be done?
o Airways: TDS physiotherapy and deep breathing exercises. Prompt treatment
of chest infections. Heart and lung transplant may be needed
o Pancreas: High calorie, high fat diet needed. Pancreatic enzyme and vitmin
supplementation needed
o Liver: Ursodeoxycholic acid can reduce bile build up
o Delta F508 mutation positive CF can be treated with a combination of
ivacaftor and lumacaftor
o Fertility: IVF may be needed
• Confirm understanding, invite questions, offer leaflet
Sickle cell disease:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Establish what they already know about sickle cell disease
• What is it?
o Inherited disease where the body can’t make haemoglobin properly. Hb is in
red cells and carries oxygen to the organs
• What causes it?
o Abnormal form of Hb (HbS). This abnormal form of Hb causes red blood cells
to sickle instead of doughnut. This sickling happens under conditions: cold,
infection, dehydration, low oxygen, prolonged exercise
o Shape change causes the cells to be less flexible and they get stuck in
vessels and block them. Also, the cells are worse at carrying oxygen
• How does this affect the patient?
o Painful crisis
o Acute chain syndrome
o More prone to infection
o Severe anaemia
• What can be done?
o What the patient can do:
▪ Be fully vaccinated and have additional vaccinations against men,
hep B, and flu
▪ Pen V antibiotic prophylaxis
▪ Folic acid supplementation
▪ Avoid smoking and excess alcohol
▪ Avoid triggers
o What the doctor can do:
▪ Fluids, oxygen, painkillers, antibiotics. Many patients will have a
personalised rescue plan agreed with their haematologist
▪ Blood transfusions if urgently needed
 ▪ Hydroxyurea
• What are the long-term complications?
o Slower growth
o Splenectomy may be needed
o Parvovirus can cause severe anaemia
o High doses of folic acid needed in pregnancy
• Confirm understanding and offer leaflet

Gastro-oesophageal reflux (in an infant):

• WIPER, establish purpose of consultation, before we dive in is there anything you
are especially concerned about or would like me to do for you today?
• Establish what they already know about reflux
• What is it?
o Reflux in babies is often called regurgitation, because it refers to milk coming
back up effortlessly after feeding.
o Not vomiting, which involves muscular contraction
o Affects 4/10 babies to some extent
o Some babies bring up milk >6 times a day
• What causes it?
o Food goes down the oesophagus into the stomach and the opening of the
stomach is not mature enough to stop it coming back up
o Exacerbated by fluid diet and lying down all the time
• What can be done?
o Doesn’t need tests or treatment
o Goes away by itself by one year
o In the meantime
▪ Burp regularly during feeding
▪ Hold upright after feeding
▪ Raise the head end of the cot
▪ Baby on back whilst sleeping
• Breast or bottle feeding?
o Can refer to breastfeeding therapist
o Can thicken feeds if formula feed. Cow’s milk protein allergy can look a bit
like reflux, if atopy can consider special formula that does not contain cows
milk
o If all the advice doesn’t work, can consider an alginate and the if that doesn’t
work, omeprazole
• Come back to GP if:
o Projectile vomiting
o Baby is bringing up anything green or red
o If baby isn’t putting on weight
o If reflux is still a problem after 1 year
• Confirm understanding and offer leaflet
Epi-pen use:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Establish what they already know about anaphylaxis
• What is anaphylaxis?
o Severe type of allergic reaction which causes the airway to swell up and
makes it hard to breathe. Calling is 999 is very important, but in this
situation, it is also very important to administer their Epi-pen
• What is an Epi-pen?
o A device containing adrenaline, which can quickly help someone breathe
during anaphylaxis
• When do I use it?
o Always know where it is, have a spare, if possible, make sure they are in date
o Remove from case, hold in a fist grip
o Remove blue cap
o Blue to sky, orange to thigh
o Aim for outer part of thigh
o SWING CLICK HOLD (10s)
o Call 999
• Confirm understanding
Newborn exam:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Initial questions
o Have they passed urine?
o Opened bowels?
o Started feeding?
o Any family history of heart, lung, or hip problems
• Record birth weight
• Head
o Measure and plot head circumference
o Palpate fontanelle and sutures
o Inspect for dysmorphic features. Check ears are patent
o Red reflex
o Check suck reflex
• Chest:
o Observe RR
o Auscultate heart and lung fields
o Central cap refill
• Abdomen:
o Palpate quadrants
o Check umbilicus
o Palpate femoral pulses
• Genitalia and anus:
o Inspect urethral meatus for patency and for spadia
o Check anal patency
o Check testes have descended
• Moro reflex
• Turn baby over
o Check for muscle tone
o Inspect back
• Hips:
o Barlow’s test – Push thigh back
o Ortolani’s test – Abduct leg and push on greater trochanter
 • Ask mum how she is doing
• Newborn hearing test

Dermatology history:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• PC – why don’t you tell me in your own words about what’s brought you in today
• HPC
o Describe the rash as best you can?
o Where is the rash?
o How long has it been there for? Ever been there before?
o Has it changed since it appeared?
o Pain, itching, bleeding, discharge?
o Any problems with nails/joints/scalp/hair/eyes
o Severity markers:
▪ Previous hospital admissions
▪ Previous treatments
▪ Missing work?
▪ Social impact?
o Systems review:
▪ General: Fever, behaviour change, rashes, change in behaviour?
▪ Cardiorespiratory: Cough, SOB, cyanosis
▪ GI: Vomiting, abdo pain, number of wet nappies/frequency if older
▪ Neuro: Fits, headaches
▪ ENT: Sore throat, earache
• PMH:
o Atopy – Fever, weight loss, night sweats
o Previous dermatological issues
o Childhood skin problems
o Systematic diseases
o Immunosuppression
• DH:
o Anything already tried for the lesion?
o Anything started before the lesion
o Cosmetics?
 • FH – Atopy, psoriasis, eczema. Anyone have anything similar in your family?
• SH:
o Occupation?
o Sun exposure – burns, sunbeds, growing up abroad
o Pets at home?
o Alcohol, smoking, drugs
• Invite questions

Dermatology examination

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Observe skin under adequate light
• Observe the lesion
o Site
o Distribution – symmetry, multiple/single, discrete/confluent
o Size – measure with ruler
o Shape – Oval/circular/annular/irregular/polymorphic
o Colour
• Palpate rash
o Macule: flat, non-palpable
o Plaque: Flat, palpable
o Papule: Solid, raised <5mm
o Nodule: Solid, raised >5mm
o Vesicle: Fluid filled, <5mm
o Bulla: fluid filled >5mm
o Pustule: Fluid filled with purulent material
o Other
• Describe the edge of the rash: Well circumscribed/ill-defined/irregular
• Describe the surface:
o Smooth/rough/hard/soft/wet
o Atrophic/indurated
o Excoriation/lichenification/pedunculated
• Check scalp/nails/joints
• Pedal pulses
Explaining Eczema:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Establish what they already know about eczema
• What is it?
o Your skin is a barrier, that has two functions: stopping water from leaving
your body and stopping anything harmful from getting in
o In eczema, this barrier is a bit weaker, so the skin gets dry and is more prone
to irritants from the environment getting in.
o The immune system can overreact to the irritants from the environment
getting in, bit like an allergy
• What causes it?
o There is usually a family history
o Autoimmunity
• What can be done?
o Fire in house analogy: steroids are like the fire extinguisher for short term
use, moisturisers are like fireproofing houses for the long term
o Steroids
o Moisturisers
o Soap substitutes
o Keep nails short
o Identify triggers and avoid
• Prognosis:
o Eczema is very treatable and often resolves by age 5
• Invite questions and signpost
Acne

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Establish what they already know about acne
• What is it?
o Your skin has lots of pores with glands at the bottom. These glands produce
an oil called sebum which helps keep your skin smooth
o In acne these pores can become blocked, and the sebum builds up
underneath, causing spots. Bacteria grow in this trapped oil, which the
immune system attacks causing inflammation and pus
o This is a very common cause of spots in teenagers as the extra hormones
cause increased sebum production
• What can be done?
o Patient:
▪ Thick layers of makeup
▪ Picking and squeezing spots
▪ Wearing tight clothes
▪ Using anabolic steroids
▪ Don’t over wash
o Doctor:
▪ We can start with a medication called benzoyl peroxide. This dries out
the pores and helps acne long term. However, can take four weeks to
work and makes skin dry.
▪ If that fails, we can add in antibiotics to kill the bacteria itself
▪ If that still doesn’t work, we can refer you to dermatology for vitamin A
derivatives
o Confirm understanding, invite questions, offer leaflet
Psoriasis

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Establish what they already know about psoriasis
• What is it?
o Normal skin is made up of layers
o The top cells gradually fall off, new cells are made underneath to replace the
top layer
o Psoriasis is an inflammatory condition in which there is inflammation of the
skin in patches. The turnover of skin increases, and this causes flaky plaques
to form.
o Triggers include stress, infections, skin trauma, drugs, alcohol, smoking
• What can be done?
o Unfortunately, once it has been developed it comes and goes throughout life
o Patient:
▪ Identify and avoid triggers
▪ Check with your GP that you are not on medications that can cause
flares
▪ Let your medications soak in one at a time
o Doctor:
▪ Moisturising creams to soften hard skin and plaques
▪ Refer to support groups
▪ Topical steroids for flares and calcipotriol
▪ Light therapy can be useful
▪ Immune modifying drugs can help with the inflammation
• Confirm understanding, invite questions, offer leaflet
Explaining normal labour

• Occurs between 37 and 42 weeks of gestation

• Early signs of labour?
o Lightening, polyuria, heavy sensation in upper thighs, lower back ache
o Increase in Braxton-Hicks
o Ripening of cervix
o Spurt of energy
• Signs of true labour:
o Painful rhythmic contractions
o Dilatation of cervix
o Show
• Stage 1:
o Onset of true labour to the full dilatation of the cervix
o Latent:
▪ Latent:
• Effacement
▪ Active:
• From 4cm dilatation
• Cervix fully dilated at 10cm
• 0.5/1cm an hour
o Descent: Foetal head moves into the pelvis and becomes engaged (cephalic
presentation, 90% born this way)
o Flexion of the neck as the vertex meets the resistance of the pelvic floor
• Stage 2:
 o Full dilatation to expulsion of the foetus
o Internal rotation: Occiput meets the pelvic floor as it rotates forward. Slope
of the pelvic floor aids rotation forward allowing the head to emerge in the
longest diameter of the pelvic outlet (anteroposterior diameter)
o Predominantly turns OA
o Shoulders enter the pelvis in transverse
o Crowning of the head
o Head born by extension
o Internal rotation of the shoulders
o Restitution
o Lateral flexion of the shoulders as they are born
o Baby lifted to mother for skin-to-skin contact
• Stage 3:
o Separation and expulsion of the placenta and membranes and control of
maternal bleeding
o Check the placenta is not retained
▪ 12-30 cotyledons
▪ Amnion and chorion
▪ Cord insertion
▪ Three vessels in cord (2 arteries 1 vein)
Examining the pregnant abdomen:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Ensure patient is correctly positioned
• General inspection:
o Comfortable at rest
o Check legs and feet for any signs of oedema
o Look for jaundice
• Abdominal inspection
o Distension – The abdomen is distended consistent with pregnancy
o “Has baby been moving yet?”
o Umbilicus – flat/inverted/everted
o Scars
▪ Suprapubic – Lower segment CS
▪ Previous ports consistent with laparoscopic surgery
o Skin changes
▪ Striae gravidarum
▪ Striae albicans
▪ Excoriations
▪ Distended superficial veins
• Abdominal palpation:
 o Check for pain, warm hands
o Assess symphysis-fundal height
▪ Palpate the top of the fundus
▪ Measure down to the symphysis with a measuring tape
▪ Should be within 2cm of the gestation date after 20 weeks
o Ballot fluid
o Assess foetal lie -
o Assess for the position of the back
▪ Use doppler or Pinnard to listen to foetal HR
o Thank patient
o Complete by requesting a BP, urine dip, height/weight

Bimanual examination

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Explain procedure and obtain consent:
o “This is an internal exam from down below, which will involve placing two
gloved fingers into the vagina. If you feel uncomfortable or want to stop at
any point let me know. There will be a chaperone present throughout. Do I
have your consent for this procedure?”
• Get the chaperone
• Brief history questions:
o LMP, last smear
• Appropriately expose patient
o “For this procedure, you will need to undress from the waist down, lie on the
couch, cover yourself with the sheet and let me know when you’re ready”
o “Pull your heels towards your bottom and let your knees fall to your side”
• Check the patient is comfortable and happy to proceed
• Abdominal exam
• External examination
o Sterile gloves
o Inspect the vulva
 ▪ Warts, cysts, erythema, atrophy, scarring
• Internal exam
o Part labia with forefinger and thumb of the left hand
o Index finger and middle sideways then rotate
▪ Vagina: Palpate vaginal wall for irregularities or masses
▪ Cervix: Assess size, consistency, mobility, tenderness. Assess the
fornixes for masses
▪ Uterus:
• Push down abdominally with one finger under the cervix in the
posterior fornix
• Size: Large in pregnancy/fibroids/cancer
• Shape: Nodular, smooth/firm/hard
• Mobility:
• Position: anteverted or retroverted
• Tenderness: Cancer, infection
▪ Adnexal palpation:
• Push down in the right and left fossa and place the fingers in
the lateral fornix of the cervix
• Feel for tenderness or masses
o Remove fingers, inspect for blood or discharge. Provide cotton wool swab or
tissue
• Summarise history and further investigations: speculum and smear, high vaginal
swab, and TVUS if indicated
Cervical smear:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Explain procedure and obtain consent:
o “This is an internal exam from down below, which will involve placing an
instrument called a speculum into the vagina and me taking a swab from the
cervix. If you feel uncomfortable or want to stop at any point let me know.
There will be a chaperone present throughout. Do I have your consent for this
procedure?”
• Correctly position patient:
o “For this procedure, you will need to undress from the waist down, lie on the
couch, cover yourself with the sheet and let me know when you’re ready”
o “Pull your heels towards your bottom and let your knees fall to your side”
• Inspect vulva
o Warts, ulcers, cysts, erythema, atrophy, discolouration
• Lubricate speculum avoiding the tip
 • Hold speculum in the non-dominant hand, separate labia with the non-dominant
hand. Warn patient before placing the speculum
• Insert speculum sideways with the blades closed, rotate 90 degrees
• Maintain downward pressure on speculum, open speculum and lock it
• Adjust light
• Inspect the cervix
o Discharge, ulceration, masses, inspect cervical os
• Inspect vaginal wall
o Scars, rashes, masses
• Insert brush into endocervical canal, rotate 5 times clockwise
• Insert into vial, shake, reseal. Label the sample
• Remove speculum, release lock once away from cervix
• Advise on results:
o You should get your results with 2/3 weeks
o If you don’t hear within 4 weeks call us

Breast examination:

• WIPER, establish purpose of consultation, before we dive in is there anything you

are especially concerned about or would like me to do for you today?
• Gain consent, get chaperone, position correctly
• Stand opposite the patient and inspect:
o Scars: Lumpectomy, mastectomy
o Asymmetry:
o Skin changes: Erythema, dimpling, peau d’orange, scars
o Nipple changes: inversion, eczema like changes, discharge
• Raise arms above head, hands on hips, lean forward
• Explain to patient that you are beginning the procedure and will start from the
asymptomatic breast
• Palpate breast quadrants systematically and palpate nipple areola complex
• Palpate axillary lymph nodes
• Ask patient to express any discharge
 • Lump description:
o 3Ss: Site, size, shape
o 3Cs: Consistency, contours, colour
o 4Ts: Tenderness, temperature, transillumination, tethered
• Complete assessment
o Summarise and suggest further investigations if appropriate
o Triple assessment
▪ Examination
▪ Imaging
▪ Tissue sampling

Interpreting cardiotocography (DR C BRAVADO):

• Define risk:
o Low or high-risk pregnancy?
o High risk pregnancies:
▪ Maternal illness
▪ Obstetric complications
▪ Congenital malformations
• Contractions:
o Each big square is 1 minute
o Comment on the number of contractions per 10 minutes
o Duration of contractions
• Baseline rate:
o Average foetal heart rate over 10 minutes
o Should be between 110 – 160
 o Foetal tachycardia: Hypoxia, infection, anaemia
o Severe foetal bradycardia: Prolonged cord compression, cord prolapse,
anaesthesia, vasa praevia
• Variability:
o Indicator of general foetal health. A result of the interplay between the
nervous system, chemoreceptors, and baroreceptors
o Should be between 10 – 25bpm. It can drop below 5bpm for 40 minutes
(foetal sleeping) but it should not be longer than this
o Reduced variability longer than 40 minutes:
▪ Foetal acidosis
▪ Foetal tachycardia
▪ Anaesthesia
▪ Prematurity
• Accelerations:
o Should be around 2 in 15 minutes
• Decelerations:
o Early: Not pathological. Correspond to contractions
o Variable: Rapid fall in BP with variable recovery. Usually caused by cord
compression and are a worrying sign
o Late: Begin at the peak of contraction and recover. Indicate insufficient
blood flow through uterus and placenta. Causes foetal hypoxia and acidosis.
▪ Pre-eclampsia, uterine hyperstimulation.
▪ Foetal blood sampling indicated
• Overall impression
o Reassuring: All four features reassuring
o Suspicious: One feature non-reassuring
o Pathological: Two or more non-reassuring
• Consider:
o Give oxygen
o Perform vaginal exam
o Foetal blood sample
o Preparation for delivery
DRABCDE – PPH:

• Check for danger and response

• Call for help, emergency buzzer. SOAPS (Senior midwife, Obstetrician,
paediatrician, scribe)
• Check airway. In APH put in a left lateral tilt
• Breathing
o RR and O2 saturations – start high flow oxygen if needed
o Look: Cyanosis, accessory muscles, recession
o Feel: Chest expansion, percuss lung fields
o Listen: Lung fields, breath sounds, air entry
• Circulation:
o HR, BP, CR,
 o Obtain 2 wide bore cannulae. Fluid challenge whilst awaiting blood
products. Cross match 6-8 units. FBC, U&Es
o Look: Pallor, sweating
o Feel: Pulses, cap refill, temperature
o Listen: Heart sounds
• Disability:
o Check pupils
o Blood sugars
o AVPU
• Exposure:
o Check site of bleeding
o Uterine massage
o 1g of tranexamic acid over 10 minutes
o Catheterise
o Slow IV syntocinon 5 U
o Ergometrine 0.5mg (check asthma)
o IM Carboprost
• Monitoring
o Pulse, RR, O2 sats, BP
• Closing:
o I would do a secondary survey and discuss with my seniors to prep for
theatre
o Check swabs and equipment to estimate blood loss
• Documentation
o Timing of events
o Obs and fluid balance
o Medications used
o Persons present

Brief history:

• S: Signs and symptoms

• A: Allergies
• M: Medications
• P: Pertinent past medical history
• L: Last oral intake
 • E: Events leading to the illness or injury

DRABCDE eclampsia:

• Check for danger and response

• Call for help, emergency buzzer. SOAPS (Senior midwife, Obstetrician,
paediatrician, scribe)
• Check airway
o Turn her to her left hand side
• Breathing:
o RR & O2 sats: start high flow oxygen if needed
o Look: Cyanosis, accessory muscles, recession
 o Feel: Chest expansion, percuss lung fields
o Listen: Lung fields, breath sounds
• Circulation:
o HR, BP, CR – Two wide bore cannulae.
o FBC, U&Es, LFTs, clotting screen
o Look: Pallor, sweating
o Feel: Pulses, cap refill, temperature
o Listen: heart sounds
o Loading dose of 4g of MgSO4 given over 5 minutes
o Insert catheter for creatinine/protein ratio
o Cardiac monitoring
o IV labetalol for hypertension. Aim for systolic of 150mmHg
• Disability
o Check pupils, reflexes, AVPU, blood sugar
• Consider IM betamethasone and CTG
• Document
o Timing of events
o Medications
o Persons present

General Antenatal Checkup:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC: Current pregnancy
o LMP
o Normal menstrual cycle
o Previous contraception use
 o BMI
o Health education
▪ Smoking, alcohol, substance misuse, diet, exercise
o Other symptoms:
▪ Visual changes, Headache, abdo pain, swelling, itchiness, bowel
change, urinary change
• Obstetric history:
o Gestation
o Previous pregnancies and miscarriages
o Previous problems during pregnancy and labour
o Health and development of children
• Gynae history:
o Pain, discharge, bleeding
• PMH:
o General PMH
o Any mental health history, any surgical history
• DH and allergies
• SH
o Support available
o Home situation
o Employment
o Screen for domestic abuse
• FH
o Any babies born with problems?
o Diabetes
o DVT
• Screen for depression
• Discuss upcoming appointments
• Thank patient, invite questions, summarise

Hyperemesis gravidarum:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC
o Onset, duration, frequency of N&V
 o Whether food and drink are tolerated, how much
o Associated symptoms: weight loss, abdo pain, fever, diarrhoea, discharge,
headache, bowel, urinary symptoms
o Effect on life and mood
• Obstetric history:
o Gestation
o Previous pregnancies
o Any previous problems in pregnancy
o Health and development of children
• Gynae history:
o Pain, discharge, bleeding
• PMH:
o General medical health, mental health, surgical history
• DH and allergies
• FH:
o Any babies born with problems in your family?
o TB
o Diabetes
o Clotting
• SH
o Support available
o Employment
o Situation at home
o Domestic abuse screen
• Examination in GP:
o Monitor weight, BP, HR
o Examine for signs of dehydration
o Urine dipstick for ketones
• Advice:
o Most women can eat and drink sufficiently to avoid hospital and anti-emetics
o Small meals high in carbohydrates can be helpful
o Ginger and acupressure may be helpful
o Avoid food or smells that trigger symptoms
o Seek urgent medical advice if:
▪ No urination for longer than 8 hours
▪ Abdominal pain or fever
 ▪ Severe weakness or feeling faint
▪ Vomiting blood
▪ Inability to keep food down for 24hrs
o Make follow up plans
• If in hospital
o Blood tests
o IV fluids
o IV anti-emetics
o PO thiamine
o High dose folic acid
o LMWH
o USS

Contraception:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
 o Why do you want contraception? What do you already know about it?
• HPC:
o Sexual history:
▪ Are you currently sexually active?
▪ Do you have a regular partner? Men or women or both?
▪ Are you currently using contraception?
o STI:
▪ Have you or your partner ever had an STI?
▪ Was it successfully treated?
▪ Have you ever been screened for an STI?
• Menstrual history:
o Regular cycle? How long?
o LMP
o Excessive bleeding or pain
o Pain during intercourse?
o Bleeding between periods?
o Any discharge?
o When was your last smear?
• Obstetric history:
o Have you ever been pregnant before? Did that result in a pregnancy?
o Is there any chance you could be pregnant today?
o Do you have children? How were they delivered?
▪ Are you breastfeeding?
o Health and development of children
o Any problems during the pregnancy or after?
• PMH:
o Migraine with aura
o Clotting problems
o Cancer
o HTN
• DH and allergies
• FH
o Cancer
o Clots
o Migraine w aura
• SH
 o Smoking, alcohol, BMI
• ICE: Did you have any type in mind? What do you know about your options?
• Explain contraception: Mechanism, method, efficacy, missed pill, pros/cons,
alternatives

COCP:

• Mechanism: Stops ovulation, increases cervical mucus, thins endometrium

• Method: Daily course for 3 weeks, then 1 week off. Start within five days of start of
cycle
• Pros: Lightens periods, 99% effective if taken correctly, can improve acne, reduces
risk of ovarian and endometrial cancer
• Cons: Need to remember to take it, no protection from STIs. Risk of weight gain,
mood changes, headache, blood clots, breast and cervical cancer.
• Missed pill:
o If 1 missed take asap and continue normally
o If two missed, take last pill, continue to take daily, barrier contraception for 7
days
▪ + emergency contraception if unprotected sex in week 1
▪ + omit pill free interval if unprotected sex in week 3
o If vomiting within 2 hrs of taking the pill, take another
o Not protected if D&V
• Hold for 4 weeks prior to surgery

POP:

• Mechanism: Increases cervical mucus, thins endometrium

• Method: Daily, same time. 99% effective if taken properly
• Pros: Does not interfere with sex, can be used during breastfeeding, usually fine if
COCP is CI
• Cons: Must be taken at the same time each day. Weight gain, mood changes,
headaches, ovarian cysts
• Missed pill:
o <3 hours late: continue as normal
o >3 hours late: Take missed pill asap but condoms for 48hrs

IUD – Copper coil:

 • Mechanism: Decreases sperm survival
• Method: Can last for up to 8 years. Can insert at any time in the cycle. Effective
immediately.
• Pros: No hormones, can forget about it, doesn’t need to be taken every day. Normal
cycles
• Cons: Can make periods heavier. Coil insertion risk

IUS – Mirena coil:

• Mechanism: Increases cervical mucus, thins endometrium

• Method: Lasts up to 8 years depending on the brand. Effective after seven days
• Pros: Can forget about it, lightens periods (fewer or no periods). Useful treatment
for fibroids, menorrhagia, and adenomyosis. Spotting for the first 6 months, light or
stopped periods. Hormonal treatment local so low risk of systemic side effects
• Cons: Coil insertion risks. POP side effects, but lower risk

Progesterone implant (Nexplanon):

• Mechanism: Prevents ovulation, increases cervical mucus, thins endometrium

• Method: Lasts up to three years. Works straight away if used in the first five days of
the cycle
• Pros: Can forget about it
• Cons: Needs a professional to insert and remove. Can feel it in arm. Headache,
nausea, breast pain, infection, scarring.

Progesterone injection (Depo-Provera):

• Mechanism: Prevents ovulation, increases cervical mucus, thins endometrium

• Method: Lasts 12 weeks. IM injection
• Pros: Can forget about it. Good if oestrogen contraindicated
• Cons:
o Injection every 3 months
o Delay in return of fertility of up to 12 months
o Can’t be removed
o Weight gain
o Effect on cycle: May stop, may become irregular or longer
Emergency contraception:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC:
o Details of UPSI:
▪ When and with whom
o Current contraception:
▪ Type, reason for failure, last time used
o Menstrual history:
▪ LMP, cycle length, regularity
▪ Earliest ovulation time: shortest cycle length minus 14
o Any chance you could already be pregnant?
o STI risk?
• PMH, DH, allergy
• What do you already know about emergency contraception?

Levonelle:

• Timeframe: Within 3 days of UPSI

• Mechanism: Prevents ovulation, disrupts implantation
• Efficacy:
o <24hrs: 95%
o 24-48hrs: 85%
o 48-72hrs: 58%
• CI: Pregnancy
• SE: PV bleeding, nausea, vomiting, headache, breast pain
• Comments: If vomiting within 3 hours, repeat dose. Do pregnancy test 3 weeks.
Hormonal contraception should be stopped and restarted next cycle. Double dose
if taking P450 inhibitors

EllaOne:

• Timeframe: Within 5 days of UPSI

 • Mechanism: Prevents ovulation, thins endometrium
• Efficacy: 98%
• CI: Pregnancy
• SE: PV bleeding, nausea, vomiting, headache, breast pain
• Comments: If vomiting within 3 hours, repeat dose. Do pregnancy test 3 weeks.
Hormonal contraception should be stopped and restarted next cycle. Check no
liver problems or taking steroids

Copper IUDs:

• Timeframe: Within 5 days of UPSI OR within 5 days after the earliest likely
calculated ovulation
• Mechanism: Prevents fertilisation
• Efficacy: >99%
• CI: Pregnancy, pelvic infection <3months ago
• SE: Pain on insertion, infection, menorrhagia, perforation, vasovagal
• Comments: Can be used long term
Urinary Incontinence:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC:
o Circumstances around incontinence:
▪ Urge: Sudden desire to pass urine
▪ Stress: Leakage when coughing
o When does it happen? How often?
o Night symptoms?
o How long has this been going on for?
o Has it been getting worse over time?
o How have you been managing this?
• Menstrual history:
o IMB, pain during sex, pain, discharge
o Last smear?
• Obstetric history
• PMH, DH, FH, SH
• Investigations:
o Bladder diary for at least 3 days
o Urine dipstick
o MSU if dipstick +ve

Lifestyle advice for urge and stress incontinence: Reduce caffeine intake, weight loss,
alcohol, stress
Infertility

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC:
o Female age
o How long how you been trying to conceive? How often do you have sex? Any
difficulties or pain? (84% of couples under 40 will conceive within one year)
o Do you track your cycle?
o Before trying to conceive, what contraception were you on?
o Partner history?
▪ Age, occupation?
▪ Any children before?
▪ Have they been investigated for infertility?
▪ Hx of surgery?
▪ Hx of mumps, orchitis, STIs
▪ PMH: DM, Hep B/C, HIV, cancer treatment
▪ DH
▪ Smoking, alcohol, recreational drugs
• Gynae history:
o LMP, cycle length, regularity
o IMB, dyspareunia, discharge, PV bleeding
o Age of menarche
o Last cervical smear?
o PCOS symptoms: Hirsutism, acne, obesity, oligomenorrhoea
o Prolactinoma
o Previous STIs, surgeries
o Anorexia, exercise, BMI
• Obstetric history:
o Ever been pregnant before? Did that result in a child?
o Type of delivery?
 o TOP
• PMH
• DH and allergies:
• FH:
• SH:
o Smoking, alcohol, exercise, drugs, stress

Menopause:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC:
o When did these symptoms start?
o What symptoms are you experiencing? Have they been getting worse?
o How has this been affecting your life? What have you tried to help so far?
• Menstrual history:
o Still having periods? How regularly?
o Last cervical smear?
• PMH:
o Clotting problems
o Migraine with aura
o Breast symptoms
o Cancer
• FH, DH, SH
• Discuss management:
o Lifestyle measures:
▪ Avoid caffeine, alcohol, exercise more
o HRT:
▪ Urogenital symptoms only: Local oestrogen
▪ Systemic symptoms:
• No uterus: Oestrogen only
• Uterus:
o Post menopausal: Continuous combined HRT
o Peri-menopausal infrequent cycle: Long cycle HRT
o Peri-menopausal fairly regular: Sequential HRT
• Discuss side effects and red flags
 o If HRT inappropriate:
▪ Clonidine, SSRIs, gabapentin
o Discuss contraception if needed
• Arrange follow up

Termination of pregnancy counselling:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC:
o Brief sexual history
o LMP, length, and regularity of cycles
o Obstetric history
o STI risk assessment
• Explore reasons for termination:
o Can you tell me a little about why you want an abortion?
o Have you considered other options?
o Have you spoken about your decision with others? Do you feel supported?
• PMH and DH: Previous smears, TOP, Hx of mental illness
• SH:
o Have you discussed with the partner? Occupation, home life?
• Outline the methods of abortion:
o Most abortion services will perform an US to check dates
o Medical abortion:
▪ Best used early on, can be used no later than 12 weeks
▪ Mifepristone first and then misoprostol
▪ After 10 weeks the law requires the medication to be taken in clinic
▪ Most women pass the pregnancy within 4 to 6 hours of taking the
second medicine. Some women need to take extra doses of the
second medicine until the pregnancy passes.
▪ Safe, effective no adverse outcomes
o Surgical abortion:
 ▪ Used later than 7 weeks
• Vaccuum aspiration up until 14 weeks: Takes 5-10 minutes,
local anaesthetic. Most women go home a few hours later.
• Dilatation and evacuation after 14 weeks: Needs the use of
forceps and general anaesthetic. Most women go home the
same day
▪ Needs anaesthesia, but can be local or general depending on patient
preference
▪ Patient does not see products of pregnancy pass
▪ Consider antibiotic prophylaxis
o Safety net:
▪ If pain and bleeding doesn’t get better after a few days
▪ Any signs of general infection or unusual vaginal discharge
o Complications:
▪ N&V, discomfort, vaginal bleeding
▪ Infection
▪ Retained products
▪ Cervical trauma
▪ Haemorrhage
▪ Perforation
▪ Failed termination
• Summarise, invite questions, arrange follow up
Gynaecological history:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC:
o Abnormal discharge
o Periods:
▪ Age of menarche, LMP, length of cycle, regularity, change in amount
or pain associated with bleeding. Intermenstrual bleeding
o Abdo pain
o Post coital bleeding, pain during intercourse
o Smear?
o Contraception?
o STIs
o Gynae surgery
o Obstetric history
• Systems review:
o Weight loss, change in appetite
o Hot flushes, night sweats
o Change in waterworks
o Change in bowel habits
• PMH, FH
• SH: Smoking, alcohol, occupation
• Thank patient
Menorrhagia:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC:
o Quantify blood loss:
▪ Number of pads per day
▪ Passing clots
▪ Nighttime symptoms
▪ Flooding
o Periods:
▪ Age of menarche, LMP, length of cycle, regularity, change in amount
of bleeding and pain associated
o Abdo pain
o Post coital bleeding, pain during intercourse
o Smear?
o Contraception?
o STIs
o Gynae surgery
o Obstetric history
• Systems review:
o Weight loss, change in appetite
o Hot flushes, night sweats
 o Change in waterworks
o Change in bowel habits
• PMH, FH
• SH: Smoking, alcohol, occupation
• Thank patient

Explaining Down’s syndrome:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• What is Down’s syndrome:
o A genetic condition caused by an extra chromosome in the baby’s cells
resulting in some level of learning disability and a range of physical
characteristics. Trisomy 21
o Affects 1 in 700 babies
o Not usually inherited but can be chromosomal changes which predispose
(Robertsonian translocation). More common in older women
o Happens randomly – Not caused by anything the parents have done
• What happens if my baby has Down’s syndrome:
o Every child is different and needs an individual plan for their specific needs
o However, all have some degree of learning disability
o Generally, take longer to reach developmental milestones and have
additional support in the form of early intervention services. Special growth
chart used.
o It's common for children with Down’s syndrome to be affected with coughs
and colds more often.
o Medical problems:
▪ Heart defects
 ▪ Bowel problems
▪ Hypothyroidism
▪ Chest problems
▪ Sinus problems
▪ Hearing impairment
▪ Recurrent ear infections
• What is life like for someone with Down’s syndrome?
o Life expectancy 60 – 65
o Lots of adults with Down’s syndrome are able to work and live independent
lives. However, most need long-term support and ongoing care
• If I have another child, will they have Down’s syndrome?
o Unlikely, trisomy down to random chance. Even with a Robertsonian
translocation risk is up to 10%
• How do we test for Down’s syndrome?
o 11-14 weeks: Combined test of nuchal translucency on US, and HCG and
PAP-A on blood test. Picks up 90% of cases (Nuchal translucency, HCG high,
PAP-A low)
o Quadruple testing 14-20 weeks: Picks up 80% of cases. AFP, unconjugated
oestradiol, HCG, Inhibin A
o If these tests show a higher risk of Down’s syndrome:
▪ Offer NIPT:
• If positive, 91% likely that foetus has Down’s syndrome.
Chance if lower risk (1 in 1054)
▪ Offer diagnostic test:
• Chorionic villus sampling (from 11 weeks):
o Passing a needle into the placenta under US guidance
o 1-2% chance of a miscarriage
• Amniocentesis (from 15 weeks):
o Using a needle to remove some of the amniotic fluid US
guided
o 1% chance of a miscarriage
o Very low risk of infection
• Preliminary results in 2-3d and full results in 2 weeks. 99%
reliable
• Summarise, invite questions, signpost
Antenatal screening tests:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• Brief history
• FBC:
o Increased risk of anaemia in pregnancy. Baby takes as much iron as it needs
despite mum’s needs. This should be rested regularly during pregnancy
• Blood groups and antibodies:
o To detect rhesus D and risks for future pregnancies
o If you are rhesus –ve and your baby is rhesus +ve, your babies RBCs can leak
into your circulation, and you can have an immune response to this. Won’t
cause harm this time, but in future pregnancies these antibodies can cross
the placenta and attack the foetal RBCs. We can prevent this by detecting it
early and giving anti-D to non-sensitised mothers
• Test for sickle cell and thalassemia
• Random blood sugar:
o Hormones released by the placenta during pregnancy can cause insulin
resistance. Can cause blood sugar levels to rise
o This can cause baby to grow too large and you and your baby have a higher
risk of T2DM
 • Hep B:
o Serious infection that can affect the liver. Can be passed mother to baby.
Can be prevented if baby vaccinated at birth
• HIV: Can be passed from mother to baby but the risk is greatly reduced if the mother
is diagnosed before birth
• Down’s screening: 11-13 for combined, 15-20 for quadruple
• Also monitored: US, abnormalities, Fluid levels, BP, urine dip
• Invite questions and provide further information

Cervical smear results:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• Establish current situation:
o The NHS cervical screening programme offers free tests to all women 25-64.
▪ 25-49yo: Every 3 years
▪ 50-64yo: Every 5 years
o HPV first screening
• HPC
o Age of menarche, LMP, length of cycle, regularity, change in amount of
bleeding and pain associated. Pain during sex. Post coital bleeding
o Abdo pain
o Contraceptive use
o Any discharge or pain?
o Vaccinated against HPV?
• Explain results:
o Normal:
 ▪ No changes noted back to routine recall
o Inadequate:
▪ Couldn’t be fully interpreted
▪ Not enough cells in sample
▪ Repeat test in three months
o Abnormal:
▪ Borderline or low grade: Observe, repeat in a year
▪ Anything higher: Refer for colposcopy
• Prognosis:
o CIN-1: 90% regress with two years, 11% progress to CIN-3, 1% progress to
invasive cancer (borderline)
o CIN-2: 50% regress within two years, 22% progress to CIN-3, 5% progress to
invasive cancer (low grade)
o CIN-3: 12% progress to invasive cancer (moderate grade)
o 2 and 3 are considered for ablation or large loop excision (high grade)
• Explain and reassure: This result does not mean you have cancer; it means there
are some abnormal cells which could become cancer if untreated
• Explaining colposcopy: Special microscope to examine the cervix. Can identify the
patches of abnormal cells with acetic acid (abnormal cells turn white) and iodine
(abnormal cells lack glycogen). Biopsy may be taken
o Ablation can be performed
o Large loop excision to prevent occurrence of cervical cancer
• Summarise, confirm plan, invite questions
Caesarian section:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• What do you understand already about a C-section?
• What does it involve?
o It involves making a cut to your belly and womb to deliver your baby
• What happens?
o Pre-procedure: Anaesthetist will come and discuss procedure with you
again. They will give you a spinal anaesthetic so the bottom half is
completely numb. You can bring one birthing partner in with you
o Procedure: During the CS, you will be awake but won’t feel anything. There is
a screen between you and your belly so you won’t see the surgery. Once the
surgery is done, they will lower the screen and hand you the baby
o Post-procedure: They will take you back to the ward to recover
 o Additional procedures: If there is a large amount of blood loss, we might
have to give you a blood transfusion. Very rarely, an additional surgery called
a hysterectomy is performed to stop the bleeding
• Risks:
o Because it is surgery, there is always the risk of infection and bleeding
o In future pregnancies you are still able to have a normal vaginal delivery but
you must let them know you have had a C-section

NVD vs C-section:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• NVD:
o Pros:
▪ Faster recovery (1-2 days)
▪ Can hold and breastfeed straight away
▪ Bacterial exposure through birth promotes normal microflora –
Protects immune system of baby
o Cons:
▪ Vaginal injury: Stretch and tear, stitches may be needed. Can cause
weakness in the perineal floor
▪ Lingering perineal pain
 • Caesarean section:
o Pros:
▪ More convenient and predictable
▪ Less painful 2nd stage
▪ Fewer urogenital problems
o Cons:
▪ Longer hospital stay
▪ Scar at site of incision
▪ Increased risk of blood loss and infection
▪ More likely to have future c-sections
▪ May be problems with placental attachment
o Indications:
• Summarise, check understanding, invite questions, thank patient

Miscarriage:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• “The important thing to say is miscarriages are common (10-15% of all pregnancy)
and they don’t mean that you have a medical problem or can’t have a baby. If you
have three in a row, we will investigate further for a cause”
• Confirm with transvaginal ultrasound
• Management:
o Conservative: Watchful waiting for 1-2 weeks if no signs of infection
o Medical: Single dose of PV misoprostol. Bleeding can continue for a few
weeks. May need to take painkillers and anti-sickness. No need for GA
 o Surgical: Happens under GA. Speculum placed, and products of conception
are aspirated. Risk of uterine perforation, infection, retained products,
damage to the neck of the womb
• Follow up: Safety net for retained products of conception and infection. Once
bleeding has stopped, perform a low sensitivity pregnancy test at 3 weeks
• Give a leaflet and signpost

Consultation with a patient about FGM:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• HPC
o In some countries it is common to have operations on genitalia. Is this
something you have experienced? Are you okay to discuss this today?
o What type?
▪ Partial/total removal of the clitoris
▪ Partial/total removal of the clitoris AND labia minora
 ▪ All external genitalia removed, narrowing of vaginal opening
▪ All other harmful procedures
o How old were you? Has anyone else in your family had this procedure?
o Do you have children? Do you have any plans to have them circumcised? Are
you under any pressure from family members to have them circumcised?
o Are you aware of the law in the UK with regards to this:
▪ Illegal regardless of wherever it is carried out
▪ Illegal to perform, aid, abet, or procure FGM on a UK citizen
▪ Up to 14 years imprisonment and fine
o Are you aware of the complications of FGM?
• Complications:
o Short term:
▪ Shock, bleeding, pain, infection, urine retention, death
o Long term:
▪ Decreased libido, painful sex, higher risk of death in childbirth and
obstetric complications
▪ Chronic pain
▪ Difficulty with menstruation
▪ Subfertility
▪ PTSD
• How to disclose:
o Anyone under 18yo with FGM report to the police
o Contact child protection if any immediate risk of FGM

Polycystic Ovary Syndrome:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• What is PCOS?
o A condition where 2 out of the following occur:
▪ >12 cysts develop in the ovary and are seen on ultrasound
 ▪ Balance of hormones is altered and LH/FSH ratio is raised.
Testosterone production may be increased
▪ Amenorrhoea or oligomenorrhoea
o Affects 1 in 10 women
• What causes it?
o Exact cause is unclear
o Many factors play a part: Complex relationship between insulin production
and testosterone
• What does it cause?
o Subfertility
o Menstrual disturbance
o Hirsutism, acne
o Obesity
o Acanthosis nigrans
• What can we do about it?
o Patient:
▪ Weight loss helps to reduce high insulin levels which reduces
testosterone
o Doctor:
▪ Metformin
▪ COCP
▪ Clomifene and specialist referral for fertility
▪ Hair growth can be treated with eflornithine
• Summarise, invite questions, follow up

Fibroids:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• What are fibroids?
 o Non-cancerous growth in the womb
o 1 in 4 women
o Usually asymptomatic
o Can cause heavy periods, pain, and urinary problems
o Rarely affects fertility
• What causes them?
o Overgrowth of smooth muscle
o Sensitive to oestrogen: grow during pregnancy, shrink after menopause
• What can we do about them?
o TVUS to confirm diagnosis
o Observation: If they aren’t causing any problems no need to treat
o Tranexamic acid:
▪ Can be used for heavy periods
▪ Take 3 or 4 times during the period
o NSAIDs: Can ease period pain
o COCP: Can make your periods lighter and help with period pain
o GnRH analogues:
▪ Can be used short term to make the fibroids shrink
▪ Ideally used pre-surgery to shrink before
o Surgery:
▪ Myomectomy: Fertility preserving, but fibroids can recur. Risk of
heavy bleeding and may not work
▪ Endometrial ablation
▪ Hysterectomy
▪ Uterine artery embolization: Fertility preserving, need to be done
under radiological guidance

Pre-eclampsia:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
 • What is pre-eclampsia?
o Only occurs during pregnancy
o Causes high BP and protein to leak into urine
o If severe: headache, visual disturbance, papilloedema, hyperreflexia,
epigastric pain, swollen hands and feet
o Can cause microsomia
o Complications can develop:
▪ Eclampsia: Life threatening seizures
▪ Blood clotting disorders
▪ HELLP syndrome – Lysis of blood cells, liver damage
▪ Cardiac/multi-organ failure
• What causes it?
o Unclear, relates to placental blood flow
o Risk factors:
▪ FH: Both mother and partners FH
▪ First pregnancy
▪ >40yo
▪ Obesity
▪ Smoking
▪ Multiple pregnancy
▪ PMH of high BP, diabetes, SLE
• What can be done about it?
o Monitoring:
▪ Regular BP and urine checks
▪ US scans to monitor baby growth
o Prevention:
▪ If at high risk, aspirin 75mg from week 12
o Treatment:
▪ Labetalol or nifedipine
▪ Birth is the only cure
▪ Magnesium sulphate in eclampsia

Gestational diabetes:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Establish PC with an open question
• What is GBM?
o A form of diabetes late occurs late in pregnancy
• What causes it?
o Hormones released during pregnancy can cause insulin resistance. Can
cause blood sugar levels to rise
o Risk factors:
▪ BMI>30
▪ Previous big baby
▪ Previous GDM
▪ 1st degree relative with GDM
▪ PCOS
• What problems can it cause?
o Macrosomia -> shoulder dystocia, still birth, emergency c-section
o Can cause problems with blood sugar for baby after birth
o Increases risk of T2DM for mother
• What can we do about it?
o Screening:
▪ OGTT at booking and 24-28 weeks for those with GDM risk
▪ Fasting > 5.6 and 2h>7.8
o Patient:
▪ Blood sugar diary
▪ Dietary changes
▪ Regular light exercise
o Doctor:
▪ Follow up in antenatal clinic
▪ Regular scans
▪ Metformin
▪ Insulin if metformin doesn’t help or fasting blood sugar >7
• Summarise, invite questions, arrange follow up
General structure for sexual health history:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• “Before we start, I want to let you know everything we say is completely
confidential, unless I need to communicate something to the team for your safety or
discuss your case with a senior. This is a sexual health clinic, so I will have to ask
you some personal questions, but I will only ask for information relevant to your
care. If you have any questions about what I’m asking, let me know”
• Establish PC with an open question
• HPC:
o Timeframe of symptoms and symptom specific questions
o Sexual health systems review:
▪ Discharge
▪ Dysuria
▪ Ulcers or swellings
▪ Pain
▪ PV bleeding
▪ Pain during sex
o Systemic:
▪ Fever, rash, malaise, bowel change, joints, eyes
• Sexual history:
o Do you have sex with men or women or both?
o In the last three months, how many sexual partners have you had?
o When did you last have sex?
o Was that with a partner or a casual encounter?
o Was it oral, vaginal, or anal? Which way round was that?
o Any condoms used? Hormonal contraception?
o Risk assessment:
▪ Have you had sex with anyone from a country with a high rate of HIV
▪ Have you ever injected drugs or had sex with anyone who injects
drugs?
▪ Do the men you have sex with also have sex with men?
• Gynae and Obstetric history:
o LMP, cycle length, regularity
 o IMB, PCB, dysparenuria, dysmenorrhoea
o Last cervical smear?
o Have you ever been pregnant? Did that result in a child? Any chance you
might be pregnant now?
• PMH:
o Have you ever been tested for an STI before?
o Have you ever been tested for HIV/Hepatitis
o Are you up to date with your vaccinations
• DH and allergies
• SH: Smoking, alcohol, drugs
• Summarise, invite questions, arrange plan
HIV pre-test counselling:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• “Before we start, I want to let you know everything we say is completely
confidential, unless I need to communicate something to the team for your safety or
discuss your case with a senior. This is a sexual health clinic, so I will have to ask
you some personal questions, but I will only ask for information relevant to your
care. If you have any questions about what I’m asking, let me know”
• Reason for testing:
o Why don’t you tell me a little bit about what’s brought you in today?
o Have you noticed any symptoms or changes in your health recently?
• Ever been tested before?
• Exposure:
o Have you had sex with anyone from a country with a high rate of HIV
o Have you ever injected drugs or had sex with anyone who injects drugs?
o Do the men you have sex with also have sex with men?
o Have you ever had sex with a man or a man who has sex with men?
• Talk about risk based on the history they have given
• Benefits of testing:
o HIV is incurable, but is a manageable condition with treatment
o Patients has a completely normal life expectancy on treatment
o U=U, with active treatment, you can’t pass on the disease
• Basics of the test:
o Finger prick test takes 3 months after exposure to be positive. Result is
straightaway
o Blood test is positive after a month but takes a few days to come back
• What do you think the result will be? How would you feel if it was positive?
• Agreement:
o Do I have your consent to carry out the test?
o Would you be happy for me to check for other STIs?
• Summarise, invite questions, arrange plan
Consenting for PEP:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Sexual history:
o When did the sex occur:
▪ 100% effective if given within 24 hrs
▪ <50% effective after 72hrs
o Condom used?
o Insertive or receptive?
• What is PEP?
o PEP is a month-long course of anti-HIV medication to reduce the chance of
becoming HIV +ve. Prevents HIV from replicating
• When is PEP indicated?
o Recommend if risk of transmission > 1 in 1000
o Receptive anal sex with:
▪ HIV +ve
▪ Someone from a country with a high rate of HIV
▪ MSM
o Insertive anal sex with someone who is HIV +ve
o Vaginal sex with someone who is HIV +ve
o Sharing equipment with someone who is HIV +ve
• How is it taken?
o 2 medications every day for 28 days
o 3 pills
• Side effects?
o Headaches, nausea, D&V, myalgia
• Before getting PEP?
o HIV test needed before otherwise you may develop drug resistance
• Whilst on PEP:
o Must use condoms
• Can I take PEP every time?
o Not a good idea, may lead to resistance
o PrEP much better for that situation
 • Summarise, check understanding, invite questions

Needlestick risk of infection

• Initial management: Dispose of sharp safely, rinse wound in water, squeeze area to
remove additional blood. Inform consultant and OH
• Risk of infection:
o HIV: 0.3%
o HCV: 1.8%
o HBV: 5% or 30% if active disease in patient
• Evaluate mitigating factors:
o Injury:
▪ Volume of blood loss
▪ Depth of injury
▪ Type of needle
o PPE: Wearing gloves drops risk by half
o Patient risk factors
o Are you vaccinated again Hep B
• Patient must consent to be tested for blood borne viruses
• Prophylaxis:
o Hep B booster
o HIV PEP
• If patient does not consent to testing, retest person injured at 2 weeks, 1 month, 3
months, 6 months
Breaking bad news HIV (SPIKES):

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Setting up:
o Private room
o Any family members you would like to be present?
• Perception:
o What have you been told so far? What is your understanding of HIV?
• Invitation:
o Are you happy to receive your test results now?
• (Knowledge) Breaking bad news:
o Unfortunately, I have some bad news for you
o State results, chunk information
▪ Disease
▪ Complications
▪ Prognosis
▪ Management
• Emotions and empathy: Listen to patient and ask how they are feeling
• Strategy:
o Shared decision making
o Summarising main concerns
o Arrange follow up
Counselling on hepatitis B:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• What is it?
o Virus that affects the liver
o Acute:
▪ 95% clear the infection and are immune to further infection
▪ 5% develop chronic hepatitis
o Chronic:
▪ Virus still present 6 months after infection
▪ N.B. Hep B acquired before the first 5 years of life has the opposite
split in risk: 95% develop chronic Help B if unvaccinated. This is why
perinatal transmission must be prevented
▪ Many have inactive infection and remain well
▪ Active infection leads to cirrhosis
• What can be done about it?
o Treatment offered to patients with active disease and patients with
compromised liver function
o Oral tenofovir or interferon
o Avoid alcohol
o Retest in 6 months to see if virus cleared
• What about pregnancy?
o Can be passed on during pregnancy
o Screened for in antenatal care
General urological history:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• HPC:
o Onset and progression
o Number of episodes
o Any blood in urine?
o Smell?
o Any pain in your abdomen or flank pain
o Recent trauma
o General urology:
▪ Storage: Frequency, dysuria, urgency, nocturia, incontinence
▪ Voiding: Hesitancy, dribbling, poor stream
▪ Testicular masses
▪ Leg weakness
o Systematic features:
▪ Weight change, appetite change, fever
• Sexual history:
o Who what when
o Condoms
o Discharge
• PMH
o UTIs, renal colic, DM, HTN, vascular disease, gout
o Surgery
• FH: Cancer, PKD
• DH and allergies
• SH:
 o Occupation, smoking, alcohol, foreign travel

PSA counselling:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Indications for the test:
o Any man over 50 who asks for the test
o Man with any symptoms of prostate cancer
o Man with lower urinary tract symptoms which could be caused by BPH
• Benefits of the test:
o Early test to catch disease
o Early treatment
• Limitations to the test:
o High rate of false negatives
o High rate of false positives
o Can lead to unnecessary treatment and investigation
• Before the test:
o Avoid sex, masturbation, or vigorous exercise 48hrs before the test
o Statins, NSAIDs, finasteride, supplements can all affect PSA
• Thresholds:
o 40 – 49> 2.5ng/ml
o 50 – 59 > 3.5 ng/ml
o 60 – 69 > 4.5 ng/ml
o 70+ > 6.5 ng/ml
• If high:
o Consider an obvious cause
o Repeat in 4 weeks
 • If low perform a DRE

Explaining BPH:

• What is the prostate gland?

o Prostate gland is found in all men
o Lies under the bladder
o Size of a chestnut
o Urethra runs through it
o Produces semen
• What is BPH?
o Prostate enlarges with age and causes problems passing urine
o May irritate the bladder
• What is it?
o Can occur naturally with ageing
• Are there any complications?
o Doesn’t increase your risk of a malignant prostate cancer
o You may get a urethral blockage and need to be catheterised to drain the
urine
• What can we do about it?
o Patient:
▪ Reduce fluid intake
▪ Double voiding
▪ Reduce caffeine and alcohol
▪ Stop smoking
o Doctor:
 ▪ Alpha blockers
▪ 5-alpha reductase
▪ TURP

Male genital examination:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Explain examination and gain consent. Offer chaperone:
o “This examination will involve me looking at then feeling your testicles and
penis”
• General inspection
• Close inspection:
o Suprapubic area: Both groins
o Whole scrotum: Testicle present, level, swelling, oedema, masses
o Shaft of penis: Lesions, ulcers, erythema
o Retract foreskin: Glans of penis and meatus, epi/hypospadias, masses
o Skin: Erythema, rashes, excoriations, scars, ulcers
• Palpation:
o Check for pain
o Inguinal lymphadenopathy
o Both testes – Inferior, middle, and superior parts: size, consistency, lumps
o Epididymis
o Spermatic cord
• Reflexes:
o Cremasteric reflex
 • Lymph nodes
• Allow patient to redress and answer questions

Mental State Examination:

• WIPER: Introduce
• Appearance and behaviour:
o Apparent age, ethnic background, body habitus
o Level of self-care and hygiene
o Psychomotor activity
o Behaviour
o Eye contact
• Speech:
o Volume, rate, pressure, tone
o Quantity and fluency
• Emotion:
o Affect: Was affect congruent with content of speech? Was affect blunted or
flat
o Mood: How are you feeling today?
o Biological: How is your sleep at the moment? How are you eating?
• Perceptions:
 o Have you ever heard or seen something you can’t explain?
o Do you ever hear a voice or voices that other people don’t hear?
▪ Characterise voice. Many vs one? Has it changed over time? Can you
discern it clearly or is it a murmur? Do you know who this voice
coming from?
• Thought:
o Assess content and form:
▪ Is there anything particularly troubling you at the moment?
▪ Are there any thoughts that you’re struggling to get out of your head?
▪ Form: Linear/disordered, flight of ideas, tangential, derailment,
blocking
▪ Content:
• Delusions
• Overvalued ideas
• Obsessions
o Assess thought possession:
▪ Do you ever feel like people can hear your thoughts?
▪ Do you feel someone is in control of your thoughts?
o Risk assessment:
▪ It sounds like things are quite difficult for you now. In hospital we
often speak to people who feel like life isn’t worth living anymore, is
that something you have felt?
▪ Have you ever thought of harming yourself?
▪ Have you ever thought of harming anyone else
• Cognition: (Quick abbreviated AMTS)
o Attention and concentration
o Orientation to time, place, person
o Short term memory
• Insight:
o Do you understand why you are here in hospital?
• Summarise to examiner
Abbreviated Mental Test Score:

• I’m just going to ask some quick questions to test your memory
• Orientation to person:
1. What is your date of birth?
2. How old are you?
3. Do you know how many people are in the room?
• Orientation to time:
1. What year is it?
2. What is the time?
• Orientation to place:
1. Where are you right now?
• Memory:
1. I would like you to remember the following address: 42 West Street
2. Can you repeat that to me now?
 3. I’ll ask you that again soon
• Attention:
1. Could you count backwards from 20?
• Memory recall:
1. Year of WW2
2. Name of King
3. What was the address I asked earlier?

Detaining under the Mental Health Act:

• When is the MHA justified?

o Patient suffering from a mental disorder that is of a nature and degree to
merit hospital treatment and there must be a risk to the health and safety of
the patient or others.
• Sections:
o 2: Compulsory admission to hospital for assessment, valid for 28 days, can
be upgraded to a section 3 once in hospital if confirmed mental illness
o 3: 6-month treatment order for a patient with an established diagnosis.
Needs an AHMP and 2 doctors who have seen the patient within 24 hrs
o 4: Emergency treatment order, valid for 72hrs, used when a S2 would be too
slow
 o 5(2): 72hr doctors holding power – For an inpatient who is trying to leave and
has a suspected psychiatric disorder. Needs a doctor with full GMC
registration
o 135: Warrant to enter property and take a person to a place of safety
o 136: Police power to take a person from a public place to a place of safety
• Patients can appeal the section and are entitled to a mental health tribunal. A
review automatically occurs at the 6-month mark of a section 3. The tribunal
consists of a consultant psychiatrist, legal representation, and a layperson
• How can the patient be taken off a section?
o The patient’s consultant, nearest relative, hospital managers, or the mental
health tribunal
• A patient can only be treated for a mental health disorder and not for a psychical
illness, except for anorexia nervosa where treatment of the physical symptoms is
necessary to treat it
• A patient cannot refuse treatment for their mental illness. Consent is required for
ECT unless the patient has no capacity or it is needed as a lifesaving measure
(patient completely catatonic)
• Can a patient leave the ward on section?
o Only temporarily when their mental state improves, as agreed with the
consultant enabling section 17
• An assessment for section 2 requires:
o One section 12 approved doctors + another doctor + an AHMP
General Psych Structure:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Why don’t you tell me in your own words what brought you in today
• HPC:
o Events leading up to presentation
o Nature of problem
o Onset, duration, frequency
o Precipitating/aggravating/relieving factors
o Symptom specific questions
o Impact on life
o Psychiatic systems review
▪ Depression screen:
• Mood
• Energy
• Anhedonia
▪ Schizophrenia screen:
• Have you heard or seen anything other people don’t seem to?
• Do you have any beliefs that other people find strange?
▪ How is your sleep now?
▪ Risk assess for harm against self or others
• PMH:
o Have you ever been treated for a psychiatric problem before?
▪ Were you admitted to a psychiatric hospital?
 ▪ Were you sectioned?
▪ Have you ever tried to commit suicide?
o What treatment worked or you previously? Was there anything which didn’t
work for you?
o Vascular risk factors, surgery
• DH and allergies
• FH:
o How do you get on with your family?
o Has anyone in your family had a problem like this?
o Family psych history
• Personal history:
o Childhood: How were things growing up?
o Education: Did you enjoy school?
o Employment
o Sexuality, current partner
o Drugs and alcohol
o Have you ever been in trouble with the police?
• SH:
o How is your living situation at the moment?
o Do you feel able to look after yourself?
o Who is there to support you?

Suicide history and risk assessment:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• PC:
o How are you feeling?
o If you don’t mind, I’d like to talk to you in a bit more detail about what
happened so I can try to understand things a little
• Before the attempt:
 o How did you feel before this happened? What do you think has triggered
this?
o How long have you been thinking about doing this? Did you plan this?
o Was there anyone you spoke to before for help?
o Did you not want to be found?
o Did you leave a note?
• The attempt:
o What did you do?
▪ If overdose:
• What did you take?
• How many?
• Did you take anything else?
• Any alcohol?
o What did you think would happen when...
o Who found you?
• After the attempt:
o How are you feeling now? Do you regret it?
o Do you still feel like you want to take your own life?
o If you were to leave the hospital now, what would you do?
o How do you see the future?
• PMH:
o Is this the first time you have tried to commit suicide?
o Have you ever been in contact with mental health services before?
• DH and FH
• SH:
o Who is at home? Are you in a relationship?
o Do you have any children?
o Are you working? What do you do?
o Alcohol, smoking, drugs
• Insight:
o Do you feel like you need help? Would you accept help?

Depression HPC:

• Core symptoms:
o Mood
o Energy
 o Anhedonia
• Other symptoms:
o Are you struggling to concentrate on things?
o Do you feel less confident?
o Do you feel guilty?
o How is your sleep?
o How is your appetite?

Eating disorders:
 • WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• Weight:
o Current height and weight?
o How do you feel about your weight now
o What would your ideal weight be?
o Amount of weight loss, time period, intentional?
o How often do you weigh yourself?
• Diet and weight loss behaviours:
o What's a normal day for you in terms of food?
o Do you ever fast?
o Has your diet changed?
o How much do you exercise?
o Drugs: Do ever take anything to help you lose weight like a laxative? Appetite
suppressant?
• Bulimia:
o Do you ever binge eat? How often?
o What do you eat during a binge?
o I’m sorry to ask, but do you ever make yourself vomit?
• SCOFF screening:
o Have you ever felt so full you have been SICK?
o Do you worry you have lost CONTROL over how much you eat?
o Have you lost ONE stone (6.4kg) in the last month?
o Do you believe yourself to be FAT when other people would say you are thin?
o Do you feel like FOOD dominates your life?
• How is your mood? Risk assess if appropriate
• PMH: Do you have regular periods?
• DH, FH, SH
• ICE
• Offer to conduct a physical examination, ECG, bloods (TFTs, U&Es, FBC, glucose)

End of Life Care:

• Lasting power of attorney for health:

 o Only valid once capacity for a specific decision is lost
o Must act in the patient’s best interests
o May or may not apply to life sustaining treatment
• Advance decisions:
o Should be written down, signed, witnessed, and dated
o Can only refuse treatment
o Must be specific
• Advanced statements:
o Expression of general attitudes and wishes regarding potential treatment
o Not legally binding
o Must be considered when deciding best interests
• Withholding treatment:
o Treatment is futile
o Not in the patient’s best interests
o Does not provide clinical benefit
o Patient refusal
• Withholding information:
o When the patient does not want to know
o If there is a serious risk of harm (i.e. suicide)

Falls history:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• PC: Open question
• HPC
o Before:
▪ What were you doing beforehand?
▪ Did you feel funny beforehand?
 ▪ Have you been ill recently?
▪ Do you remember falling?
o During:
▪ How did you fall? Any injuries?
▪ Did you lose consciousness? For how long?
▪ Did you experience any of these symptoms?
• Chest pain, SOB, palpitations
• Blackouts
• Dizziness
• Tongue biting, abnormal movement of arms and legs
• Headache
o After:
▪ How did you feel afterwards?
▪ Any weakness in your arms, legs, or face?
▪ Any change in speech?
▪ Has this happened before?
• PMH: HTN, cholesterol, diabetes, stroke, epilepsy, arrhythmias, surgeries
• DH: Antipsychotics, TCAs, anti-HTNs. Any change in medication recently?
• FH
• SH: Smoking, drugs, alcohol. Are you independent at home?

Memory loss:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• PC: Open question
• HPC:
 o Onset, age of onset, progression
o Anterograde or retrograde
o Fluctuating? Lucid periods?
o Preceding trauma, infection, stress, anxiety, life events
o Dangerous situations:
▪ Have you ever wandered outside and not known where you were?
▪ Ever left the gas on?
▪ Ever left the front door unlocked?
o Associated symptoms:
▪ Neurological: Headaches, weakness, rigidity/dyskinesias, altered
speech, visual disturbances
▪ Psychological:
• Depression, hallucinations, agitation, aggression,
disinhibition. Fluctuating consciousness?
▪ Systematic:
• Appetite
• Weight loss
• Sleeping pattern change
• Incontinence
• PMH: HTN, cholesterol, diabetes, stroke, epilepsy, arrhythmias, surgeries
• DH + allergies: Any change in medications?
• FH: Alzheimer's? Vascular problems?
• SH: Smoking, drugs, alcohol. Occupation. Housing. ADLs

Visual loss history:

• WIPER, establish purpose of consultation, before we start is there anything you are
especially concerned about or would like me to do for you today?
• PC: Open question
• HPC:
o Which eye?
o When did it start?
o How was the vision lost?
o Associated symptoms? Flashes/floaters? Haloes? Gritty eye? Swelling?
Change in eye movements? Pain?
o Time? Seconds? Minutes?
o Exacerbating/relieving factors?
o Systemic symptoms: Headaches, scalp tenderness, migraine, N&V, fever,
joint pain, rashes, urethral discharge
• PMH: Glasses/contacts/previous eye surgery. Diabetes, hypercholesterolaemia,
hypertensions, thyroid disease, infection
• DH + allergies, FH, SH
Visual system examination:

• WIPERQQ
• General inspection:
o Walking aids, glasses
o Eyes:
▪ Pupil size and symmetry
▪ Vergence correct
▪ Any ptosis or proptosis?
▪ Scleral colour?
▪ Around eyes: scarring, lesions, pus, discharge, swelling
• Acuity:
o Do you wear glasses? (conduct assessment with glasses on)
o Assess each eye separately
▪ Snellen chart
▪ Near vision
▪ Colour vision
• Fields:
o Visual inattention: point to the fist that is moving
o Visual fields: one eye covered, counting fingers in four quadrants
o Blind spot: red pin, move horizontally from the middle and map where it
disappears
• Extra-ocular muscles: H-test and ask about pain and double vision. Check for
nystagmus
• Reflexes:
o Accommodation
o Direct and consensual
o RAPD
• Ophthalmoscopy
• Thank patient
Red flags for spinal cord compression:

• Thoracic or cervical pain

• Progressive lumbar pain
• Spinal pain antagonised by straining
• Localised spinal tenderness
• Nocturnal pain depriving sleep
• Limb weakness
• Loss of coordination
• Sensory disturbance
• Autonomic dysfunction:
o Urinary retention
o Faecal incontinence
o Constipation
• Cauda equina:
o Bladder/bowel dysfunction
o Saddle anaesthesia
o Leg weakness
o Gait problems
o Back pain
Explaining a DNACPR:

• Establish and explain current situation. Assess current feelings and knowledge
• What is CPR?
o When a patient’s heart and lungs stop, CPR is something we can perform to
try to restart them. This involves pressing down on the chest and placing a
tube down into the lungs
• Why have we decided not to use CPR?
o It’s a medical treatment like a drug or a surgery, and we don’t put patients
through treatments that we don’t think are going to work.
o By not performing CPR, which is traumatic, we try to allow a more dignified
death where possible
• How successful is CPR?
o It depends on what the patient has, it is very unlikely to be successful in
someone with multiple organ failure. Generally speaking, 1 in 5 patients
survive in-hospital CPR, but many have significant long-term disability
• What are the long-term effects?
o When the heart stops, blood cannot reach the organs
o This means there may be brain or organ damage by the time the patient has
recovered
o The chest compressions may themselves break ribs
• What is a DNACPR form?
o Does not mean any other treatment is being stopped
o This is to specify CPR
o This can be regularly reviewed and reversed
• Who makes the decision?
o All staff involved in the patient’s care have discussed the case and the
consultant has made a decision, based on what they believe is in the
patient’s best interest. It is good practice to discuss with the family before
 making the decision however, and patients/family must be informed of the
decision
• What can I do to challenge this decision?
o Can seek a second opinion from another consultant
o Can seek legal advice