Surgery

Dr Riley Harrison
Case list
Perioperative Period
• NOAC counselling*****
• Warfarin counselling*****
• Incarcerated hernia***
• Hypokalaemia before operation*
• Atelectasis**
• Post op patient wants to go home**
• Post op SOB***
Heaptobiliary
• Post cholecystectomy syndrome*****
• Dark urine*****
• Pseudocyst of pancreas****
• Upper abdominal pain CT scan*****
Upper GI
• Dysphagia**
• Haematamesis*
Backbone, upper limb and lower limb
• Neck pain*
• Tingling in arm after mastectomy*****
• Lymphoedema*
• Upper arm DVT*
• Mechanical back pain*****
• Wedge fracture*
• Osteoporosis*****
• PVD***
• DVT*****
• DVT warfarin Counselling*
• Shoulder dislocation****
• Shoulder pain (rotator cuff)****
• Knee pain (ACL tear)*****
• Plantar fasciitis *****
Neck
• Papillary Ca thyroid*
• Neck lump ***
• Hoarseness of voice*
Genitourinary system
• Urinary retention*
• Adenocarcinoma prostate****
• Haematuria****
• Ureteric colic*****
• Hydrocele*
Bleeding PR
• Haemorrhoids/DDx/diverticulitis/anal fissures****
• BPR and abdominal ****
• Perianal pain
 • ISBAR*
Miscellaneous
• AAA***
• Gynaecomastia*
• Male breast lump*
• Cellulitis**
• Epistaxis***
• Hip surgery counselling****
Perioperative Period
NOAC counselling
You are a HMO at a hospital. You are going to see Noel, 55 years old patient, diagnosed with
diverticulitis, now it was infected and resulted in diverticular abscess. He is currently on antibiotics and
IV and under watchful waiting. If not improved in 2-3 days, surgery will be carried out. He is a case of
AF but it is controlled and he is on Apixaban (NOAC) and Atenolol and Atorvastatin. (please check the
powerpoint for the guidelines)
• Address his concerns
• and counsel the pt

• Info : ((He is concerned about bleeding and stroke and mentions his cardiologist is not available
(his mom died because of stroke) and afraid of colostomy))

• Ask about his concerns. Ask about any history of stoke or VTE previously? If present, when?
• Counselling – First of all, let me explain you why we need this surgery. As you have already known,
there is collection of pus in the outpouching of your large bowel. Currently, you are on antibiotics
through veins. Sometimes, the collection of pus can be drained a needle but depending on the
patient’s condition, a major surgery is needed to remove part of the large bowel which is already
dead.
• I understand that you are afraid of having a stroke when your medications have been stopped.
Let me explain you about this.
• The surgery we planned is a major surgery which has relatively higher risk of bleeding. So we need
to stop the Apixaban which is a blood thinning medication you have been taking. If we don’t
suspend this medication, the chance of major bleeding is so much higher than the chance of
stroke. But the good thing is these drugs like Apixaban are the new agents that have quicker
actions and live shorter in the blood. So they allow a short-term cessation and early re-initiation
after surgery. So we can stop it only 2-3 days before surgery and no other bridging drug is
required. And we can restart it 2-3 days after surgery when you have secured with any bleeding.
The actions can be seen within 2 hours we recommence it. During this time, if needed, the
specialist might consider other blood thinners.
• Also you don’t have any history of stroke or VTE previously and your AF is well controlled, so
stroke is less likely to occur within this short period of cessation.
• During surgery, we will keep blood and blood products ready if any bleeding occur.
• Before surgery, you’ll be reviewed by MDT including Haematologist, cardiologist, Anaesthetist
and surgeon to make sure you are safe for Sx
• During the surgery, the surgeon will cut into the large bowel, remove the damaged pockets or
pouches, then reattach the remaining segments of the bowel.
• Sometimes, when the reattachment is impossible, the surgeon may create a colostomy which is
a small hole that allows stool to exit through the stomach and requires the person to use a
colostomy bag. Usually it is temporary too.
• Colostomy – living with colostomy is much easier these days. The patient will just have to follow
the instructions about the diet, medications and proper care. They are ordor proof and no one
will notice if they are not told.
 • For other drugs you are taking, you may continue till the evening before surgery. We may need
to run blood tests and imaging before surgery. The bowels will be washed out with laxatives and
enema. (antibiotics already given).
• After surgery, the patient will be able to do normal activities within 1-2 weeks.

Warfarin Counselling
You are a HMO at the hospital. Your next patient is Anna, 67 years old lady, who was diagnosed with
bowel cancer and waiting for an operation in 3wks time. She had aortic valve replacement 10yrs back
and has hypertension. She is on warfarin for her atrial fibrillation, Ramipril and Atorvastatin. All
investigations were normal with INR 2-3. (please check the guidelines in powerpoint)
Tasks:
• History regarding medications and risks
• Discuss with the examiner about preop preparation and medication plan.

History
• Greetings. Show sympathy about her condition. How are you doing now?
• Bowel Ca – How is your bowel habit now? Any tummypain? Difficulty in passing stool? Bleeding?
Any incomplete emptying? Enough support?
• Warfarin - how long you are taking warfarin? Why are you taking it for? Regular INR check and
follow-ups? Last visit? How was your INR at that time? Taking regularly according to the
prescription? Notice side effects like bleeding?
• Ramipril –How long? When was you diagnosed with HTN? Are you taking medication regularly?
Do you check BP regularly? Any vision problem/weakness in any part of the body?
• Atorvastatin – How long? How is your blood lipid levels?
• Risks –
• Are you aware of the type aortic valve you have been replaced?
• (CHADS2) – Heart failure – SOB, chest pain, swelling in the legs? Hypertension already asked. Age
(in the stem), any history of diabetes? Any stroke/ weakness? mini stroke before?
• VTE – any previous leg pain? Clot formation in the legs? If +, when?
• Past surgical history? Family history of clotting problems?
• SADMA

• Discuss with examiner. The surgeon will first decide the risk of bleeding. If moderate to high risk
of bleeding, the interruption in Warfarin treatment is needed. Warfarin will be stopped 5 days
prior to the surgery.
• Decision will be made by the MDT. The patient will also be assessed for thromboembolism risk.
• Regarding the risk for thromboembolism, this patient has a prostethtic valve replacement with AF
and CHADS2 score of ….
• If low to moderate risk, no bridging therapy is required.
• If there is high risk, a bridging therapy with Enoxparin (if no contraindication) will be commenced
at on 4 days before surgery if INR <2. This will be ceased 24 hours before the surgery. INR will be
checked again whether it is below 1.5. After the surgery in the evening, after adequate
haemostasis the previous therapeutic dose of Warfarin will be restated again. Therapeutic dose
of En
• oxparin will be delayed 48-72 hours and just a prophyalatic dose is recommenced and will be
continued until the target INR is reached. During the operation FFP will be in hand.
 • Regarding beta blockers and statin both will only be stopped on the day of surgery.
• Regarding preop, bowel wash out will be done and the patient will be NPO since the midnight
before the surgery. May be antibiotics as well. After surgery we will do catheter, i/v
fluids,compression stocking, and early mobilization.

Incerated Hernia
You are an intern in a city hospital. You are going to see a 60 years old lady, Laura, who had stent
insertion into the coronary artery in the past. For that reason, she is on Aspirin and Clopidogrel. She is
now presenting with incarcerated inguinal hernia. The surgeon decided to do the emergency operation.
She doesn’t want to do this operation because she is afraid she might experience serious complications
during surgery since she is taking blood thinning medication.
Tasks:
• Address patient’s concern
• Counsel her

• Greetings!
• Stability!
• How are you now? How can I help you?
• I completely understand your feeling that there may be risk of bleeding and other complications
because of surgery. Are you aware of the stent you are having? Whether it is plain or drug eluting?
• Every surgical procedures has risks like risk of bleeding, anaesthesia, injury to the nearby
structures and infections. We do it because the benefits outweigh the drawbacks.
• So even the normal person can have the complication like bleeding without blood thinning
medications but we still have to do surgery especially life saving ones.
• In elective surgeries, we can have more time to manage with the medications and arrange
beforehand. But in emergency, we have to to take the risk and only manage accordingly when the
complications happen. Because the surgery is live saving!
• The condition you are having is incarcerated hernia, i.e, part of the bowel or tummy content is
coming out of the tummy and cannot go back. And it has become obstructed. So surgery is
emergency, If operation is not done in time, the bowel may die and become the source of
infection- bugs will be breeding there – spreading through blood stream – get to the whole body
– life threatening (septicaemia). And it will happen for sure if there is no surgery done for it.
• That’s why the surgeon has decided to do the emergency operations,
• He will remove that part of the bowel and reconnect the healthy parts of the bowel.
• Although this is emergency, let me tell you what we can arrange for you.
• We can do your blood tests and get platelet infusion ready which will be given if needed to reverse
the antiplatelet action of the medications you are having. Also the surgeons and the team here is
well experienced in handling those cases so you will be safe during surgery.
• We don’t need to suspend your medications as they are essential to be taken regularly for 1 year
after stent. So taking them is mandatory keep the vessel opened.
• Haematologist and cardiologist will come and review you before surgery, do the investigations
(blood and imaging as necessary) and make sure you are safe to go through the surgery.
Hypernatremia
You are about to see patient 52 years old John was admitted for hernia operation, before Pre operation
preparation for hernia (reducible hernia and not obstructed) and before operation certain investigation
where found to be changed
K 3.4 mmol, Na – 155 mmol (H) , HCo3 – 31 , low Cl, Glu- high in blood.
In the past history patient is known hypertensive patient taking regular Hydrochlorothiazide 25mg .On
clinical findings on physical examination no apparent abnormalities.
Your tasks are:
• ◦ Interpret the investigation to the patient, take short history
• ◦ tell him the cause, and discuss further course of management

• ◦ Dear examiner I would like to know if my patient is oriented with time place and person.
• ◦ Vitals are stable ? Stable you can proceed ?
• how are feeling ? I noticed that you have been advised to go for elective surgery for hernia. We
have collected some blood samples. But some of the blood samples with chemicals shows some
disturbances which I would Like to discuss with you today.
• K is a bit lowered (supposed normal value 3.5)
• Sodium is high( condition call hyper-nateramia)
• HCO3 bicarbonate is also also raised (alkalosis in your blood)
• blood glucose is also high too.
• I would like to ask few questions if is that ok ?
• Loss - Did you have any recent episodes of Vomiting and diarrhoea? Increased urination/ recent
surgery? (diabetes insipidus, diuretics) Are you aware of how much fluids you are given through
veins? (iatrogenic in hospital), How is your water intake? any pain while passing urine? Changes
in smell? (infection)
• Symptoms – weakness? Cramps? Increased thirst? Fits? Difficulty in balancing yourself?
• How long you have been hydro-cholorothiazide treatment ?
• Any change in medication? Increase or decrease dose?
• Hyperaldosteronism – headache? Numbness? Muscle weakness?
• Past history any renal condition? Diabetes? (Raised glucose) Any hospitalization or admission?
• SADMA
Explanation
• This condition of hypernatremia and alkalosis is most likely because of a condition called
hyperaldosteronism in which too much aldosterone is produced by the adrenal glands. It could be
because of the hydrochlothiazide that you are taking. Other causes of hyperaldosteronism could
be tumors in that glands, dehydration, infection, chronic medical condition and diabetes insipidus,
SIADH (hormonal imbalance in pituitary) but less likely according to your history.
• Hypernatraemia most often occurs in people who don't drink enough water. Symptoms vary
based on the condition's severity, but include thirst, restlessness and fatigue.
• Treatment may include drinking more water or intravenous fluids.
• Treatment – stop hydrochlothiazide. Specialist will review and change to another drug for
hypertension.
 • Correction – drink more water if you can or IV fluids will be given to neutralize the excessive
sodium and bicarbonate.
• Your blood sugar level is also increased – diabetes? Will be monitored too. And if the fluid balance
corrected and blood sugar level still high, we will run investigations for diaabtes, OGTT and HbA1C
(If the patient is unaware that he has diabetes)
Atelectasis
As part of your duties as surgical intern, you are at the bedside of the 45-year-old woman, Emma, who
had a laparoscopic cholecystectomy for gallstone yesterday. You note from the chart that her
temperature is 37.9’C.
• Your tasks:
• History
• PEFE
• Provide a diagnosis and management plan

History
• DDX – Pulmonary atelectasis, pneumonia (48 hours) wound haematoma/infection (5-7 days), Bile
leak, thrombophlebitis, DVT (7-10 days), UTI (3-5 days), MI, allergic reaction
• How are you? Any SOB? Any pain in your wound? How is the drain site? Does it look well?
• Any cough? SOB?
• Any tummy pain?
• Any problems with pee? Any color changes, burning sensation, smelly urine?
• Pain over cannula site (Thrombophlebitis)
• How about bowel habits?
• Any pain in the calf muscles?
• Any pain or redness in cannula site? Any blood transfusion? Any chest pain?
• Past medical/past surgical – any illness before including clotting problems, lungs and airway
problems?
• SADMA (smoking is important!)

PEFE
• General appearance – dyspnoeic, vital signs
• Head to toes – inflammation
• Respiratory system examination – crackles
• Abdominal – pain, wound – redness
• Upper limb – cannula site – inflammation?
• Lower limb – DVT
• Bedside test – Urine dipstick, ECG

Management
• The condition is most likely to be atelectasis – in which the small air sacs in the lungs become
deflated or filled with fluid – so the lungs cannot expand – shortness of breath. It is one of the
most common complications after surgery especially in patients with underlying lungs disease and
smokers. It may be because of anesthesia which compromise the ability of chest and abdominal
muscle to contract, hence affecting the breathing. Or it could be because of inability to cough
after surgery leading to accumulation of mucus blocking the airways.
• Other possibilities are pneumonia (infection in the lungs), thrombophlebitis (infection in cannula
site), UTI or wound infection. So we need to run a few investigations.
 • Investigations – Blood tests (inflammatory markers), urine culture, blood culture, Chest Xray,
wound swab
• Initial management - Oxygen, Bronchodilator, Painkillers, antibiotics if infection suspected,
change cannula site every 24 hours, regular vitals
• Further – Early mobilization, elastic stocking to prevent DVT, chest physiotherapy, breathing
exercises
• When better – go home and continue breathing exercise – follow-up in two weeks

Post operative Fluid Overload

You are a HMO in surgical ward of Austin hospital. You are called by a concerned nurse regarding a
patient, James who is a 55 year old male and underwent a major abdominal surgery 2 days back. Nurse
tells you that the patient has been complaining of shortness of breath for the last 2 hours and it has
become worse [Link] arrival in the ward you see that James is in lot of distress. You ask for the nursing
charts, daily progress notes, vitals chart and pre and post operative notes. The nurse has provided you
the above mentioned charts and while going through them you see that Mr. James underwent a
colectomy 2 days back for nasty growth which was recently diagnosed and also he is Known case of
Hypertension for which he was taking Furosemide before [Link] is his 2 nd post operative day and
he has a foley’s catheter in place. The charts are given below. Intraoperative period--- Uneventful, Blood
loss-350 ml, 1L NS given [Link] chart--- IV Fluids, IV Cefaclor, IV PPI, IV Tramadol, IV
Emeset, Morphine plus symptomatic T/T.

Tasks:
• Ask physical examination findings from the examiner.
• Explain to the patient the possible causes for his condition and discuss with him your further
management plan.
Notes:
Post operative Shortness of breath
• Pulmonary atelectasis
• Can be caused by inadequate analgesia**
• Chronic smokers are at a higher risk
• Pulmonary
• Pulmonary Embolism
• CHF- leading to Pulmonary Edema
• Pneumonia
• Pneumothorax
• Acute Kidney Injury (Sec to Hypoperfusion/dehydration…etc)
• Acute Exacerbation of COPD

PEFE
• General appearance and vitals
• Ask about any drains/catheters/IV Lines
• Start with a head to toe approach
• Volume status of the patient- CRT/Skin tugor/ oral mucosa/Sacral odema, pedal edema/ abdomen
for ascites
• CNS– Level of consciousness
• JVP- Raised
• CVS- S4 +
• RESP- Bibasal crackles +
• wound- no drains, bandages intact, suture line intact, no signs of infection or discharge, pain +
around surgical wound
• Abdomen exam – I,P,P,A
• Peripheries – pedal edema +++
• UDT, BSL, ECG

Management
• Tell the patient that you understand that the patient is in a lot of discomfort.
• Put him in a propped up position
• Check the O2 mask
• Check if IV lines are connected and stop the fluid.
• Reassure the patient.
• Tell him that there could be a lot of reasons for this SOB, one of which is Pulmonary Edema which
can be due CHF (which means you have received more water than what you have actually
urinated. Probably because of which there has been a excessive load on heart and there is fluid
accumulation in body). I can hear there is water in your lungs and I’ll ring my registrar right away
and will discuss the further plan of action –Most likely this is the cause but will need to do some
tests to confirm the diagnosis.
 • Investigation- FBE/UEC/LFT/ABG/CXR/ECG/ECHO/USG-KUB
• Management
• Meanwhile after discussion we will start you on Water pills (Diuretics) to take out excess water
and monitor your vitals closely (strict Vital charting/ Intake/Output Charting)
• we’ll try your best to get you better
Post operative discharge plan
You are going to see a patient in surgical ward, Ted, after Laparoscopic cholecystectomy, Post op day2
initial plan was to discharge after 72 hours. Pneumatic stalking ambulating on heparin. Vital chart all
stable. Temperature – 38.0’C.
Task-
• History
• PE from examiner
• talk about dc plan with patient

History
• Ask for respiratory infection – Cough, runny nose, sore throat?
• Atelectasis – SOB? Chest pain?
• Urinary infection Questions – waterwork? Pain? Burning sensation? Color? Smelly urine?
• Wound – how is your wound? Pain? Discharge?
• Leg pain?
• Any pain in cannula site?
• Any problem? Why do u want to go urgently?
• Past medical surgical
• SADMA
• PE – Vitals, leg swelling, Wounds, CVS, respiratory. UDT, RBS
• Explain the findings, I have seen a fever in you and also some leucocytes in urine which means
that there infection in waterwork. We will arrange a urine culture and sensitivity test to confirm
it. That usually happens after surgery because of the stasis of urine. I will get involved senior for
possible oral course of antibiotics and decision for discharge. Your mom – we can arrange a social
worker or translator.

Hepatobiliary
Post-Cholecystectomy Syndrome
Your next patient is a 32 year old female,Laura, complaining of abdominal pain and fever. She has been
having this pain since 2 hours. Her stools have been paler than usual, but there is no history of
diarrhoea.
Your Tasks:
• History
• Physical examination from examiner
• Tell the patient most likely diagnosis/diagnoses

History
• Pain questions – where? 1st time? Character? Radiation? Duration? Severity? Pain killer? relieving/
aggravating factors? Persistent or off and on? (can’t ask whether associated with food if first time)
• Associated symptoms for hepatobillary – fever ? Chills and rigor? Jaundice? Bloating sensation?
What did you eat before? Any changes in urine color and stool color? Diarrhea?
 • DDX – history of gall stones? Acute on chronic pancreatitis – any previous pains before? CVS –
racing of heart beat before? Shortness of breath? CA – LOW, LOA, viral hepatitis – travel? Blood
transfusion? Tattoos? Piercing? Occupation?
• Sexually active? Safe sex?
• General history, past medical, past surgical?
• SADMA

PEFE
• General, Jaundice, Vitals
• Abdominal examination – Inspection, palpation, percussion, auscultation
• UDT
• Draw liver, gallbladder and bile ducts, Since GB removed, there is bile excess since there is
nowhere to store. So the patients become yellow and stasis of bile leads to inflammation of the
small bile ducts in the liver and sometimes infection. This is called cholangitis and it is one of the
complications after removal of the gall bladder, postcholecystectomy syndrome. (pain, fever and
jaundice)
• Rx –
• Immediate
- admission, I will contact the specialist to come and check I will take blood samples for
investigation ( FBC, Renal function (U&E), liver function -AST, ALT, bilirubin, phosphatase,
gama-GT , amylase, serology for hepatitis A,B and C, cardiac enzymes) and ECG
- abdominal X-ray, US and CT scan.
- IV antibiotics and painkillers

• Definitive
• ERCP - A flexible camera is introduced through your mouth till your stomach under anesthesia.
The specialist can than introduce tools to removes the stones if present and drain the bile.

• Viral hepatitis, cholangiocarcinoma, head of the pancreas tumor, Injuries and strictures after
surgery, diverticulitis, liver abscess, perforated Peptic ulcer but less likely

Dark Urine
• In a GP, 65 years old Jenny was complaining of dark colored urine.
tasks:
• History
• PEFE card
• diagnosis/ differentials

PEFE card
• General appearance, vitals - normal
• No Pallor, moderate jaundice
• No clubbing, no leukonychia, no palmar erythema, no spider naevi,
• Abdomen –unremarkable except slight tenderness in RHC
• UDT – urobilinogen -, bilirubin+

History
 • Dark color urine? What color is it? Red or Dark yellow or Cocoa colored? Any loin pain? Any pain
while passing urine? Any burning sensation? Increased frequency? Smelly? Reduced flow? Any
injury?
• What about stool? Any stool color change?

• Pain questions – where? 1st time? Character? Radiation? Duration? Severity? Pain killer? relieving/
aggravating factors? Persistent or off and on? (can’t ask whether associated with food if first time)
• Associated symptoms for hepatobillary – fever ? Chills and rigor? Jaundice? Itchiness? Nausea?
Vomiting? Bloating sensation? What did you eat before? Diarrhea?
• DDX – history of gall stones? Acute on chronic pancreatitis – any previous pains before? CVS –
racing of heart beat before? Shortness of breath? CA – LOW, LOA, viral hepatitis – travel? Blood
transfusion? Tattoos? Piercing? Occupation? Recent medications?
• Sexually active? Safe sex?
• General history, past medical, past surgical?
• Family history of cancers
• SADMA (Drug abuse!)

Explanation
• LOW, LOA positive and abdominal pain – explain about liver and biliary system with a pic. This is
the liver and these are the bile ducts which transport the bile from the gall bladder to the first
part of the small bowels.
• Now, according to your symptoms and my physical examination, there is some blockage in the
bile flow. There are many causes leading to this.
• DDx - It could be a nasty growth in the those bile ducts cholangiocarcinoma because you have a
significant weight loss and LOA , head of the pancreas tumor compressing the bile ducts, Injuries
and strictures of the ducts after surgery, viral hepatitis, Cholecystitis which is the inflammation
of the gall bladder (if no cholecystectomy history), Cholangitis – inflammation of the ducts, liver
abscess – pus collection in liver,
• We need more investigations to look for the exact cause.

Pseudocyst of Pancreas
You are HMO in ED. 55 years old lady. Anna, presented with abdominal pain. Your colleague found a
mass in epigastrium and went for a CT.
Tasks:
• History
• Explain CT
• Explain the causes or most probable cause
History
• Abdominal pain Q
• Ddx Gall stone – nausea, vomiting, bloating after meal, Fever, Jaundice, changes in color of pee
and poo
• . PU – heart burn
• CVS – Racing of heart, SOB?
• Hepatobiliary – yellow color skin, dark urine
• chronic pancreatitis – nausea, vomiting, diarrhoea. Fatty stool, don’t flush away easily,
• Any surgery done in tummy? (Adhesions leads to pseudocyst), LOW, LOA
• Past medical
• SADMA

• Explain CT – this is the CT scan of your tummy in transverse section and it is the mirror image so
the things we see in left here will be the actually the organs from the right side of our body. So
this area here is liver. This is the stomach. And this is the back bone. So what I am concerned is
the black area here compressing the stomach. It is originated from pancreas and since it is black
in color, it is a cyst. So it is most likely pseudocyst of pancreas.
• Pancreas is the gland located in our gut system to produce pancreatic enzymes for digestion and
other hormones for maintaining blood sugar in normal range. So now, there is collection of fluid
forming like a cyst like structure what we called pseudocyst of pancreas in it. It is most likely
because of chronic pancreatitis, the inflammation of the pancreas leads to fibrosis and scar and
form a sac. Again, the cause of chronic pancreatitis are gall stones, alcohol or previous surgery.
But in your case, most likely it could be gallstones blocking the passage of pancreatic enzymes to
the guts. So those enzymes go back to pancreas, irritating it and causing inflammation. (still
possible for stones in CBD even after cholecystectomy)
• Rx (not in task) – refer go surgeon
• Small- watchful waiting
• Large – 5-6cm – drainage – can rupture , can press on nearby structures, can lead to septicemia
(infection spread to whole body)
• Blood test for CEA, CA 19-9, pancreatic enzymes and base line check-ups

Upper abdominal pain with CT scan

60 years old patient came in ED with severe epigastric pain for 2 hours. Pain for the first time. Pain killer
given. Now pain subsided. He is generally healthy, no alcohol hx. Blood result pending. CT scan done
and report are written own showing multiple composed calcified GB stone, but no GB wall thickness,
no fluid around GB, no acoustic shadow. CBD normal. Extensive several diverticula in sigmoid colon but
no sign of inflammation, single hypodense liver lesion 5*7 mm/cm, no portal vein dilatation. No
dilatation of the portal vein. No comment on pancreas.
Tasks:
• Explain the CT scan result to the patient
• DX /ddx
• Choice of investigations / Explain further Ix you want to order with reasons
• What could be cause of pain

• Your CT scan is showing that there are multiple gall stones. Gall stones are the small stones formed
in the gall bladder which is a cyst that stores bile from the liver. Sometimes bile gets precipitated
in the gall bladder and leads to formation of stones.
• We can also see that GB wall is not thickened that means at this stage your gall bladder is not
inflamed. The CBT which is the main bile duct that opens into the first part of the bowel is normal.
• A tube that carries bile from the liver and the gallbladder through the pancreas and into the
duodenum (the upper part of the small intestine). The CT shows it is normal.
• Also, the Ct showed Extensive several diverticula in sigmoid colon (lower end of the large gut) but
no sign of inflammation that means you have a condition called diverticulosis. Diverticulosis is the
finger like outpouching from the wall of the bowel which are multiple in number. The cause of it
is constipation and low fibre diet. Because of constipation, hard stools put pressure on the wall
weakening it and leading to outpouchings known as diverticula. They are asymptomatic, but
sometimes the stools can get blocked in the pouches and become good media for the bacteria
leading to inflammation called diverticulitis. But your Ct scan is showing no sign of inflammation.
• Liver is an organ situated just under the ribcage in the right side of upper tummy. It helps in
digesting food and ridding your body from toxic substances. CT also shows single hypodense
lesion in the liver which can indicate to several differentials. Like- Hepatic hemangioma (benign
tumor filled with abnormal blood vessels), adenoma (benign tumor of epithelial tissue with
glandular origin), biliary hamartoma (benign tumor made up of abnormal mixture of normal cells),
hepatocellular carcinoma, intrahepatic cholangiocarcinoma (bile duct cancer), metastasis, simple
hepatic cyst, hydatid cyst (sac like pocket containing fluid, air etc), hepatic abscess.
• There is no portal vein dilatation that means no portal hypertension or increase pressure in the
portal vein. Portal vein is a blood vessel that carries blood from the gastrointestinal tract,
gallbladder, pancreas and spleen to the liver. This blood contains nutrients and toxins extracted
from digested contents.
• The causes of your pain could be biliary colic in which the gallstones block the bile ducts and
causing pain, peptic ulcer, Acute cholecystitis (which is an inflammation of the GB but not likely
from the CT), Heart attack, Pancreatitis or the liver lesions I mentioned but those liver lesions
so not usually cause symptoms.
• further investigations – FBE,ESR, CRP, ECG, Pancreatic enzymes such as Amylase and Lipase,
endoscopy and colonoscopy, Ultrasound of the tummy, hepatitis serology, and liver enzymes,
tumor markers AFP, CEA and CA 19-9 for liver and pancreatic cancers and a liver biopsy.

Upper GI
Dysphagia
You are a general practitioner. Your next patient is a 56 years old Nathan who presents to you with
difficulty in swallowing for 6 months.
Your tasks:
• Take relevant history
• Tell the possible dx and ddx
• Tell the investigations you are going to do

History
• Greetings
• What do you mean by difficulty in swallowing? (Sticky or painful?)
• Dysphagia – 1st time? Duration (in the stem), Are you aware of the level of obstruction that you
feel sticky/pain? Can you show me with one finger? Does it happen with solid/liquid? Is it
progressive? How is your diet these days? (liquid diet?), any vomiting?
• DDx –
• Any pain in oral cavity or throat? (candida)
• Any history of heart burn? (GORD and Barret’s oesophagus)
• Recent history of stroke? Any weakness in the limbs? (neurological)
• Swelling in front of the neck? (thyroid)
• Any regurgitation of old food? (retrophryangeal pouch)
• Any skin changes? (scleroderma)
• CA – voice changes, LOW? LOA? How is the color of stool?
• Any chronic medical illness? (HIV? – candidiasis), radiation treatment?
• SADMA

PEFE (not a task in this case)

• GA – skin changes, vitals
• Dehydration (if vomiting)
• Nutritional deficiency (anaemia, leukonychia, koilonychias, hair changes)
• Oral cavity – tonsil, oesophageal web, dental problems, peritonsillar abscess
• Neck – thyroid
• CVS, Respiratory
• Neuro – 9,10 cranial nerves, Upper limb and lower limb neurological
• Bedside test – oesophageal obstruction test (normal – hear sound of gurgling at 7-10s, obstruction
- >10s) check by swallowing water

Explanation
• After thorough history, you have difficulty in swallowing which is progressive over time. We can
see that there is delay in passage of food which means that there is obstruction in your gullet/food
pipe. (draw a diagram, mouth, gullet and stomach)
• Most likely the problem is oesophageal stricture (narrowing of gullet) caused by long standing
reflux. When there is long standing reflux – spincter in lower end of the gullet become
incompetent and causes the regurgitation of food and stomach content into gullet. That results
in chronic inflammation of lower end of gullet leading to fibrosis (new tissue formation) and
stricture.
• Other possibilities are cell changes in lower gullet also due to repeated regurgitation – we call it
Barret’s oesophagus. It could be achalasia cardia, the lesions of nerves supplying the gullet.
 • Another consequence of chronic reflux is nasty condition of the gullet causing growth and
obstruction.
• So I will refer you to the specialist who will assess you and do the investigations:
• Baseline blood tests (FBE – anaemia?)
• Barium swallow (a special dye need to be swallowed and do a serial X ray for any growth – filling
defect)
• OGD scopy – small flexible tube with light source and camera will have to be swallowed and check
the gullet for any lesion and take biosy.
• You will be treated accordingly after the diagnosis.

Indigestion
You are a general practitioner. Your next patient is a 47 years old Mark, coming to you with indigestion
for 6 months.
Your tasks:
• Take relevant history (not more than 4 mins)
• PEFE (card)
• Dx and DDx to the patient
• Tell the investigations you would like to do

PEFE card
• General – slight pallor, no jaundice
• Abdominal examination – inspection – no visible mass, palpation – tenderness present in
epigastrum (slight), percussion – no ascites, Auscultation – bowel sound present
• PR – black tarry stool present
• There is enlargement of the two supraclavicular lymph nodes on the left side
• Approach
• Indigestion – how long? Bloating? Pain? Associated with food? Onset? Severity? Did you try
anything? Anything better or worse?
• Pain – epigastrium, How long? Onset? Severity? Radiation? Character? Aggravating, relieving
factor?
• Associated GI symptoms – any heart burn? How long? Vomiting? Any blood in vomiting? Any
blood color stool? Any weight changes? Loss of appetite? Any problem with swallowing of food?
• Signs and symptoms associated with diet? For example, coffee?
• Past medical, past surgical
• SADMA

DDX
• Barette’s oesophagitis – long standing reflux – inflammation and cell changes in lower part of
gullet
• Peptic ulcer disease – ulcer in the stomach or first part of the intestine
• Ca stomach – nasty growth in food bag
• Ca oesophagus – nasty growth in food pipe
• Biliary cholic, pancreatitis, diverticulitis, colitis, MI less likely
• Explain the investigations – FBE, Renal function, liver function, pancreatic enzymes
• Endoscopy and biopsy – a small flexible tube with the camera will be inserted from mouth, check
the tract and take a piece of tissue and send for biopsy if any suspected lesion
 • Colonoscopy – back passage
• Cervical lymph nodes biopsy
• ECG

Haematemesis
You are a HMO at the hospital. You are going to see 55 years old Robin whose presented with blood in
vomit.
Tasks:
• h/o for 6 minutes.
• Ddx to patient

History
• Stability
• haematemesis – First time? When did it started? How was it started? Duration? How many times?
Amount in cups? (large – oesophageal varices, small – ulcers), contents? Color?
• Any blood in the stool or dark stool? (how long? How frequent? How many times?)
• Severity - Dizziness, fainting
• Symptoms of heartburn/indigestion/waterbrash, upper tummy pain
• Liver – Jaundice? Swelling in the tummy? (ascites)
• Any repeated vomiting, relching? (Mallory-Weiss tear)
• Weight loss/loss of appetite/night sweats
• Past medical, past surgical
• Medications esp NSAID in details, blood thinners
• Family history of GI cancers
• SADMA
• DDx – depending on history, please change the order – Peptic ulcers, Oesophageal varices
(cirrhosis), Oesophagitis, CA stomach, Mallory Weiss tear

Backbone, upper limb and lower limb

Neck pain
You are a GP. You are going to see a 30 years old female, Clarie, with a history of lifting heavy boxes
developed pain in the neck and left shoulder since one day. Vitals are so far normal.
Tasks;
• PEFE
• Explain diagnosis and DDx
• Investigations you would like to order
• Management to the patient
PEFE from examiner
• General appearance, vital signs and pain killer
• Neck
• Look
• Both shoulders are equal in level.
• Gross deformity
• Muscle wasting
• Redness and swelling
• Feel
• Check tenderness on neck, shoulder and clavicle
• Spine tenderness
• Pulses (Brachial and radial pulses)
• Capillary refill

• Move
• Neck
• Flexion (forward and lateral)
• Extension
• Rotation

• Power – shoulder, elbow, wrist, fingers

• Sensation – check as the dermatomes
• Reflexes –
• biceps (C5 and C6)
• Triceps (C7 and C8)
• Special test
• Spurling’s test (Axial loading and distraction test)

• Cervical radiculopathy – draw a pic

• This is your back bone. The back bone is composed of several blocks of bone like this. In the central
canal of these bones, there runs the spinal cord. The small nerves which supply our upper and
lower limb emerge from spinal cord through small holes in these bones. In between these blocks
there are cushion like substances which we call vertebral discs.
• Cervical Radiculopathy damage or disturbance of nerve function that results if one of the nerve
roots near the cervical vertebrae is compressed. Damage to nerve roots in the cervical area can
cause pain and the loss of sensation along the nerve's pathway into the arm and hand, depending
on where the damaged roots are located.
• So this can be correlated with the symptoms you are having now.
• There are several causes leading to cervical radiculopathy.
• It can occur as a result of pressure from material from a ruptured disc, degenerative changes in
bones, arthritis which inflammation of the joints or other injuries that put pressure on the nerve
roots. In younger people, cervical radiculopathy tends to be the result of a ruptured disc or
prolapsed disc, perhaps as a result of trauma. This disc material then compresses or inflames the
nerve root, causing pain.
 • In your case, most likely it could be due to the sudden injury you got by lifting the heavy box which
led to prolapsed cervical disc.
• Tests – baseline blood tests and inflammatory markers and Xray of the cervical spine, MRI spine
• Currently, we are going to put you on conservative management. (Note : A CT or MRI is needed
when this conservative management fails for 6 weeks when you don’t doubt any truma or
herniated disc)
• So you will be given enough painkillers and muscle relaxants and referred to physiotherapist for
physical therapy involving strengthening, stretching, and potentially traction. And you’ll have to
avoid heavy weight lifting.
• Reassure, Review, Reading materials

Tingling in arm after mastectomy

You are a GP. Your next patient is 63 years old Lady, Amber, with history of breast cancer coming with
complaints of neck pain and unusual sensation in her hands.
Your tasks:
• Take history
• DDx to patient
• Investigations
• Prognosis

History
• Empathy about her breast cancer
• Neck pain – pain questions + differentials – tingling and numbness positive (cervical spondylosis),
Any injury? Any inflammation or pain in other joints? (RA, OA), Did you carry any heavy object
recently/ repetitive usage of the hands? Enjoying any sports? (disc prolapse), any weakness?
(stroke), any SOB? (Pancoast tumor)
• Unusual sensation in the hands – what exactly is the feeling, pain or numb or tingling? Which side?
Which part? Any relieving factor? Aggravating factor? Any part of the day it happens?
• Breast cancer – which side? How many years ago? How was it treated? Follow up regularly? Any
swelling in the arm? (lymphedema)
• LOW, LOA, lumps and bumps all around the body for metastasis
• Medical, surgical, SADMA

• Differential diagnoses – Draw two cervical vertebrae and nerve. It could be cervical spondylosis (a
wear and tear process leading to narrowing of the space between the two pieces of back bones
and that’s why giving pressure to the nerve supplying the hand). Or it could be cervical disc
prolapse where the cushion between the two pieces of bone has been slipped out. Or it could be
trauma, lymphedema (which is the collection of the fluid called lymph in the arm which is common
after breast cancer treatment) , nerve damage because of radiation or it could be secondary of
breast cancer in bone but those are less likely according to your history. Invx – imaging Xray and
MRI of the spine is needed and also the blood tests including tumor markers, nerve function tests,
LFT, RFT, FBE, CXR, maybe PET scan (esp if she is not following up regularly for breast cancer).
• Prognosis – cervical spondylosis can be managed with painkillers, muscle relaxants and
physiotherapy and patient gets better after a few weeks but it can recur at anytime.
Lymphoedema
You are a GP. Your next patient in GP is a 52-year-old Anna, complaining about swollen right arm. She
had a surgery for breast cancer, total mastectomy and axillary clearance and radiation therapy one year
ago. She also had chemotherapy and now on Tamoxifen on regular follow-up.
Your tasks :
• Explain the condition
• Offer management

History
• Show sympathy first
• A touch about surgery and lymph nodes removal – When was it done? Which side?
• Flow of the lymph channels, like blood vessels, containing immune cells draw a picture
• Flow disturbed by removal of LN and radiation, called as Lymphoedma, which is lymph collection
in arms
• But this is just minor comparing to cancer
• Tests – USG (Doppler) , lymphangiogram
• Supportive – Lymphodema clinic – teach exercise to reduce, compression strapping
• Dos- loose clothing, Moisturize to prevent dryness and infections, elevate arm at night
• Don’ts – excessive use, gardening, washing dishes, sun burn, avoid BP or drip on that side
• Not a serious problem, managed effectively
Not improved - surgery

Upper arm DVT

• You are a GP. Middle-aged lady, Priscilla, has a swollen right arm.
Tasks-
-Take history.
-Ask Physical examination findings from the examiner
-What is the diagnosis and what investigations would you arrange?

History
• Swelling -how long? sudden or gradual? is it constant or come and go? getting worse or increasing
in size? is there swelling anywhere else?anything makes it better or worse? happened before?
 • Association for DDx–redness, ulcer of overlying skin? weakness, numbness or tingling? any fever?
have you had any chest pain or shortness of breath? any trauma ? any insect bite? have you had
any repetitive movements of arm or shoulder? Surgery, breast?
• DDx- injury, trauma, inflammation, infection, cellulitis, DVT, neurovascular, lymphodema

• Risk factors- COST VMPF

• C – contraception, O – obesity. BMI? S – recent surgery? T- Travel history?
• V – problems with Veins? M – malignancy – LOW, LOA. Lumps and bumps, P- pregnancy, F- family
history of clotting problems
• Social – occupation
• SADMA

PEFE
• general appearance
-pallor, cyanosis, dyspnea + BMI
V/S
• arm examination + compare
inspection
-extent of swelling
-redness
-trauma, injury or insect bite
palpation
-tenderness
-temperature
-CRT, Pulse
-oedema (pitting or non pitting)
-neuro (tone, power, reflex, sensation).
Neck
-look, feel, move (deformity, tenderness, movements)
Leg examination (DVT + varicose )
• -CVS and Respiratory

Explanation
• Painful localized swelling in your arm can be due to several reasons.
• Muscle injury during basketball playing, insect bites or blockage of the lymphatic vessels, or
infections, and extra rib in neck region. But less likely due to history.
• What I am concerned is it could be clot formation in the vessels in the arm. OCP – stasis in blood
flow, more prone to form clot
• This is not serious but when complicated, it can cause serious problems. When the clot dislodged
and travels along blood stream – block the vessels in lungs – life-threatening
• Inx – I will transfer you tp the hospital and do investigations
• I need to arrange for Doppler US of the upper limb, along with basic blood Ix; FBC, LFT, UCE,
coagulation profile, D-dimer, clotting screen. X-ray to rule out cervical rib.
Mechanical Back Pain
You are a general practitioner. Your next patient is Ethan, a 60 years old man coming with low back
pain. He had that pain since two weeks ago.
Your tasks:
• Take a relevant history
• Physical examination from the examiner
• Tell diagnosis and differential diagnoses to the patient

History
• Greetings
• Offer pain killers
• Pain questions – LOSTRADIO Location, Onset, Severity, Type, Radiation, Relieving factors,
Aggravating factors, Duration, Intensity, Other association
• fever?
• Any problems with pee and poo?
• Disc prolapse – weakness of lower limbs? Tingling and numbness in lower limbs?
• CA –LOA. LOW, lumps or bumps
• Osteoporosis – diet? Diary intake? Usually go out in the sunlight? Job?
• Medical history (steroids, estrogen blockers if female)
• SADMA

PEFE
• GA, vital signs - normal
• Gait - OK
• Look –no deformities, no Swelling
• Feel – tenderness in lower lumber vertebrae
• Move - Spine movement – flexion, extension, lateral flexion – all movement restricted
• Straight leg raising test - positive in both legs
• Lower limb neurological examination – tone, motor, power, reflexes, sensation - unremarkable
• PR examination – normal anal tone

Explanation
• Diagnosis
• If significant weight loss positive, no trauma–primary or secondary nasty condition which is the
cancer spread to the bone (reassure, we need investigations)
• If weight loss positive, lifting heavy box positive – fracture due to primary or secondary nasty
condition
• If no weight loss, positive history of heavy box lifting – muscle strain or if severe – fracture due to
osteoporosis
• If Shober’s test positive, no trauma – Ankylosing spondylitis which is a degeneration process
• DDx – (rearrange the order according to the positive findings) – Muscle strain, primary or
secondary cancer in the back bone, Ankylosing spondylitis, Osteoarthritis, disc prolapse (the
herniation of the jelly like disc between backbones) and nerve compression (sciatica) and less
likely multiple myeloma.
Wedge Fracture
Your next patient in GP is 62-year-old Sarah, who comes today because she is having low back pain
which happens suddenly after lifting a box while gardening.
Your tasks :
• Take history
• Ask investigations from the examiner
• Explain the investigation and the condition to the patient
• Further advice on management

History
• I understand that you are here for your back pain, How's your back pain? Pain killers?
• Pain Q
• How did it happen? Did you bend your knees when you lift the box?
• Disc prolapse/ fracture – weakness of lower limbs? Tingling numbness? Poo and pee? Any loss?
• CA/multiple myeloma –LOA. LOW, recurrent fevers, tiredness?
• Osteoporosis – Menopause? HRT? Bone scan? Any supplements? Like dairy products? Sun
exposure? BMI? Coffee intake? Regular exercise?
• Medical history (esp steroid taking)
• SADMA

Explanation
• This is the Xray of your back bone. Penetration is good, The black areas are tissues and the white
areas are bone. What I am concerned is this small piece of back bone is medially compressed and
there is linear small break. That’s why you are having back pain.
• Sometimes, those fractures compress the nerves causing other symptoms but I don’t find in you.
• The break of the bone is most likely due to the thinning of bone, Osteoporosis. (draw a dense
bone and draw a thin bone by filling with spots). Normally, the bone is thick, In Osteoporosis –
Bone density is thin and bone is not strong enough and becomes very fragile, easy to break.
• Strongly related with reduced estrogen levels in menopause.
• Other causes – pathological conditions – malabsorption, hyperthyroid, Kidney problems, nasty
condition of bone but less likely
Investigations
• Back Xray
• DEXA scan
• Ca level
 • Phosphate
• Alkaline phosphate
• Vit D level
• Blood and urine Bence-Jone’s protein
• TFT

• Management – I will examine you and if neurovascular intact, refer you to specialist, will be
manged accordingly, vertebroplasty (injection of artificial bone cement)
- enough rest, pain killers, Back bracing
• Further advice
• Adequate dietary Ca intake – fish (salmon),citrus fruits, Seeds(sunflower seeds), Ca and Vit D
supplements
• Limit alcohol, limit coffee
• Quit smoking
• Maintain BMI
• Exercises after recovery (moderate) – walking, hogging, play tennis
• Sun exposure (15-30 mins a day, 50 mins in winter)
• Avoid falls (avoid sedative medications, regular eye-check up),low heel shoes because bone – thin
and prone to fracture with minimal injury
• According to the result, if osteoporosis present, we will discuss about reducing bone loss with
medications.
• Note : (please check her mechanism of injury, if the fracture occurred with minimal injury in
postmenopausal woman, we are going to start bisphosphonates straight away with or without
BMD)
• Follow –up in two weeks
• Red flags – pain, difficult to move, weakness

Osteopenia with COPD

You are a GP. A 55 yrs male patient came to you for his bone densitometry results. He had this because
he got two times if falls this month. He with a history of COPD on steroids whenever he has acute
attacks. He is a generally healthy person except COPD. He is a chronic smoker. He currently is on
Budesonide. He drinks 3 glasses of wine a day,
T score of Femur = -2.0 (normal > -1 and above)
T score of spine = 0.3
Z score of femur = -2.3
Vitamin D level = 37 (normal > 50)

Task –
interpretation of results to patient
long term and short-term management

History
• Check the vitals
• How are you? I believe you had a fall. Any pain?
 • 1st time? How many times before? How long? What were you doing in each attack? Similar
mechanism? (Prolonged standing or immediate change in position sitting/lying position),
dizziness? loss of consciousness, any witness? Did you hurt yourself? Any head injury?
• DDx – CVS causes - before you fall, any usual symptoms? (racing of heart beat, sweating, dizziness,
chest pain), OA – any pain in the joints? Stroke - Any brain attacks/strokes before? Can you walk
well now? Any gait disturbance? Any weakness? Electrolyte imbalance – any vomiting, diarrhoea?
• Medical history? DM? Hypertension? Well controlled? What medications? Visual problems?
Follow-up regularly.
• COPD - when diagnosed, what medication on, regular follow up with specialist, when was last
episode of exacerbation, any side effects of steroids – weight gain, excessive body hair, etc)
• Osteoporosis –Like dairy products? Sun exposure? BMI? Coffee intake? Regular exercise? Any
thinning of bone in the family? Any history of fractures in you or family?
• SADMA

Interpretation of results
• As you were suffering from recurrent fall, We have done one test on you . It is called as bone
densitometry. It is test to calculate the strength of your bone.
• Draw the diagram of bones showing normal with high density.
• The T-score is a comparison of a person's bone density with that of a healthy 30-year-old of the
same sex. It is used to determine primary osteoporosis. The Z-score is a comparison of a person's
bone density with that of an average person of the same age and sex. It is useful in diagnosing
secondary osteoporosis.
• Normally the score should be -1.0 and above.
• In your case it is -2.0 which means osteopenia. It means that your bone are getting thinner. It can
lead to osteoporosis which is the next level if not treated properly.
• Don't worry it is very common condition and we can stop the progress of thinning of bone. It
happened as a side effects of the steroids you are having.
• Risk factors - >40 years old, BMI – low, Diet – reduced Ca level, Lack of Exercise, Lesser sun
exposure (vit D)Smoking, alcohol
• Further advice
• We will estimate your future fracture risk, if it is high, we gonna start medications like
bisphosphonates to reduce bone loss. Most likely your risk is high, so we may need to start.
• Review steroid with specialist
• Adequate dietary Ca intake – fish (salmon),citrus fruits, Seeds(sunflower seeds), Ca and Vit D
supplements after checking Vit D level
• Limit alcohol, limit coffee
• Quit smoking
• Maintain BMI
• Exercises after recovery (moderate) – walking, hogging, play tennis
• Sun exposure (15-30 mins a day, 50 mins in winter)
Avoid falls (avoid sedative medications, regular eye-check up, refer to falls clinic),low heel shoes (if
females) because bone – thin and prone to fracture with minimal injury
• Follow –up in two weeks

PVD
You are a general practitioner; a 56 years old Denny came to visit you. He is complaining of pain in right
leg for 6 months
Your tasks :
• Take a relevant history
• Explain provisional diagnosis and possible causes

DDX
• PVD (artery)
• Varicose veins (Veins)
• Neurological – entrapment neuropathy, spinal cord stenosis, peripheral neuropathy

History
• Leg pain – when it become worse? Have you ever consulted a doctor? Persistent or off and on?
Any rest pain? Nature? (gripping, squeezing?), severity? How far blocks can you walk without
pain? Aggrevating factor? Relieving factor? Any changes in walking distance? What about the
other leg?
• DDX – low back pain? Trauma? And tingling and numbness? Ulcers? (Neuro) Dilated veins in your
legs? (Varicose veins) Redness and swelling in leg? (DVT)
• Can you cope well with daily activities? Notice any pallor on your leg?
• Risk factor – have you ever check your blood sugar level? Blood fat level? When was the last
check? Exercises? Family history of heart diseases and stroke? Smoking? Hypertension? Any SOB,
chest pain in you?

PEFE
• General appearance, Vital signs (*BP, PR), BMI
• Features of hypercholesterolaemia – Xanthelasma in face, Tendon xanthoma in limbs
• CVS examination
• Lower limb – inspection – color, hair distribution, ulcers, muscle wasting
• Palpation – temperature, tenderness, capillary refill, All pulses
• Buerger’s test
• Ankle brachial index (normal – 0.9-1.1)
• BST – Blood sugar

• Explain – peripheral vascular disease, draw a picture, vessels along the thigh and calf have become
narrowed causing pain. Most patients don’t have symptoms while resting
• Walk or make movement – increased demand – imbalance between supply and demand – pain –
ischamic pain or intermittent claudication
• Causes of narrowing – localized collection of fat or direct damage of the vessels (chronic smoker
– throboangitis obliterans) Labetalol (beta blocker could be contributory)
• Other risk factors – Heart disease, diabetes mellitus and hypertension, alcohol drinking, increased
fat level in blood, lack of exercises, family history of heart diseases.
• Can be managed with lifestyle changes if not severe, Blood test, USG, angiogram, refer to vascular
surgeon
DVT
You are a HMO in ED. Your next patient, 45 years old Michelle came with ultrasound report showing
deep vein thrombosis in lower leg. (popliteal vein)
Tasks :
• take quick relevant hx.
• Explain result of ultrasound and dx to patient.
• Mx and counselling.

History
• Pain questions
• SOB? Stable?
• Fever? Trauma? Insect bite?
• Risk factors- COST VMPF
• C – contraception, O – obesity. BMI? S – recent surgery? T- Travel history?
• V – problems with Veins? M – malignancy – LOW, LOA. Lumps and bumps, P- pregnancy, F- family
history of clotting problems
• Social – occupation
• SADMA

• Make sure she is stable

• Explain the ultrasound result, blockage of the vein that’s why blood pooled in legs and then pain
in calf muscles. Blocked by blood clot, result from prolonged immobilization of the legs during
flight.
• Risk – not treated – dislodged and travel down the blood stream, block the main vessel in lungs,
life-threatening.
• Reassure – safe hands now
• Specialist review, blood tests including baseline FBC, EUC, LFTs, coagulation studies (APTT, PT,
Fibrinogen) and imaging CTPA if SOB
• blood-thinning medications will be given in oral or LMWH injection (most likely Rivaroxaban for
oral) or and then will be monitored as outpatient for any dose adjustment.
• Follow-up, for blood thinning medications which you might need to take for a few months
• Any bleeding, from anywhere or black stools or brown urine, go to see the doctor
• Tell the doctor about your medication whenever you consult the doctor
• Review

Warfarin Counselling
Your next patient in general practice is a 55-year-old Mr. Grant Burge who has been diagnosed with
new onset AF which did not respond to medical treatment and the cardiologist has started him on
warfarin.
Tasks:
• Talk to the patient about the medical condition and warfarin treatment
• Answer question

• It is an anticoagulant medication used for the treatment and prevention of further clot formation
by thinning the blood. It is taken for 3-6 months but if you are thrombophilia positive it needs to
 be taken lifelong. It is usually indicated for stroke, venous thrombosis prophylaxis, AF, prosthetic
heart valves.
• The dose of warfarin is adjusted according to the values of a blood test called INR. It is the ratio
of the time that your blood takes to clot to the time taken by the blood of normal person of your
age to clot. In your case, we will keep it between 2-3. The INR of a person not taking warfarin is
about 1. When you take warfarin your INR will be higher, which means that your blood takes
longer to clot. For most people, the INR result that provides the best balance between the chances
of bleeding and clotting is between 2 and 3 – this is called the “target INR range”. Your INR is 2.4
now. So we can say that it is optimal now.
• In your case, I also observed that your kidney functions is a bit impaired which means we are going
to start with lower dose of Wafarin and you can reach the Targent INR range with lower dose than
other people because the filtering and excreting rate of waste in your kidney is slower.
• If INR is high, there is a high chance of bleeding, but if it is low, there is chance of clot formation.
That is why we should be very careful with warfarin.
• Carry this diary with you all the time. Remember to take the tablets strictly as directed and the
blood tests. Same brand every time -Marevan or Coumadin
• Take the dose at the same each day, preferably in the evening and INR measured in the morning.
Note in a diary the drug dosages and INR results. The INR reflects the warfarin dose given 48 hours
earlier.
• keep a record of your INR results in the record section of this booklet. Bring this booklet to your
next doctor visit. Dose of warfarin can be altered accordingly to the INR.
• Keep a well-balanced and healthy diet, but avoid eating foods containing vitamin K like green leafy
vegetables. Avoid cranberry juice. Drink to safe levels and avoid binge drinking. I will refer you to
a dietician
• Always mention that you take warfarin to any doctor, dentist or chemist. If you forget to take a
dose, and remember in 4 hours, you can still take it but if longer than this, then skip the dose and
carry on with the usual dose. (Do not take a double dose to compensate for a missed dose!!!).
• Note the date of the missed dose and inform the doctor about it.
• Do not take any medications (including herbal also) unless prescribed by your doctor because
warfarin can interact with them. These include medications including OTC such as for common
cold.
• Stop aspirin and NSAIDs.
• Red flags: Immediately report to hospital if you have unexpected bleeding from minor cuts,
unusual nose bleeds and bleeding from gums, Bruises, bleeding at any time especially from back
passages or change of color of stool/urine, purple toe syndrome (1st 3-8 weeks of treatment),
heavy menstrual bleeding. (if Female)

Shoulder dislocation
You are a HMO at the hospital. You are going to see a 20 years old football player with shoulder pain.
• Your tasks:
• Take history
• Dx and course of the condition

History
• Do you want me to prescribe painkillers
• Duration of pain?
 • Any injury? Details of the injury –what happened exactly? When? Is it the first time? Is there any
other associated injury? Where exactly is the pain? Any radiation to other areas? Any aggravating
and relieving factors?
• Associated symptoms – do you have any arm weakness? Can you move your shoulder joint? Any
tingling and numbness in the upper and lower arm? Any catching or locking sensation? Any
discoloration in shoulder and arm? Any swelling or redness in the shoulder? Any deformity? Do
you have any fever?
• Do you play sports a lot?
• Do you have any other joint problems?
• Any medical, surgical history?
• SADMA
• Management and course of the disease
• You will be on enough pain killers. A senior will come and examine you.
• Probably you are having anterior dislocation of the shoulder. We will check the X-ray for any other
associated injuries in the shoulder too.
• Shoulder is a ball and socket joint. When the ball comes out of its socket, it is called dislocation.
This can damage the ligaments, muscles and bone of the shoulder joint.
• So the senior will put it back manually and the X-ray will be checked again after the reduction.
• After reduction, you’ll have to wear a sling for a few days. Exercises for elbow and wrist will be
necessary in this period to avoid complications in these joints. It will take 12-16 weeks to
completely recover from shoulder dislocation. You can resume most activities in 2 weeks time but
still have to avoid sports and heavy weight lifting for 3 months.
• There also is a high chance of similar dislocation too. Doing the recovery exercises with the
physiotherapist will reduce this risk and maybe you’ll have to wear a strap while playing.
• You will have to be followed-up regularly after the reduction.

Shoulder Pain (Rotator cuff case)

You are a GP . You are going to see 66 years old female with Rt shoulder pain. An ultrasound report was
given showing tears in Supraspinatous, Infraspinatous and Subscapularis with the gap of 5cm , no signs
of bursitis and fracture.
• Take history for 4 mins and explain the patient the report and tell the Dx.

History
• Do you want me to prescribe painkillers
• Duration of pain? Is it the first time?
• Any injury? Details of the injury –what happened exactly? When? Is it the first time? Is there any
other associated injury? Where exactly is the pain? Any radiation to other areas? Any aggravating
and relieving factors?
• Associated symptoms – do you have any arm or hand weakness? Can you move your shoulder
joint? Any tingling and numbness in the upper and lower arm? Any catching or locking sensation?
Any stiffness? Any discoloration in shoulder and arm? Any swelling or redness in the shoulder?
Any deformity? Do you have any fever?
• Long duration in this case (patient responded she has got this for ages), How does it affect your
daily activities? Does this pain disturb your sleep?
• Do you play sports a lot? What do you do for a living? Do you use your shoulder a lot?
• Do you have any other joint problems?
 • Any medical , surgical history? Family history of joint problems?
• SADMA

• Explain the ultrasound (it’s a long report in the exam so explain as given in the exam)
• The most likely diagnosis - A chronic tear of the rotator cuff tendon (which is the band of tissue
around the shoulder) which occurs slowly over time. At some point, the tendon wears down and
tears.
• DDx – adhesive capsulitis (frozen shoulder) which is the scarring, thickening, and shrinkage of the
joint capsule, shoulder impingement (where a tendon inside your shoulder rubs or catches on
nearby tissue and bone as you lift your arm), osteoarthritis (which is a degenerative or wear and
tear process) or nerve problems.

Knee pain
You are a GP. A 32-years-old lady came to you pain in her right knee for 1 day.
Your tasks :
• Take history for 6 mins
• Physical examination from the examiner
• Diagnosis and differential diagnoses to the patient

PEFE card
• General - patient looks well.
• Vitals - normal,
• Instable gait
• Right knee movement - restricted movement
• Patella tap - positive
• Pain and tenderness in anteromedial side of the knee
• Sensation intact
• Instability observed on anterior drawer test/Lachman’s test
• Apleys grind test cannot be performed because of pain

History
• Offer pain killers
• Details of knee pain – site, severity, radiation redness or swelling, any injury? what happened?
Continuous since then? Aggravating, relieving factors? Are you able to bear weight? Giving way?
• Detail of injury – what happened exactly? Mechanism of injury? Any popping sound?
• Fever? Chills? Recent illness?
• How about left side?
• Other joints?
• BMI?
• Family history of joint problems
• Past medical, past surgical, any bleeding disorders
• SADMA

• Explain –diagnosis according to your own positive findings(draw a picture and explain) It could be
injury those ligaments called anterior cruciate which is located in front of the knee, Medial
meniscus injury in inner surface of the knee also happened together with ACL.
 • DDx – other ligaments injury, septic arthritis which is joint infection, Chondromalacia patella
which is a softening of the cartilage undersurface of patella, fractures, infections, muscular pain
• We gotta do USG and MRI to confirm (Xray if possible fracture)

Notes:
• Differential diagnoses for knee pain
• Chondromalacia patella
• Patella tendopathy
• Osgood-Schlatter
• Bursitis
• Hamstring knee injury
• Infra-patella fat pad inflammation
• Ligamental injury
• Osteoarthritis (if the scenario is old age and pain is chronic)

Plantar fasciitis
You are a GP. You are going to see a lady 40 years old presenting to you with pain in the foot. She says
her heel side is bigger on that side too. She has an injury to that right ankle 10 years ago but was
managed.
Tasks:
• History for 5 mins
• PEFE card from the examiner
• Ddx

PEFE card
• Generally, well patient with vitals OK
• Has limping gait
• No other joint problems
• On ankle inspection – ankle and heel are mildly swollen without any redness, mild tenderness
there
• All the movements of the ankle on right side is restricted because of pain
• Left side is OK

History
• Painkillers
• Details of the pain – Where exactly is the pain? How long? Continuous or on and off? Is it getting
better or worse overtime? Any aggravating or relieving factors? Any history of injury? Is it the first
time? Did you try any medications? Is the pain the worst when you get up from bed? (plantar
fasciitis)
• Association – any deformity? swelling? Redness? Stiffness? Tingling and numbness? Can you walk
well? Any pain in other joints of the body?
• Risk – do you wear high heels? Any ill-fitting shoes? Are you aware of your body weight? What do
you do for a living? Are you a sports person?
• Any medical or surgery history before?
 • SADMA

DDx (depending on your own history and site of the pain)

• It could be plantar fasciitis – which is the inflammation of the thick ligament connecting the heel
to the front of the foot
• Secondary OA as a consequence of previous injury
• Heel spur – a bony protrusion under the heel bone
• Archilles tendonitis – The inflammation of the band of the tissue that connects the calf muscles
to the heel bone
• RA
• Stress fracture
• Tarsal tunnel syndrome – which is a nerve compression that runs through your ankle
• Bursitis – inflammation of the cushions of the bones
• Incomplete healing of the ligaments (if there is recent injury a few months before the onset of the
pain)
• Morton’s neuroma – which is the thickening of the nerve in the foot

Ankle pain (gout)

You are a GP. A 62 years old woman coming to see you because of the pain in the right ankle for 2 days.
Your tasks:
• Take history
• Ddx to her

History
• Address the pain
• How much is it from a scale of 1 to 10? Do you need any pain killers?
• Pain questions
• Onset –
• Location –
• Duration –
• Character
• Aggravating factors –
• Relieving factors
• –Radiation –
Differential diagnosis
• Is there any redness, swelling? Is there any fever with chills?
• Rash ?
• –Any discharge, pus, blisters, skin discoloration, severe pain or high fever (necrotizing fasciitis) -?
• Is there any history of trauma?
• Insect bites? What was u doing before?
• DVT –any recent travel history? Any swelling in the legs?
• PVD - Can you walk well? Any ulcers? Pain in the calves?
Risk factors
• Do you have a family history of gout?
 • Do you have hypertension / diabetes / been diagnosed with any kidney problem?
Precipitant for this attack
• Could I know about your diet? (purine rich food)
• Do you drink alcohol? How many glasses a day?
• Are you on any medication? (diuretics)
• Do you drink a lot of soft drinks? (fructose high drinks)
• Have you had any recent surgery in the past?
• SADMA

Explanation
• It could be gout It is a metabolic disease and it leads to recurrent joint inflammation due to
deposition of a substance called urate.
• There could be many reasons why urate could be high, but most commonly it is genetic along
with associated conditions like hypertension, diabetes and high blood fat levels. You are also
taking thiazide which precipitates it too.
• It could be septic arthritis which is the infection in the joint but you don’t have any fever.
• It can be cellulitis which is an infection of the skin and soft tissue as you told me like you walked
in the garden and it may be associated with minor lacerations and bugs enter through it. You
also have diabetes as risk factor for it.
• It could be trauma or injury but less likely
• (OA/RA)
• Management
• Investigations (depend on your own findings in the history)
• I shall take a small amount of fluid from your joint to send for analysis to make sure it is not an
infection. I shall also send the same fluid for it to be seen under a microscope to confirm gout.
• I shall also take blood to check for urate levels, but they could be normal as well
• Apart from that I shall run a FBE, blood sugar, blood culture to rule out cellulitis, serum lipids
and urea and electrolytes to confirm the risk factors.

Neck
Papillary Thyroid Cancer
You are a general practitioner. A 37-year-old man, came to you with the biopsy result of a thyroid
nodule. The biopsy shows the papillary thyroid carcinoma.
Your tasks:
• Tell the biospy result to the patient
• Offer the management and explain the management and complications of the management to
the patient

• Breaking bad news

• Tell the diagnosis (5 C approach)
• Papillary very common and best prognosis
• Sandwich approach (Good – best prognosis among thyroid cancers, bad- you may need surgery
for removal, Good- less chance to metastasize)
• Investigations – CT for metastasis
 • Surgery – risk of anaesthesia (dizziness, hypersensitive, allergy, headache, vomiting), Bleeding,
infection
• Thyroid removal – risk of recurrent laryngeal nerve injury (voice changes but can be recovered,
thyroid replacement medications and life-long follow-up require

Neck Lump
case : neck lump in midline. Task: hx, dx (need more details)
History
• Lump Qs:Where exactly is the lump? When did you notice it? Did you notice any change in size
or shape of the lump? Change in color of overlying skin? Is it hard or soft? Is it fixed or mobile?
Any other lumps and bumps in the body?
• Associated symptoms – Pain? Difficulty or pain during swallowing? Change in voice? LOW? LOA?
• Hyperthyroid symptoms – do you think you’re sweaty these days? Racing of heartbeat? Easily
provoked? Any weather preference?
• Hypothyroid symptoms – being slow? tired? Weight gain? Dry skin?
• Waterworks and bowel motions?
• DDx - Any previous history of fever, night sweats? Did you have a recent URTI or other infection?
Any ear infection? Any loss of weight and appetite?
• Past medical, surgical, SADMA, family history of head and neck cancer
• Possible ddx
• Thyroid – Goiter, thyroid nodules, swollen lymph nodes which are neck glands enlargement due
to infections or lymphoma, Lipoma which is a benign tumor or thyroid cancer.

Hoarseness of voice
You are a general practitioner. Your next patient is a 50-year-old female teacher, Patricia, complained
about hoarseness of voice for a few months.
Your tasks :
• Take a relevant history
• PEFE
• Explain the DDx with reasons

History
• Main complaint – how long? Persistent getting worse?
• I understand that you are a teacher. So you have to use your voice a lot. How long have you been
a teacher?
• Infection – pain in throat especially on swallowing? Fever? Cough? Runny nose?
• Neuro – difficulty on swallowing?
• Vocal abuse, growth – apart from teaching, do you have any intensive voice training?
• Foreign body- Any instillation of FB?
• Thyroid – any swelling in front of the neck?
• Asthma – any history? Any recent exposure to dust? Noisy breathing?
• Stroke – any tingling and numbness? Any weakness in limbs?
• Ca – LOW. LOA, SOB, lumps?
• General health, any surgery to the neck before?
• SADMA
PEFE
• general appearance, vitals
• Hands – nicotine staining, anaemia, clubbing, HPOA, moist palm, pulse, hand power
• Face – Horner’s syndrome, neck – thyroid, Oral cavity – inflammation, tonsillitis
• Cranial nerve 9, 10
• Cervical lymph nodes
• Respiratory system examination, CVS, abdomen, Neurological examination
• Bedside test – PEFR, indirect laryngoscopy (to access vocal cord function)

• Various reasons
• It could be due to excessive usage of voice.
• In my examination, I found ……… So it could be due to nasty growth in upper part of the lungs.
• Other differentials.
• But we will need to run blood investigations, imaging (CXR, CT) and direct laryngoscopy by the
specialist

Genitourinary
Urinary Retention
A man with lower tummy pain for 12 hours.
Tasks:
• Take relevant history
• Physical examination from the examiner
• Explain the condition and management to the patient

History
• Painkillers
• Pain questions (site, duration, intensity, nature, radiation, continuous or intermittent, relieving
factors, precipitating factors)
• Associated factors (mass, nausea, vomiting, diarrhea, bleeding PR, fever)
• General health and wellbeing
• Past medical and past surgical history
• Medications
• SADMA
PEFE (abdominal examination- inspection, palpation, percussion, auscultation and Per rectal)
Tell the diagnosis and management to the patient
• 5 c approach (Condition, commonality, causes, course, complications)
• Management
- immediate (catheter)
- Long term (refer to surgeon, potential removal of part of prostate and biosy)
• Never forget to reassure!!!!

STD painful urination

25 years old man c/o painful urination. You are a GP.
Task:
• History
• Investigation
• DDx
• and Management
• Urinary symptoms – UTI – change in color, smell and frequency? Duration? Fever?
• CONFIDENTIALITY!!!
• Rash -? Burning sensation in private area?
• Associated sexual health Sx:
• discharge - from where? Duration? Color? Amount? Consistency? Smell?
• obstructive symptoms - hesitancy, poor and/or intermittent stream, straining, prolonged
micturition, feeling of incomplete bladder emptying, dribbling,
• Irritative - frequency, urgency, urge incontinence, and nocturia.
• Any swelling/ growths/ ulcers
• Any pain ? – SOCRATES
• Any trauma? Any allergy history? New brands of skin products or underwear?
• Partners - last 3 or all partners in last 6mnths:
• How many?
• gender
• any partner STIs ?
• condom use
• Type of the intercourse? (oral, anal, vaginal)
• Any systemic features: SoB, fever, night sweats, loss of weight , loss of appetite? Any diarrhoea?
Lumps or bumps in body?
• Recent travel? Occupation?
• Past medical- any underlying medical condition I should be aware of ?Past history of genitourinary
disease, previous STIs? Ever checked before?
• Any surgical history
• Known HIV, HBV, HCV status? Gardasil vaccine?
• SADMA

• Explanation –
• It could be the urethritis Chlamydial urethritis which is infection of the urethra caused by the
sexually transmitted disease, chlamydia. The urethra carries urine from the bladder, through the
penis, and to the outside of the body. As a DDx, it could be Gonorrhoea
• To confirm this, we need to check the urine sample for Chlamydia. We should need to check for
all STI namely HIV, Hepatitis B and C, Gonorrhoea, Syphilis, Chlamydia, Human Papilloma Virus
and etc. Some can be cured but some conditions cannot. But the earlier we detect the disease,
the better the prognosis we can expect. The samples are blood, urine and discharge.
• If anything like Gonor or Chlamydia, we can treat with antibiotics and notify to DHS and do the
contact tracing of your partners too. (highly suspicious case, we start antibiotics without waiting
for the lab results)
• I really know that it must be exciting to test for STDs. If So if u agree to test these, please sign the
form for consent and we will move on.
• Do you have any questions? Ok. So I will see u again with results. We will treat accordingly
depending on the result.
Haematuria
You are a GP. A middle aged, 62 years old man, Liam, presented with blood in terminal urine.
Tasks:
• Take history
• PEFE
• Differentials to patient.

History
• Haematuria – urine color changed totally or clear and changes at the end? Any pain? Any smell?
• Urine symptoms (to ask the symptoms in the following pic)

• flank pain? (stones) LOW, LOA (RCC or Ca bladder)

• Any fever? Urine smelly? (UTI) Safe sex? (STI) Bleeding disorders? Blood thinning medications or
other medications? Any trauma?
• Family history of stones or kidney diseases, cancer?
• Past medical, surgical (any procedure causing stricture?)
• Food – Beetroot?
• SADMA and occupation! ( Ca bladder) Medicines also important!
• PEFE – GA, vitals
• Abdominal examination - don’t forget renal angle tenderness!
• DRE,
• UDT
• Haematuria due to enlarged prostate. (draw a picture, a gland located in male urethral system)
The vascular component of the prostate is also enlarged so bleeding occurs. Since it has a smooth
surface, less likely to be nasty. We will need investigations. Others – UTI, stones (kidney and urine
bag), STI, bleeding disorders, medications or cancer unlikely.

Adenocarcinoma prostate
You are a general practitioner. A 68 years old Mark who initially presented to you with frequency,
urgency and dysuria coming for follow up. On examination before, you have found enlarged prostate.
You referred him to urologist. Who did DRE, urine tests and sent the results. Investigations are given
below:
• Urine test – MSU growth of [Link]
• Blood test – PSA – 6ng/ml (normal <4ng/ml)
• Core biopsy – show adenocarcinoma prostate with gleason score 7
• Cystoscopy – normal, no bladder neck obstruction
• Radio nucelotide scan – shows no metastasis
• CT pelvis- Ca cells within prostate capsule (stage 1 and 2)
• CT Spine – normal
• Your tasks:
• Explain the results
• Offer the management options
• Greetings!
• Explain the results one by one
• The first test we check is the urine culture to check for any infections in the urine tract. We found
the growth of [Link] which is confirmed as infection in the urine tract. The second is PSA which is
a protein produced by the cells of the prostate grand. It’s level is a bit increased which means that
there is increased number of cells in the prostate. We also took a biopsy from the prostate and
the result shows adenocarcinoma, a type of nasty growth and it’s medium-graded with a Gleason
score of 7. Don’t worry. It’s a common condition in men in their 60s. We also checked the urine
bag from the urinary opening with a flexible tube and we found no obstruction in the bladder
outlet which means that the enlargement of prostate is not obstructing the urine flow. Another
tests, radio-nucleotide scan and CT spine which are the scans to detect the spread but luckily,
there is no spread. In addition, when we checked the CT pelvis, we know that the nasty cells are
still inside the capsule of the prostate. So it’s a very early stage.
• Diagnosis – UTI and CA prostate
• Reassure – early stage, no metastasis, can be cured
• Management – 1 st problem is Ca prostate
• Option 1 - Radical prostatectomy- Removal of whole prostate –
- Removal by surgery under anaesthesia
- Suitable for young patients and early stage
- Benefits – can be cured, treatment completed in one day. Drawbacks – Incontinence,
Impotency, infertility and blood in urine (short term and long term)
• Option 2 – Regular observation –Active surveillance - wait and see regularly and monitor – PSA,
Clinical exam and DRE and MRI in regular intervals- suitable for patients over 70 years and low
risk patient who do not want surgery like in your case. The pros are fewer side effects than active
management, can still monitor the cancer closely, may never need further treatment. The cons
are you may need regular examinations and biopsy and might worry that you are not doing
anything.
• Others –Radical radiotherapy, Brachytherapy (radiation by inserting implants) Radiation is also a
curative treatment but may result in bowel and urinary problems and skin changes, infertility.),
Hormonal – suitable for patient with advanced disease
• 2 nd problem – UTI – infection in urinary tract most likely because of the stasis of urine due to
prostate enlargement
• Less common in male, happens when there is obstruction of urine flow
• Will be treated with antibiotics changed after culture result)
• Brothers? Recommended for screening program
Ureteric colic
You are HMO. 40 years old Freddy came with complaints of pain in the tummy lasting for more than 10
mins probably A few hours back. The pain is radiating from loin to groin and lasted 15 mins. Patient is
stable now. A CT has been done and provided below.
• Tasks-History for 3 mins
• interpret investigations
• management

History
• Painkillers?
• Details of pain questions – First time? duration? Continuous or off and on? Radiation? How does
it look like? Getting worse? Aggravating or relieving factors?
• Associated symptoms for DDx – any nausea? Vomiting? Changes im pee and poo? Contain any
blood? Any constipation? Diarrhoea?any change in color or urine stream? LOW, LOA? Trauma?
• Did you drink enough water everyday? Occupation? Regular medications? Family history of kidney
stones?
• Medical, surgical, SADMA

• Explain CT scan and structures – this is the CT scan in cross section of your tummy. It’s a mirror
image so the structure on the left can be seen on the right side. These shadows are the kidneys.
There is a stone in the ureter which is a tube that connects kidneys to the urine bag on the right
side.
• Management –urinalysis and check for infections, serum calcium, uric acid and electrolytes, USG
(for hydronephrosis)
• Conservative - wait and see with more fluid intake, if no complications. Up to
• 70% of stones less than or equal to 5 mm in transverse diameter will pass spontaneously. It is
advisable to catch urine in a white container for analysis later. So you will be given enough pain
killers as well. You will need repeat imaging after 6 weeks.
 • If this does not help or the stone is larger, we will do ureteroscopic laser lithotripsy – a flexible
tube will be inserted from urinary opening and the stone will be destroyed with laser.
• Stone prevention –
• increasing fluid intake, especially water, sufficient to maintain dilute urine output
• avoiding added salt
• maintaining a well balanced diet and avoid oxalate rich foods if it is an oxalate
stone which is common variant.

Renal Colic
You are HMO. 40 years old Freddy came with complaints of pain in the tummy lasting for more than 10
mins probably A few hours back. The pain is radiating from loin to groin and lasted 15 mins. Patient is
stable now. A CT has been done and provided below.
Tasks-
• interpret CT scan to the patient
• Management to patient

• Explain CT scan and structures – this is the CT scan in cross section of your tummy. It’s a mirror
image so the structure on the left can be seen on the right side. These shadows are the kidneys.
There is a stone in the left kidney which you can see as a white dot.
• Management –urinalysis, serum calcium, uric acid and electrolytes
Treatment for kidney stones (ref. better health channel)
• Most kidney stones can be treated without surgery. Ninety per cent of stones pass by themselves
within three to six weeks. In this situation, the only treatment required is pain relief. However,
pain can be so severe that hospital admission and very strong pain-relieving medication may be
needed. Always seek immediate medical attention if you are suffering strong pain.
• Small stones in the kidney do not usually cause problems, so there is often no need to remove
them. A doctor specialising in the treatment of kidney stones is the best person to advise you on
treatment.
• If a stone doesn’t pass and blocks urine flow or causes bleeding or an infection, then it may need
to be removed. New surgical techniques have reduced hospital stay time to as little as 48 hours.
Treatments include:
 • extracorporeal shock-wave lithotripsy (ESWL) – ultrasound waves are used to break the kidney
stone into smaller pieces, which can pass out with the urine. ESWL is used for stones less than 2
cm in size. Side effects – pain, blood in the urine significant
• percutaneous nephrolithotomy – for stones larger than 2cm. A small cut is made in your back,
then a special instrument is used to remove the kidney stone. Pain and infection common.
Hospital stay will be like 3 days.
• endoscope removal – an instrument called an endoscope is inserted into the urethra, passed into
the bladder and then to where the stone is located. It allows the doctor to remove the stone or
break it up so you can pass it more easily. Pain, infection, blood in urine and injury.
• surgery – if none of these methods is suitable, the stone may need to be removed using traditional
surgery. This will require a cut in your back to access your kidney and ureter to remove the stone.
Risk of bleeding, infection and pain from the surgical incision. It is rarely performed nowadays as
it has a week of hospital stays and 6 weeks recovery period for the patient to return to normal
activities.
• Stone prevention –
• increasing fluid intake, especially water, sufficient to maintain dilute urine output
• avoiding added salt
• maintaining a well balanced diet and avoid oxalate rich foods if it is an oxalate
stone which is common variant.

Hydrocele
You are a GP. Your next patient is a 52 years old Paul presenting to you with painless scrotal swelling
for 6 months. Physical examination done. You can get above the swelling. Left testis is not palpable.
Right testis and scrotum normal. Trans illumination test positive.
Tasks:
• Explain the result of your PE
• Diagnosis and differential diagnoses
• Investigations
• Further managment

• Are you comfortable?

• Draw a diagram – scrotum, testes. What I suspect is hydrocele (collection of the fluid between the
layers of the coverings of the testis). It can happen at any age. two types - Primary -Cause –
imbalance between the secretion and reabsorption of the fluid from layers. Secondary - causes –
infection, trauma or cancer
• Other differentials – varicocele (dilated veins), haematocele (blood), Spermatocele/epididymal
cyst (sperm), Pyelocele (pus) but less likely as it could most possibily clear fluid as my examination.
Others – lipoma, hernia or testicular mass further very unlikely as well because the content is
fluid.

Investigations
• FBE, ESR, CRP, Urine RE, C&S, USG (scrotum), screen STI with informed consent (1st void urine –
chlamydia and Gonorrhoea), tumor markers
• Rx – depend on the underlying cause
• Infections – Antibiotics
• Tumor – Surgery and send for biopsy (removal of affected testes)
 • Normal result – primary hydrocele – simple aspiration – increased chance of recurrence so we
inject sclerosing agent which will make the layers stick together or surgery to remove the sac
• If it is not bothering – conservative – wait and see, advice comfortable underwear, scrotal support
and avoid trauma.
• Reassure – Simple hydrocele – less likely to be cancer – will not interfere with fertility

BPR
Haemorrhoids
You are a GP. A 30 year old male, John, complained about bleeding from the back passage for 3
weeks.
Your tasks:
• Take relevant history
• Ask physical examination from examiner
• Diagnosis and management to the patient

History
• Stability check
• Details of bleeding – how long? 1st time? How did you notice it? Fresh blood? Stool sticky to the
pan? Amount? Mixed with stool or streak of blood? Blood clots? Do you feel dizzy? How did it
stop?
• Do you think it is related with bowel habit?
• DDX – Pile – Does the blood stain over the stool/ toilet paper? Anything coming out in back
passage? Infection – any mucous? Any fever? Travelled recently? IBD – nature of stool? Problems
with eyes? Joints? Fissures/fistula in Ano – any pain around the back passage? Polyp – ever had
bowel problem? Bleeding disorder – Are you on blood thinning medication? Blood diseases? CA
– notice any changes in bowel habit? Loss of weight? Loss of appetite? Do you look pale? Tummy
pain?
• Risk factors – constipation? How often do you open the bowel? Have you ever tried something to
solve the problem? Laxative? How often do you use it? Tell me more about diet. Any preference
of food? Regular exercise? What do you do for a living? Any problem with thyroid?
• General health? Any history of liver/bowel diseases?
• Family history – Family history of bowel cancer?
• SADMA

PEFE
• GA, Vitals, pallor
• Heart and lungs
• Abdomen and PR exam
• Inspection - distension, visible mass
• Palpation – tenderness, organomegaly
• Auscultation – bowel sound
 • PR with patient consent – DRE – anal tone, mass, blood on examining finger
• Proctoscope – pile 3,7,11 (if present – we will go for sigmoidoscopy to check for proximal growth)

• Explain – There are haemorrhoids when I did exam on your back passage which is the most likely
cause of your bleeding. Draw a picture. This is the back passage – in the walls – the vessels become
dilated and tortuous in the lower part of the bowel and back passage.
• Usually occurred in patients with chronic constipation. In females, also associated with pregnancy.
• Cause is considered to be pressure in the large bowel. Increased pressure – increased blood stasis
– congestion
• Complications – haemorrhoids itself is not serious but when large, bleeding can be severe. This
may leads to anaemia and SOB, tiredness, interfere with daily activities.

• Advice – lifestyle modification – open the bowel everyday, make a routine, eg wake up at 6am
and sit on the toilet seat
• Change diet pattern – more vegetables, at first you may feel bloating, but will be tolerated soon.
• Using laxatives is not an answer!
• Avoid prolonged standing, sitting, straining
• Walk 30 mins a day
• Definitive management – if not improved and depends on the severity
• Sclerotherapy – a substance is injected into the bulky pile to shrink (advantage – easy,
disadvantage – recurrence)
• Rubber band ligation –ligate the dilated veins
• Surgery –advantage – less recurrent, disadvantage – risks of surgery –infections, bleeding, risks of
anesthesia
• Refer to the surgeon for further discussion
• Review

Tummy pain and BPR

You are a HMO at the hospital. A 35-year-old female came with tummy pain for the last 3
months. Task is to
• Take History for 6 mins
• Explain the cause of tummy pain and probable reasons

• Greeting, pain killers

• Pain questions - Details of pain questions – First time? duration? Continuous or off and
on? Radiation? How does it look like? Getting worse? Aggravating or relieving factors?
• Associated GI symptoms - Vomiting? Any blood in vomiting? Any blood or black color
stool? Any problem with swallowing of food? Any mass?
• Blood (+) - Pile – Does the blood stain over the stool/toilet paper? Anything coming out
in back passage? Fissures - Any pain while passing stool? Infection – any mucous? Any
fever? Travelled recently? IBD – nature of stool? Problems with eyes? Joints? Polyp –
 ever had bowel problem? CA – notice any changes in bowel habit? Loss of weight? Loss
of appetite?
• Diet, job
• Anemia symptoms: SOB, lightheadedness, do you think you look pale?
• 5P history (female patient to exclude gynaecological causes)
• SADMA
• family Hx of cancers
• DX: Diverticulosis, Colon CA, mass causing compression leading to pain and constipation
• DDx - Diverticular disease – which is the formation of the pouches in your bowels
causing pain and constipation , IBD – ulcers and inflammation in bowels, Colorectal
cancer – nasty growth in lower part of the bowels because you also have lost of weight
anal fissure – small tears around the back passage unliky because you don’t have pain
around back passage, pile but less likely as pile won’t cause tummy pain.

Perianal pain
You are a GP. You are going to see a 23 years old with Perineal pain and lump feeling.
• Task : History + Dx/ DDx

• Pain questions - Details of pain questions – First time? duration? Continuous or off and
on? Radiation? How does it look like? Getting worse? Aggravating or relieving factors?
• Association – any discharge? Any itchiness?
• How does it related to passing stools?(being afraid to move bowels) or pain while
sitting? (pilonidal sinus)
• DDX – Pile – Does the blood stain over the stool/ toilet paper? Anything coming out in
back passage? Infection – any mucous? Any fever? Travelled recently? Polyp – ever had
bowel problem? Bleeding disorder – Are you on blood thinning medication? Blood
diseases? CA – notice any changes in bowel habit? Any diarrohoea/ constipation? Loss
of weight? Loss of appetite? Tummy pain?
• Sexual history (preference)
• Diet, job
• Past medical and surgical history esp anal surgery (important!)
• Family history of cancers
• SADMA
• DDx –Pilonidal cyst/sinus, Fissures/ fistula in ano, Piles, Anal abscess, tumors and
infections

ISBAR
You are a surgical intern. You are going to make a call to another intern who is going to have a duty
hangover from you. You are going to inform her about this recent case admitted to your ward.
Patient, Mr Simon Testa, 45 years old patient was brought to your hospital ED by Blue team. He
complained of 2 episodes of Melaena and dizziness. Now he got fainted and the team brought him to
you. On arrival, his blood pressure was 80/50 mmHg, pulse – 120/min, SpO2 – 98%, Respiratory rate –
22/min, temperature was normal and well conscious. He was stabilized by ED team by giving fluids and
his vitals now are – blood pressure 110/70mmHg, pulse – 88/min, SpO2 – 98%, Respiratory rate – 20/
min. On his past medical and surgical history, he had undergone cruciate ligament repair 6 months ago.
He also has history of Asthma which is well controlled with reliever inhalers. He also had a history of
appendicectomy 10 years ago. On medication, he is on diclofenac 50mg BD for his knee pain,
Amlodipine 5mg for hypertension and aspirin 100mg daily. He is a social drinker and smokes cigarettes
15/day. The registrar had seen him and stopped Diclofenac and put him on 2 hr vital sign monitoring.
He is allergic to Penicillin. Please make a note and the phone will ring in 4 mins. The registrar thought
that it is diverticulitis and planned for colonoscop0y the next day.
• Task:
• Handover to the other concern

• Introduction
• I am Dr Riley, I am tonight oncall HMO. May I confirm whom I am talking?( identity check). I am
calling you to inform about the new case which was just admitted to the ward.

• Situation:
• I would like to inform you about the recently admitted case ro our ward
• It is a bout (Patient particulars)
• He was brought in here for Melaena and dizziness. On arrival vitals are (…). Stabalized by ED team
and now it’s (…))

• Background
• He has history of Melaena for two times. He is taking Diclofenac 50 for his knee pain, Amlodipine
for his hypertension and Aspirin.
• He had a ligament repair surgery of knee 6 months before and appendicetomy.
• He also has asthma which is well controlled by inhalers.
• He is a smoker as well.

• List of: medications, allergies, IV fluid status ( in – and out- put), latest pathology results (+
comparison to previous)
• He is allergic to Pencillin.
• Assessment done by the registrar. His diclofenac had been stopped. He is now on 2 hours vital
monitor.
• what we think the problem is: diverticulitis and the patient is now planned for a colonoscopy
tomorrow.

• Recommendation suggest or request – I need you to continue monitoring this patient and prepare
for the colonoscopy tomorrow.
• Recheck understanding
• DOCUMENT IN PATIENT’S FILE!!!

Miscellaneous
AAA
A 65-year-old man, Fred, came to your GP clinic and you noticed an abdominal mass which is pulsatile.
CT scan and contrast X ray were ordered. The results show as the next slides. He is preparing for a
caravan trip.
Your tasks:
• Explain the result
• Explain the contributory factor and
• Further management

• Approach
• Explain the contrast X ray and CT scan. (abnormal bulging of the aorta which is the main vessel
from heart, this is the two kidneys and you can see the dilation here just below the kidneys) (CT
– bones and vertebra and show dilation)
• It originates from heart, normal size is less than 3 cm. In your case, we will need to investigate
with USG for the size but in this scans, we can see that it is obviously dilates.
• The extent –It’s relation (above or below) the bifurcation to the renal arteries.
• The causes are due to the fat deposition in the artery wall and reduced elasticity
(artherosclerosis), increased blood pressure ,hypertension, smoking, degenerative diseases,
collagen diseases and familial
• Symptoms – pulsatile mass, dragging sensation, tummy discomfort
• Leak – pain and buttock discomfort
• Rupture – tummy pain followed by collapse and death
• I understand that you don’t have any symptoms. But when the size is increased – increased risk
of rupture – massive bleeding – lack of blood supply to lower part of the body – fatal
• Once it is ruptured – mortality rate is very much higher – too late to be treated
• Good point – now we have detected it – we can do the repair before the complication.
• Your trip ? Where are you going? With whom? How long will you stay there? What activities will
you enjoy?
• Management – we will check the size first.. The management is depending on the size- 3-3.9 –
follow –up 2 yearly, 4-4.5 – 1 yearly, 4.6 to 5.0 – 6 monthly, >5 – 3 monthly, >5.5 – intervention)
 • But your case – significantly enlarged – I am concerned – caravan trip – road is not smooth, and
far from medical facilities.
• So I would like to check with a vascular surgeon after knowing your size.
• Elective surgery may be considered if size is larger than 5.5 cm –
• endoluminal repair (inserting the aortic graft through femoral artery through groin incision) or
• open surgery
• Complications – injury, bleeding, risk of anaesthesia, clotting problems and minority reported
impotency but less likely under experienced hands
• So for the moment, I am sorry, I want you to postpone the trip for a while and check with vascular
surgeon.
• Red flags – back pain, tummy pain, dragging sensation or collapse (tell the family members)- ED

Gynaecomastia
You are a GP. Your next patient, Simon, who is in his 50s complained of breast enlargement bilaterally.
Tasks:
• History,
• PEFE card,
• diagnosis,
• differential Dx.

History
• Is it first time for you? How big was it initially? Do they get larger suddenly or gradually?
• Both of your breasts?
• Any other symptoms? Like pain? Both sides?
• Any discharge from your nipples? Do you feel any lumps in your breasts?
• Any lumps in your armpit?
• LOW? LOA? Anyone comment that you look pale?
• Anyone in your family who has breast cancer like your mother or sisters?
• Any headache or visual disturbance? (prolactinoma) Weather preference? (thyroid) Any yellow
discoloration of skin? Swelling in tummy? (liver)
• Do you know your body weight?
• Medical/surgical history? On any medications? Details – duration, dose, recent change in dose?
Any steroid usage?
• SADMA

• PEFE card shows BMI – 31 kg/m2, no palpable breast lump, no axillary lymph node enlargement.
Liver is enlarged (2-3 cm) with firm edge.
• Now, I’d like to explain you about the most probable reason for your breast enlargement.
• In your case, I noticed that the BMl, weight height ratio is 31, which is on the high side,
• which means you are overweight. In patients who are overweight, the breasts can get enlarged
as a result of fat deposition, medically we call this pseudogynaecomastia. (if the breasts are not
painful – more likely to be pseudo. If painful, pseudo will be less likely dx)
• Also, you have been taking spironolactone and there is recent change in dose. This
 • medication is good for controlling blood pressure, but one of the side effects is that it can cause
breast enlargement. Also it could be because of thyroid problems, steroid use or liver insufficiency
but less likely in your case.
• According to the history – Spironolactone, chronic liver insufficiency, Pseudogynaecomastia,
thyroid, prolactinoma, Steroids usage, Cushing’s, Cancer less likely.

Male breast lump

In a GP, you are going to see a 50 years old male, Josh with breast lump.
• Tasks:
• PEFE
• explain the diagnosis/differentials
• Management

History
• Lump history – site, size, movable, painful or not ? Redness? Skin changes? progressive/?
Continuous or appear and disappeared? Discharge?
• Association - Weight loss, loss of appetite
• Fever
• Lethargy, SOB
• Pain elsewhere – e.g. spine / axilla / abdomen
• swelling in neck and armpit?
• Ddx – BMI? Gynaecomastia – steroid? Liver diseases? Any jaundice? Thyroid problems? Any
medical illness? Any trauma?
• Family history of breast cancers?
• Past medical, past surgical
• SADMA

• PEFE – examination of the breast as we do in female

• ?? breast cancer
• DDx: fibroadenosis, fibroadenoma, traumatic fat necrosis, breast cyst, breast abscess, lipoma,
sebaceous cyst

Cellulitis
You are a GP. A 60 years old female, Paula, has presented to you with leg pain. The picture is below.
Patient is afebrile, hypertensive, smoker, diabetic.
Tasks
• history,
• tell patient diagnosis and risk factors leading to this
• and immediate management.
 • Pain history
• DDx of pain and redness – associated features – any fever? Insect bites? Any swelling? What was
u doing before? DVT (venous eczema) – COST VMPF - C – contraception, O – obesity. BMI? S –
recent surgery? T- Travel history? V – problems with Veins? M – malignancy – LOW, LOA. Lumps
and bumps, P- pregnancy, F- family history of clotting problems. Sports? Any trauma? PVD - Can
you walk well? Any ulcers? Pain in the calves?
• Any discharge?
• Any past medical (DM), surgical?
• SADMA
• Dx- cellulitis – Antibiotics
• Red flags – discharge, pus, blisters, skin discoloration, severe pain or high fever (necrotizing
fasciitis)
• Review after 3 days of antibiotics

Epistaxis
Middle aged guy, nose bleed. Already soaked through many handkerchiefs, nurse has done some nasal
packing. BP- 140/90
Tasks-
• Immediate mx of nosebleed,
• Hx for Causes
• Mx

• Suction ready
• Sitting upright
• Pressure to nostrils 5 mins (ask to pinch the nose)
• Ice to bridge of nose or oral mucosa (may decrease nasal blood flow up to 20%)
• Not controlled – Cauterisation, anesthetic spray or put cotton balls soaked with it, or prepare
adrenaline plug with and put it in the nose
• Mechanical – ballon tamponade – 3-4 days

History
• Ask 1st episode? What was he doing? Previous episodes? Did you feel the blood going into your
throat? (posterior nasal bleeding) What happened? Amount? How stopped? Trauma? Nose
picking? Sudden change in temperature? Bleeding disorders?
 • Past medical, past surgical (facial surgery)
• Regular, frequent use of medications, Blood thinning medications
• SADMA
• ? Thinning of mucosa due to prolonged use of steroid spray – easy to bleed. Sometimes. It
happens because of the wrong technique of using steroid sprays. I will check your method and
teach the correct way if needed.
• Other DDx – high blood pressure, nose picking, temperature changes
• Monitoring of hypertension, do baseline blood checks, coagulation profile
• Avoid strenuous/heavy activity
• Avoid cold/dry environments
• Avoid nose blowing or picking the nose
• Avoid bending over or straining
• If bleeding occurs – pinch the nose, ice compression for 5 mins and then repeat
• Go to hospital if bleeding very severe and uncontrolled

Hip Replacement counselling

60 years old man, with arthritis of right hip. He wants to get total hip replacement. He wanted it last
year but the GP said the symptoms weren’t bad enough.
Tasks:
• Take History
• Explain in general terms the process of total hip replacement

History
• Hip pain details -How long? where exactly is the pain? How frequent is the pain? How severe
when it happens? Which medication did you use wen you have pain? What about at night or at
rest? Is it affecting your work and your daily activities? Do you have to use any support?
• Other factors for hip pain – are you aware of your BMI? Have you tried any physiotherapy or
exercises?
• Contraindication for hip surgery – do you have any red and swollen joint? Fever? (infection), do
you have any history of thinning of bone? Do you smoke? How many? (10 times higher risk for
revision hip surgery in smokers than non-smokers)
• Any other medical or surgical condition?
• SADMA

Explanation
• Hip replacement surgery is indicated when you can’t tolerate the pain, when your joint is stiff and
you can’t move around as you wish, when it disturbs your work or when you can’t sleep because
of the pain.
• So the hip joint is composed of the head of the thigh bone as a ball and the pelvic acetabulum
which is a large cup-shaped cavity in the pelvic bone as a socket.
• Hip replacement surgery is where we remove the damaged ball and socket of the hip joint and
replace them with an artificial hip made of metal, hard wearing plastic and ceramic.
• It is done under spinal anaesthesia (needle in the back to numb the legs) or general anaesthesia
(complete asleep). So you won’t feel any pain.
• There are some risk of the surgery like anaesthetic like heart attacks, strokes, breathing difficulties
and allergic reactions but the chance of these are very low as you will be checked by the physicican
 and anaesthetist before the surgery. There are some other risk like infection, nerve injury,
dislocation, leg length discrepancy, blood loss and blood clots problems in the legs but all these
are rare with our patients under experienced hands.
• After the operation, most patients can go home after 3-4 days. You will need a walker or crunches
at that moment and later you can use a cane. You will need regular appointments and
physiotherapy to gradually return to normal.
• Recovery and return to normal activities varies individually. Most people can do the normal
activities in 5-6 weeks if this is not complicated.
• After hip surgery, there is a chance that this artificial joint being loosened and worn out and need
reoperation which we call hip revision surgery in 10-20 years.
• Any questions?