© PLAB Right Limited @ PLAB Right timitea PLAB - 2 MANUAL PLAB RIGHT LIMITED Thank for attending the PLAB 2 course at PLAB Right. Group study is the key for success in OSCE examination. This manual is produced to guide your group study. It is better if you stay in a small group of three. You need to take roles of examiner, actor and candidate in turn and solve the OSCE vignettes Each Vignette has a mark sheet and a brief instruction to the actor. It is recommended that the candidate who will perform the task should not read the" instructions to the actor” or the mark sheet. Candidate should only read the vignettes. You can take up to 40 seconds to read a question and 5 minutes to perform the task. The person who takes on the role of examiner can manage the time and let candidate know when 4.30 minutes are over. Examiner should give a brief feedback at the end of 5 minutes. All members of the group should then look at the mark sheet and learn how to improve your own skills. Please make notes in the provided space for future reference I would like to take this opportunity to wish you very best of luck in the exam, Please remember that you should not hesitate to contact us at any time© PLAB Right iimicea”” Manikin stations Breakdown of Marks for ALL Manikin Stat 1. Clinical Skills (Your ability examine or conduct procedure in a professional manner 2. Ability to appreciate the findings or successfully complete the procedure In 5 minutes 3. Your ability to describe the No marks are awarded in PLAB exam for telling the examiner what you would have liked to do. Examiner can only award marks for the actual procedure. * For PLAB exam, Most times the question will clearly tell you to carry out the procedure or examination and all pre requisites have been completed. Read the question carefully. You do not have to do the steps written in italic font Introduces self, explains procedure to patient, position required, level of exposure and gains consent * Wash hands in a systematic manner using ayliffe technique* ‘Ask for Chaperone. In PLAB Exam you can assume examiner as Chaperone * Ensure the patient has emptied her bladder, and ask for her LMP * ‘Only expose as much of the patient as is needed * Put on a pair of gloves Inspect and comment on the external genitalia for any redness, swellings, scars, discharge, warts and vesicles. Ask patient to bear down to look for any prolapse and to cough to look for any incontinence. Part the labia with your thumb and index finger and indicate you would check urethra for any discharge (to r/o gonorrhoea) Lubricate fingers of examining hand Insert index finger and then middle finger into the vagina Vaginal examination (note findings) * On vagina (rugosities, swellings and tenderness), cervix (position, surface, tenderness), external os and fornices. imanual examination (note findings) Place other hand on the abdominal wall and attempt to feel the uterus © Note its size and position « Palpate both adnexae © Note the size © Identify consistency whether firm or hard © Find out and not, surface, position, mobility and shape © Comment on posterior fornix for fullness and check for cervical mobility at the end before withdrawing fingers. Remove and inspect fingers for signs of blood or mucus. spose of gloves properly _ Cover patient, and thank her. Document findings and report management plan© PLAB Right Limited @& PLAB Right timiea Do a per rectal examination and report your findings to the examiner Please perform a digital rectal examination on this patient Introduce self to patient and explain procedure, position and level of exposure required.* ‘Gain consent to carry out the test* Ensure a chaperone is present, * ‘Request patient to lle on left side with hips and knees flexed, or with knees bent up to chest. Ensure the patient is not exposed too much.* Wash hands using the ayliffe technique * Wear non sterile gloves to both hands and lubricate index finger of examining hand Inspect the anus and surrounding area for redness, swellings, vesicles, warts, and discharge. Part the buttock to look for anal fissures, fistulas and skin tags. Ask patient to bear down to look for any prolapse. Insert finger into rectum. Explore the posterior and lateral walls of the rectum Rotate your wrist and examine the prostate Determine the consistency of prostate as either firm or hard Note prostatic size, surface and lobes. (Throughout examination you would be looking at patient's face for tenderness, or ensuring he is comfortable) Before withdrawing finger ask patient to sqeeze to check for anal spincter tone. Inspect finger on withdrawal Dispose of gloves correct! Maintain dignity and cover patient, and thank him. Tell the examiner your findings State any tests you may now like to complete Who would you refer to?© PLAB Right Limited @ PLAB Right timitea 1. Inspection: skintags- ischaemic bowel disease Haemorroids Fistula Bleeding / discharge ~ Ca, 1B, STD 2. Examination: Prepare- glove and lubricant(expiry date) Posterior wall Lateral walls Anterior wall (Prostate) Medial sulcus Lobes > Consistency ~ firm/ hard/soft > Size ~ equal on both sides /enlarged > Shape > Surface ~ smooth/ irregular Prostate Normal The median sulcus is felt between the lateral lobes which are equal in size, firm in consistency and have smooth surface. Unilateral _ | The median sulcus is felt between the lat lobes of which one side is larger than enlargement | the other which are firm in consistency with smooth surface. Bilateral | The median sulcus is felt between the lat lobes but is very deep. Both lat lobes enlargement seem to be enlarged which are firm in consistency with smooth surface? Benign prostatic hypertrophy. Unilateral | The median sulcus is felt between the lat lobes of which one lobe is normal in irregular _| size, shape and consistency and other lobe has irregular surface(hilly and craggy nodule) - ? carcinoma Bilateral | The median sulcus cannot be appreciated as both the lat lobes are irregular in irregular size and shape and consist@ PLAB Right iinived™ Examine 36 yr old pregnant lady who is 32 week pregnant bs Please examine this pregnant patient and report your findings Introduce self to the patient ,explain procedure, level of exposure and galn consent.* Indicate the need for a chaperone* Wash hands using the ayliffe technique Ensure patient has emptied her bladder, and ask for her LMP.* Inspect the abdomen, commenting on protuberance, umbilicus being evertered, looking for striae. Look at flanks for any fullness (evident in transverse lie of fetus) Perform a fundal height measurement from symphysis pubis to fundus of the uterus in cm Palpate the uterus using both hands Identify foetal lie Identify foetal presentation Identify foetal position Identify level of foetal engagement Listen to and count foetal heart rate remember to indicate you would check mothers pulse at the same time Maintain patient dignity throughout (exposing abdomen only) Ensure to minimise patients discomfort throughout (not using undue pressure, keeping hands on abdomen as much as possible during the examination) ‘Thank the patient and ask her to get dressed Report your findings to the examiner and comment that examination would be complete by measuring mother’s blood pressure, weight and urine for any proteins. Inspection: umbilicus ( everted) Striae Fullness of flanks Palpation: ffundal height (+/- 2m ) > Fundal grip breech: broad, soft and irregular mass Head: smooth, hard and globular mass > Lateral Back: smooth, curved, resistant, continuous Limbs: irregular, knobby > Pelvic grip: presenting part, ballotable© PLAB Right Limited @ PLAB Right timitea© PLAB Right Limited @ PLAB Right timitea Gervical Screen Please can you take a cervical smear on this patient. Introduces self, explains procedure to patient, position required, level of exposure and gains consent Indicate need for a chaperone, when requesting patient to undress from waist below. * Check menstrual history with patient. * Prepare your equipments. Write the name of the patient on the glass slide (if not used state you would dispose of it in sharps bin) Wash hands using the ayliffe technique and don gloves Lubricate the speculum with warm water. Introduce the speculum at 45 degrees to the normal position pointing towards the small of the back After initial insertion rotate gently through 45 degrees into the position for opening the instrument Open the speculum gently and locate the cervix ‘Take a note of the appearance of the cervix (bleeding or discharge, shape and appearance of the external os), and lock your speculum by turning the screw. Insert the endocervical brush or the long arm of the Ayre’s spatula into the external os and rotate through 360 degrees three times to collect cells Apply the cells immediately to the slide or place brush into the container. Unlock the speculum and gently withdraw the speculum slightly before closing to avoid trapping the cervix Always remove the speculum under direct vision Seal slide and place into transport box. Indicate you would place speculum in a tray to go for sterilisation. Remove gloves and wash hands Cover patient, thank her and report your findings Inspection —= Swelling© PLAB Right Limited @ PLAB Right timitea Examinations Uleers/ vesicles! warts/ sears Discharge / bleeding Bear down - ? prolapsed Cough - ? incontinence Prepare gloves/ lubricant Vagina: > Rugosities > Tenderness > Swelling Cervix: > Size/ shape / Surface/ tenderness > Position ~anterior, central, posterior > Mobility Bimanual examinatic Uterus: > Anteverted / retroverted Gi \drvexa: > Size/ shape/ surface/ consistency Normal (| Can feel the fundus of the uterus, normal in size. Anteverted) Retroverted | Not able to feel the fundus of uterus. Cannot comment on size Enlarged | Can feel the fundus of uterus but is significantly (Anteverted) | enlarged in size. ? Fibriod, pregnant belly ‘Adnexal Can feel the adnexa which is enlarged in size, mass firm in consistency and smooth surface. ? ovarian pathology.@ PLAB Right timitea Please examine this patients breast and report your findings. Introduces seff, explains procedure to patient and gains consent®* Indicates need to wash hands in a systematic manner * Ensure a chaperone is present * ‘Ask the patient to undress to the waist and sit with arm by her side * Inspect the breasts for size, symmetry, shape, skin colour and superficial veins Inspect the nipples for everted, flat, inverted (note If recent or longstanding) Inspect the nipples and areola for cracking or eczema, bleeding or discharge, abnormal reddening or thickening Inspect the breast whilst patient raises arms above her head and comment on any nipple retraction, puckering or tethering, any swellings visible in the axilla, and any redness or eczema on the under-surface of the breast. Then ask her to place her hands on her hips and apply pressure which can help exaggerate abnormalities. Then ask patient to lean forwards and examine breast from the side to observe for any obvious swellings. Lie the patient down with one pillow behind her head arms by her side or with one arm behind head, and check for the temperature of both breasts with the back of your hand. Palpate the breast using the palmar surface of three middle fingers. Use a rotary motion to gently press the breast tissue against the chest wall and be looking at the patient's face for any obvious tenderness. Examine each breast systematically covering the whole cone of the breast tissue, following concentric, zigzag or radial paths. Ask patient to rest arms above head and examine the axillary tail of Spence for any lymphnodes. ‘Ask patient to gently compress the nipple attempting to express any discharge Note colour of discharge and send for cytology and microscopy Palpate axilla glands, anterior group, posterior group, medial group, lateral group, apical group and supraclavicular and infraclavicular group. Ask the patient to get dressed and thank patient Report you findings to the examiner and comment that examination would be complete by examining the spine, lung, liver and the lymphnodes. Describing your findings: Site (Quadrant), Size (mm/ cm), Shape, Consistency, Edges (smooth or irregular), Surface (indentation), Discharge, Sign of emptying on pressure, Tenderness, Redness, Stability (mobile or fixed), anatomical plane or origin of a lump (skin, subcutaneous tissue, muscle or bone) and surroundings (lymph nodes or other lumps) Award of mark: How you have examined in a professional manner and have given an accurate and complete description. This Is a difficult station and needs lot of practice.© PLAB Right Limited @ PLAB Right timitea Inspection: Pt position: sitting/ leaning forward/ hands above head/ hands over hips. Breast: symmetry/ contour. Nipple: > Equal on both sides/ level > Inverted/ retracted ( uni/ bilateral) > Redness/ discharge/ cracking > Puckering/ tethering — peau d’orange( inflamed tumour under skin) Palpation: Four quadrants: Index, middle and ring finger only for most sensitive examination. Lump: > Size/ shape/ consistency/ margin > Mobility ( attached to underlying skin/ tissue) Important: > Axillary tail of Spence > Axillary lymph nodes Benign Malignant Surface Smooth Variable Consistency Firm/ rubbery Hard Margin ‘Smooth/ regular Irregular Mobility Mobile /not fixed Fixed to skin or chest wall Skin No puckering/tethering | Puckering/ tethering Nipple No retraction Retraction Discharge May be green/ yellow Bloody discharge {unilateral/bilateral) 10@ PLAB Right iimivea™” Please examine the testicles of this 28 year old and report your findings Introduces self, explains procedure to patient and gains consent* Indicates need to wash hands in a systematic manner using the aylife technique* Ensure a chaperone is present™ Examine the patient lying down and standing * Wear non sterile gloves ensure your hands are warm Expose as little of the patient as possible Inspect the scrotal skin Left testis lies lower than the right but both should be visible Using gentle pressure examine both testicles using the thumb and first two fingers ‘Note the size and consistency of the testicles Palpate the epididymis Roll with the fingers and thumbs the vas deferens ‘Thank the patient and ask him to get dressed Tell the examiner your findings Describing your findings: Position (side, anterior, posterior) Size (mm/ cm), Shape, Consistency, Edges (smooth or irregular), Discharge, Sign of emptying on pressure, Tenderness, Redness, Stability (mobile or fixed), anatomical plane or origin of a lump (skin, subcutaneous tissue, testis and epidiymis) and surroundings (lymph nodes or other lumps) If you found a lump who would you refer to What tests might you do now Inspection: swelling/ redness/ lumps/ scars/ underneath for any infection(fungaly/ rugosity Palpation: Temperature ‘Thumb, index and middle finger Spermaticor Testis > Sive/ consistency } : j—— Fie Lump io > location/ size/ Solum consistency/ Epididymis/ spermatic cordw PLAB Right porate oe od Gas samy Please take a blood gas sample from this patient Introduces self, explains procedure to patient and gains consent* Wash hands in a systematic manner using the aylffe technique* Selects appropriate equipment. Performs Allen test Palpates radial artery Flexes wrist and places on sterile field Clean area well with steret allow to dry for 30 seconds Don gloves Prepare syringe (attach needle without contamination and expel all heparin) Locate artery (without contamination) and insert need at 45 degree angle ‘Slowly advances needle until blood spontaneously starts to fill pulsator Cover puncture site immediately with wad of gauze as needle is removed and hold Remove needle with one hand using sharps box Hold gauze tightly 10 pounds of pressure for 5 minutes (don’t ask patient to hold you must do it) Remove air from syringe then cap and push plunger on syringe to seal Label and place in ice immediately Do not move gauze until 5 minutes is up if bleeding has not stopped hold for longer Place fresh gauze on wound and tape leave for at least 20 minutes Thank patient and clean up mess 12i © PLAB Right Limited ey PLAB Right timitea ‘Suture Hand This patient has cut his hand on a sharp edge. Tetanus has been given. Wound has been anaesthetised. You are gowned and gloved Clean the wound and give two sutures Do not shake the examiners hand Do not waste time Introduces self and explains procedure to patient and gains consent Clean wound area aseptically using clean hand dirty hand technique Understand the need and how to assess nerve/tendon damage Remove dead or doubtful tissue Apply two sutures appropriately without contamination Ensure haemostasis is achieved Dispose of needle immediately into sharps box Apply dressing Dispose off other disposable equipment ‘Thanks patient Difficult Station needs lot of practice Marks are awarded for your ability to put 2 sutures (tight enough to achieve wound closure) in 5 minutes. This is a sterile procedure. You must dispose sharps in to sharps box. Use yellow bin to dispose clinical waste. 13© PLAB Right Limited ay PLAB Right timitea Venepuncture Please collect a sample of this patients (Michael Jones) blood and label it correctly Washes Hands using Aylif technique* Introduce soto patont” Explains procedure* Gains consent” Gathers correct equipment appropriately ‘Watch, rings ete removed sleeves above elbow" Identifies suitable vein Applies tourniquet ensuring not too tight Cleans skin and allows to dry for 30 seconds Attach needle to holder without contamination Insert needle at 30 degree angle Attach sample tube appropriately Remove sample tube from holder Cover puncture site with gauze Place needle into sharp box immediately Ensure patient has stopped bleeding Dispose of all equipment correctly Label sample and send to lab Thank patient PLEASE REFER TO THE COLOUR CODED BLOOD COLLECTION TUBE GUIDE AT THE MANIKIN ROOM FOR SELECTING APPROPRIATE TUBES FOR THE TEST 4© PLAB Right Limited @ PLAB Right timitea Int Please insert an intravenous cannula into this patient Introduces self, explains procedure to patient and gains consent® Indicates need to wash hands in a systematic manner (Not Demonstrated)*. Selects an appropriate sized cannula. Pink or Green. Collect equipment (steret, gauze, non sterile gloves, dressing, 10 ml syringe and 5mls saline flush) Applies tourniquet, check radial pulse is retained and palpates vein Cleans area with steret in circular motion for 30 seconds allow 30 seconds to dry Wear gloves Gently squeezes cannula out of packet and checks white cap is loose Insert cannula at 30 degree angle a short way into the vein until flash back seen by cap Insert the cannula 2mm further only Change grip on the cannula so that you are holding the wings with one hand and the needle with the other Pull back on the needle a small amount (2-3mrn) until a flash of blood flows along the plastic cannula Hold the hand with the needle in completely still and slowly push the cannula over the needle into the vein (never pull the needle out) Keep pushing until the cannula is level with the skin (do not leave a gap as infection can enter) Let go of everything now and place gauze under the cannula Remove tourniquet Remove the white cap and keep hold of it Remove the needle and place immediately into sharps box (the mannequin will bleed just let it) ‘Screw the cap onto the cannula to stop bleeding Remove gauze and clean blood from around the area Remove dressing from packet and apply over cannula Write the date and time of insertion on the dressing if label is provided Draw up 5mis of sterile saline for injection Lift the coloured cap on the cannula and flush with the saline observe to ensure cannula is patent and patient is comfortable Dispose of waste correctly remove gloves and wash hands REFER TO THE POSTER IN THE MANIKIN FOR DIFFERENT TYPES OF CANNULA. SIZE FOR ADULT: 16 15© PLAB Right iimivea”” ination of the ear a ani Please examine this patient’s ear and tympanic membrane and report your findings. Introduces self, explains procedure to patient and gains consent Washes hands using the aylife technique* Selects appropriate equipment and ensures it is in working order Inspect the pinner and adjacent tissues Position the patient with head flexed laterally away from you Hold the pinner firmly and gently pull upwards and backwards to straighten the canal using the hand not holding the otoscope Hold the otoscope in the same hand as the ear being examined ‘The speculum should be as wide as possible to fit into the ear canal Hold the otoscope like a pen horizontally with your curled fingers resting on the patients cheek Identify the normal structures of the ear. Note findings © Colour, shape © Perforation © Scars © Ossicles Light reflex Gently remove otoscope Remove speculum and place for cleaning Report you findings to the examiner Would you refer further? 16© PLAB Right Limited a PLAB Right Limit patient has been complaining of dizziness please record a lying and standing blood pressure, Introduces self, washes hands with gel and explains test, checks patient is rested Record sitting blood pressure first. Removes clothing from the upper arm. Ensures arm is supported on pillow and at the level of the heart. Selects appropriate size cuff. Places sphyg. level with the heart and no more than three feet away from the student. ‘Applies cuff so the centre of the bladder is over brachial artery on the inner aspect of the upper arm. Palpates radial or brachial artery, inflating bladder to the point where pulse is no longer palpable, then deflates bladder, remembers estimated systolic pressure. Re-inflates cuff to 20-30 mmHg above palpated systolic pressure, place stethoscope over brachial artery and slowly deflates at a rate of 2-3mmHq/second. ‘States result, confidently, correctly and interprets result. ‘Asks patient to stand whilst you support them. Record standing blood pressure in same manor but using the estimated systolic reading you obtained earlier. States result, confidently, correctly and interprets result. ‘Thank the patient and ensure their clothing is pulled back into place and they are comfortable.© PLAB Right Limited @ PLAB Right timitea hete: Please catheterise this patient assume you are wearing sterile gloves Introduces self, explains procedure to patient and gains consent.* Checks catheterisation trolley (prepared) and all appropriate equipment is present. Check cleaning solution is in the galli pot (just saline as the patient should be socially clean already) Prepares sterile field. (sterile towel with hole in it) and places it in position. Retracts foreskin with piece of sterile gauze and cleans glans penis without contamination, using clean hand dirty hand technique with at least three pieces of cotton wool Indicates need to change gloves Checks content of lignocaine gel (lubricating gel) and expiry date. ‘Administers gel and indicates need to gently pinch end of glans penis, to prevent gel escaping from the urethra, for three to five minutes. Empty sterile receiver and place below penis to stand the end of the catheter in Inserts urethral catheter by only touching the outside plastic bag Continue inserting until urine drains (in male mannequin abut 20cm) ‘Once urine drains insert the catheter another 3cm to ensure the balloon bladder. Checks content of sterile water ampoule and expiry date. Draw into syringe exactly up to the 10m! mark Inflates balloon with recommended amount of sterile water, observing the patient for verbal and non verbal signs of pain. Attaches catheter bag without contamination. Place the foreskin back over the glans penis Remove sterile field and clean up all equipment. Thank patient and ensure they are comfortable. 18Ww PLAB Right ppp Eye Examination Please complete an eye examination on this patient and report your findings. Introduces self, explains procedure to patient and gains consent Wash hands using aylife technique* Selects appropriate equipment. ‘Ask patient to fix their vision on a distant object the lights. Hold the opthalmoscope close to your eye with your index finger on the lens dial ‘Approach the patient from a shallow angle of 15-20 degrees ‘Approach on the same level as the equator of the patients eye Note and comment on red reflex Note and comment on anterior structures of the eye Focus on retina Identify optic disc Follow blood vessles into four quadrents Seek to identify macula and fovea ‘Thanks the patient Report your findings to the examiner 19© PLAB Right Limited @ PLAB Right timitea Wound Dressing Washes Hands using Ayiffetechnique* Introduco soto pationt* Explains procedure” Gains consent® Wear Apron Check all equipment is presenGathers equipment Wash hands again using Ayliffe technique Watch, rings etc removed sleeves above elbow Opens sterile equipment without contamination Applies sterile gloves without contamination Removes old dressing using yellow bag Cleans wound with clean hand dirty hand technique Asepsis maintained throughout procedure Apply new dressing with clean hand Dispose of all equipment correctly Thank patient 20© PLAB Right iimiced Ayliffe Handwashing Technique To correctly and effectively wash your hand completes each step with 5 repetitions, Use 5mis soap or 3mis of alcohol gel. Always use soap if hands are visibly soiled or after 5 uses of alcohol gel. Bp LFA Palm to Palm Right palm over Palm to palm, Back of left, fingers fingers interlaced Interlaced, and then Vice versa. Back of fingers Rotational rubbing Rotational rubbing Opposing palms of thumbs enclosed backwards and forwards fingers by palm. Of fingertips in palm of Interlaced opposite hand. Rotational rubbing of Wrists with opposite Palm. 21Wipe back of each hand thoroughly with Towel, working down From the wrist to Fingertips. Rub palm to palm © PLAB Right Limited oO) PLAB Right Limited Twist the towel once around each finger and thumb making sure the Whole finger from Base to tip is dry. Place towel in yellow clinical waste bin,© PLAB Right Limited ay PLAB | Right Limited Victim bystanders and you Check for a response Gently shake the shoulder and ask LOUDLY” Are you alright Shout for Local Help: “Help, Help” Check for cervical s| injury: Feel back of the neck for any injuries. look in the mouth Open the airway, and then Look Listen & Feel for breathing for no more than 10 sec. Feel for carotid pulse for no more than 10 sec You can do this simultaneously Call for help by calling 4444/ Crash team. Get a defibrillator (Look around and say I will look for a defib) 30 Chest Compressions Rate 100 -120/min 2 Rescue breaths 30 compressions Apply the electrodes of the defibrillator as soon as they are available 23© PLAB Right Limited ey PLAB Right imines Victim bystanders and you Check for a response Gently stimulate and ask LOUDLY “Are you alright” Don’t Shake the child, you may tap on the floor Shout for Local Help: “Help help” Check for cervical spine injury: Feel back of the neck for any injuries. Look Listen & Feel for breathing for no more than 10 sec. 5 initial rescue breaths | look in the mouth Open the airway, and then | Check for circulation Feel for carotid pulse for no more than 10 sec away from the ribs. Rate 100-120/min | 2 Rescue breaths : 15 compressions After 1 min call for help* Continue with CPR, That is breathing and cardiac compressions. | 15 Chest Compressions with one hand, keep fingers | 24@ PLAB Right iimivca” EXAMINATIO! VES I-VIE “Good morning Mr/Mrs Briggs. My name is Dr. XXXX, one of the Junior doctors in the unit, I have been asked to examine the nerves of your face. Will that be all right? I will try and be gentle, please feel free to stop me if you feel any discomfort” OLFACTORY NERVE CN I Ask the patient “Has your sense of smell changed recently 2. " You can also mention taste as well - sensory component of Cranial Nerve VII Facial Nerve . OPTIC NERVE CN II Visual Acuity Formally tested with snellen’s chart. Test each eye separately Ask the patient to read some print or to count fingers. Colour Vision Formally tested with Ishihara’s chart As a rough guide ask the patient whether they have any problems with the colours of the traffic light, Alternatively point to some coloured objects in the room or the hat pins can be used. Visual Inattention 1. Ask the patient to look directly at your eyes and keep them fixed there. 2. Place your index fingers just at periphery of the temporal field of vision. Move your index fingers first in turn and then at the same time. Ask the patient to point to the finger that moves. In the presence of inattention, the patient will only point to one finger when both the fingers are moved. This denotes a parietal lobe lesion. Visual Fields - confrontation test st ensure you have the correct position, this is sat directly opposite the patient facing them. 2, For the peripheral field, ask patient to cover right eye with their right hand and close your left eye. 3, Start with the temporal field. With the hand stretched out at the far left , start to move your wagging finger (or the white hat pin) from the periphery to centre form both the upper and lower temporal quadrants. Let the patient know that he should inform you when he first sees the movement of the finger. 4, Asking the patient “Do you see it moving all the way” will pick up gross defects in the field of vision 5. Change your hands to repeat on the nasal side. 6. Repeat for the left eye in the same way. 7. Go slowly - don’t rush as you may miss a visual field defect. 8. You might wish to test for the central visual field as well (detailed below) The following tests can also be done at this step ~ they will test cranial nerve Il and III Direct and Consensual Light reflex 1, Stand at the side of the patient. 2. Ask the patient to fix their gaze straight ahead at point in the room. 3. Shine the torch into the eye - look at the eye the light is shone: watch for constriction of the pupil confirming that direct reflex is present. The second time look into the other eye in which light Is not shone to see if the pupil constricts confirming the consensual reflex. 4. Repeat the above for the other eye. 25@ PLAB Right timicea”” 5. Check for afferent papillary defect by swinging the light from one eye to other. (optional) Accommodation 1. Ask the patient to fix their gaze straight ahead at a distant point 2. Then bring your index finger close to the tip of the nose and ask them to focus on it. 3. Look at the eyes they should converge and the pupils constrict. Finish the above two steps if all findings are normal by saying “pupils are bilaterally symmetrical and reactive to light and accommodation. (PERLA) Fundoscopy Mention the need for Fundoscopy as well. Occulomotor C N III Trochlear_¢ Abducent Crai Nerve VI ‘These nerves are tested together because all three are responsible for ocular movements and also testing these now together saves valuable time. Cranial Nerve 7 Muscle Supplied ] ‘OCCULOMOTOR CN IIT ALL OTHER OCULAR MUSCLES —_ TROCHLEAR CNIV SUPERIOR OBLIQUE ‘ABDUCENT CN VI LATERAL RECTUS 1. Sit opposite the patient - Look out for ptosis/alignment of the eyes 2. Ask the patient to follow your index finger with their eyes. They should let you know if they see double. 3, Move your fingers in a °H" pattern covering all of the horizontal and vertical axes. This tests the pursuit movernents of the eyes. 4, Now check for the saccadic movements by asking the patient to look from side to side rapidly (“Look at my palm and now my fist”. This brings out internuclear ophtalmoplegia which might indicate demyelination. 5. Comment on your findings - “ extraocular movements are free and full with no nystagmus or diplopia.” ‘Trigeminal Nerve CN V Remember it has two parts a sensory and motor part - always examine both components. Sensory Ask the patient to close their eyes and touch on both sides of the forehead ( ophthalmic division) then their cheeks (maxillary division) and the jaw (mandibular division) with the wisp of cotton confirming whether it feels the same on both sides and can they appreciate it at all . ALWAYS COMPARE SIDES Mention that you would also like to test for the corneal reflex ( where a wisp of cotton is taken and the junction of the sclera and cornea is touched eliciting a blinking action Jas well. 1. Ask them to clench their teeth and feel both masseters and temporalis. “Clench your teeth” 2. Ask them to open their mouth against resistance to check the pterygoid muscles.”Open your mouth ~ don’t let me close them” Jaw jerk 26© PLAB Right Limited N VIE This also has two components a sensory and a motor. Sensory ‘You can simply ask whether they have had any change in their sensation of taste at all. 1. Observe for any obvious weakness for instance flattening of nasolabial folds or Involuntary movements e.g hemifacial spasm. 2. “Can I ask you to close your eyes tight ~ now let me open them” 3. “Show me your teeth” or “give me a smile” 4, Ask them to puff out their cheeks 5. “Raise your eyebrows” or “wrinkle your forehead” OUI-XIT \Vestibulocochlear Cranial Nerve VII This nerve has two components a vestibular and cochlear Cochlear component 1, Inspect BOTH ears looking for ‘* Discharge * Bleeding * Vesicles * Hearing aid 2. Hearing can be tested by rubbing your fingers held close to the ear 3. TUNING FORK TESTS Rinnes 1. You are comparing two components of hearing - air conduction and the bone conduction . ‘Take a tuning fork either of 512hz or 256hz frequency make sure you check!. Test for air conduction - Hold the vibrating tuning fork with the parallel to the external auditory meatus of the ear 4, Then test for bone conduction by placing the base of the tuning fork on the mastoid process. Normally Rinne is positive * If Air Conduction>Bone Conduction then hearing is normal or sensory neural hearing loss * If Bone Conduction>Air Conduction then this is conductive hearing loss 1, Now test for Weber's test ~ place the base of the tuning fork on the vertex of the skull of the patient. Ask the patient where they hear it best. Interpretation © Lateralizes to the good ear in Sensory Neural Loss * Lateralises to the affected ear in Conductive Loss © Midline this is normal or Bilateral Hearing loss 6. Then mention that you would also like to do an otoscopy. Vestibular component : [Link] for nystagmus 2. Rombergs test : Ask them to stand with their feet together hands by sides and close their eyes. Be standing right next to them ready to catch them if they fall. Positive romberg’s test Is if the patient is more unsteady and tends to fall with the eyes close. This indicates sensory ataxia and NOT cerebellar ataxia, 27Oy PLAB Right = 3. Check for gait. Make sure you walk with them so that you may be able to hold them if they fall 4, Other tests: caloric test. RYNGE: x VAG! 1, “open your mouth open please - now say “AAH" : look to see whether the uvula Is central and the palatine arches rise symmetrically. 2. Assess quality of speech “No nasal intonation” 3. Say you would also like to check the gag reflex. ACCSESSORY NERVE CN XE 1. “Shrug your shoulders please * - “Now don't let me push them down” 2. Then ask them to turn their face to the left against resistance and palpate the sternocleidomastoid of the right side and then repeat vice versa. “Please turn your head to the right and now to the left” HYP. \L NERVE. 1. Ask the patient to open their mouth: look for any fasciculation or wasting of the tongue. 2. Ask the patient to stick their tongue out - it will deviate to the side of the lesion. 3. N 4. Then ask them to push their tongue against the inside of their cheeks against resistance. \TIO! ELDS Start with VISUAL ACUITY ALWAYS! Tell the examiner you are doing so to rule out any monocular blindness. 2. Check for visual inattention 3. Ensure that the patient has got intact colour vision (if you are using the white and red hat pin) 4. Check for peripheral visual fields as above - the peripheral visual fields can also be tested with the white hat pin 5. The central visual fields are tested with a red headed pin. ‘Compare patient's right eye with your left as above. Move the red headed pin slowly at eye level from the temporal field to the centre and then to the nasal fleld Let the patient to inform you if the colour of the head of the pin changes or the head disappears. If there is central scotoma there will be loss of central field of vision. The blind spot can also be compared along the same lines (enlarged in papilloedema) 6. If you have time doing the light reflexes might yield useful findings like the RAPD in optic neuritis TUNNEL VISION BITEMPORAL HEMIANOPIA Glaucoma’ Pituitary Tumor Retinitis Pigmentosa Meningioma Choridoretinitis, Craniopharyngioma Papiloedema 28a PLAB Right ihe. Limited EXAMINATION OF EAR OF A PATIENT WITH DIZZINESS VESTIBULOCOCHLEAR NERVE CN VIIL This is essentially the same exam as before but with added components - to try and localize the lesion 1. Test the Cochlear Component. 2, Test the Vestibular Component. 3. Perform one or two cerebellar signs 4, Otoscopy. 5, Mention that you would like to check Cranial Nerves V,VI,VII, IX and X to rule out the possibility of an Acoustic Neuroma, EVALUATII -ZINESS/VERTIGO > First start off by asking "Do you feel dizzy all the time or only when you stand up" ; as postural hypotension is a common cause of “dizziness”. A standing and lying BP would exclude this Pallor - anaemia can make patients dizzy Pulse ~ Heart blocks can be symptomatic vv > Assessment of cranial Nerve VITI as above > Otoscopy > Cerebellar examination ~ do one or two test for assessment of cerebellum > Romberg's test > Assessment of gait > Mention that you would like to finish by ‘* Auscultation of the heart and carotid artery. Examination of cervical spine Detailed neurological assessment Hallpike’s test ( test for Benign Paroxysmal positional vertigo) Causes of Vertigo 1, Peripheral causes - related to ear Meniere's disease (vertigo + Sensorineural hearing loss + tinnitus) Benign positional vertigo. Acute Labyrinthitis Wax, infection. Motion sickness Ramsay hunt syndrome Drugs eg aminoglycosides 2. Central causes Migraine Stroke Multiple sclerosis 3. Cerebellar problems including cerebello ~ pontine angle tumour 4, Cervical spondylosis In a history taking station of vertigo questions should be tailored to cover these areas. 29© PLAB Right Limited @ PLAB Right timitea EVALUATION OF. ITH DIPLOPIA > First confirm that the patient indeed has double vision > Secondly confirm whether it is monocular or binocular diplopia. Monocular dipolpia usually indicates an ocular abnormality like refractive error or retinal pathology > Thirdly localize which eye is responsible for diplopia and which muscle is responsible. 1, Inspect the eyes looking for : Ptosis, proptosis, alignment of eyes, head tilt, stigmata of head injury, aural discharge, neck swelling etc 2. Test the ocular movements in an H shape fully in the vertical and horizontal axes. 3. Are the images separated horizontally (side by side) or vertically? Horizontal separation is likely to indicate sixth nerve palsy or a medial rectus palsy (rare in isolation). 4. In which direction is the diplopia worse? ~ The direction of gaze in which the images are separated widely is the direction of action of the paretic muscle. 5. Once you know in which direction double is seen then ask them what they see. 6. The outer image is the false image - patient often says image is hazy or indistinct (seen by the eye with muscle weakness). The inner image is the true image seen by the normal eye. By covering the paretic eye the false image disappears. 7. Ask can you read the newspaper ok? Or do you have any problems getting down the stairs? Would indicate Superior Oblique Palsy. 8. Ask patient to count 1-20 in a single breath, if they tire suggests Myasthenia Gravis . 9. Check the direct and consensual reflex. 10. Assess cerebellar system - ?Multiple sclerosis 11. Finish by saying “I would like to do a Fundoscopy and complete neurological exam.” NEUROLOGICAL EXAMINATION OF UPPER LIMB Greeting /Introduction. Establishes identity of the patient. Empathy/ Ensures comfort of patient, Explains purpose of the visit/nature of the examination. Takes consent for examination Appropriate exposure. Chaperone. INSPECTION Wasting Fasiculation Abnormal movements/tremor Abnormal posturing/deformities Check for pronator drift by asking patient to hold the arms out with palms facing up and close their eyes. Look for any drift of the arm suggestive of weakness. Also look for any winging of scapulae. eNOuaoNE paoge 9. TONE: First ask the patient if they are sore in the arms or hands. Request them to let the arms go floppy. Passively bend the arm at the elbow and in the hands including the wrist in a rotatory manner. 10. POWER. a. Shoulder abduction ; “Hold your arms out to the side ~ stop me pushing them down" : Supraspinatus and deltoid b. Shoulder adduction: “Now push me down” major c. Elbow flexion: “Bend your elbow ~ dor’t let me straighten it” : Biceps,brachioradial nultiple muscles including pectoralis, 30© PLAB Right Limited Oy PLAB Right timitea Elbow extension: “Now straighten it ” (resist extension) : Triceps Wrist extension : “Cock your wrist up ~ don’t let me bend it down" Wrist flexion : "Bend your wrist down ~ now don't let me straighten it” Finger flexion : “Squeeze my fingers” Finger extension: “Hold your fingers out - don’t let me bend them” ~ radial Finger abduction : “spread your fingers apart ~ don’t let me push them together” (Dorsal interossei) - ulnar Finger adduction : “Hold this paper between your fingers ~ now don’t let me pull it away”.(Paimar interossel) - ulnar k. “Hold your thumb and little finger together ~ don’t let me pull them apart” (Opponens pollicis) ~ Median nerve rseroa 11. Pulses. Quickly assess the vascular status by taking the pulses and checking capillary refill. 12. Reflexes : Biceps, Triceps, supinator jerks. 13. Hoffmans' Sign - place your right index finger under the distal interphlangeal joint of the patient's middle finger. Use your right thumb to flick the patients finger downwards. Look for any reflex flexion of the patients fingers. 14, SENSATION- Pinprick © Use neurotip. Let patient know the sharp and blunt end by using the sternum as a baseline. © Ask him to close his eyes and to report whether it Is sharp or blunt. © Assess the sensation over the various dermatomes of the upper limb. © With distal sensory impairment establish a sensory level © DON'T FORGET TO BIN TT IN THE SHARPS BINIHNHNNTNHNI111111 PROPIOCEPTION Hold the middle finger of the hand and stabilise the joint distally by holding it by the sides ° With the patient's eyes open demonstrate that you will be moving the joint “UP” (towards their head) and “DOWN” (in the reverse direction) * Then ask them to close their eyes » Gently move the distal joint up and down and ask the patient to report the direction of movement VIBRATION Use a 128hz tuning fork not Allow the patient to appreciate the vibration sense first over the sternum. Then hold the vibrating tuning fork over the distal Interphalyngeal joint 15. Co-ordination ~ elicit one of the cerebellar signs.(finger nose test) 16. FUNCTION- Ask patient to pick up a pen and write with it or undo and redo one of their shirt buttons. 17. Thank the patient. 31© PLAB Right Limited @ PLAB Right timitea LEX, 1, Greeting/Introduction. 2. Establishes identity of the patient/rapport. 3. Empathy/checks the comfort of the patient. 4, Explains purpose of visit/nature of exam. 5. Takes consent for examination. 6. Asks for chaperone. 7. Appropriate exposure. 8. INSPECTION a. Wasting b. Fasiculation c. Abnormal movements/tremor d. Abnormal posturing/deformities 9, TONE: First ask the patient if they are sore in the legs. Ask them to relax. Then either log roll the legs at the hips, then lift the knee and let it drop gently. 10. POWER Hip flexion ; “Lift your leg towards the ceiling ~ don’t let me push it down” Hip extension : “Now push me down” (with your hands behind the thigh) Knee flexion : “Bend your knee ~ now don't let me straighten it” Knee extension : “Now push against my hand” (with your hand on the shin) Ankle dorsiflexion : “Cock up your foot ~ don’t let me pull it down” Ankle plantar flexions : "Now push me down” (with your hand on the sole) If time allows you can check for ankle inversion/eversion. A Grade 5. No weakness. B Grade 4 Movement against gravity and resistance . C Grade 3 Movement against gravity but not against resistance. D Grade 2 Movement with gravity eliminated, E Grade 1 Flicker of contraction F Grade 0 No movement. 11. Pulses 12, Reflexes ~ Knee, Ankle, and Plantar reflex. 13. Sensations : Pinprick Use neurotip. Let patient know the sharp and blunt end by using the sternum as a baseline. ‘Ask him to close his eyes and to report whether it is sharp or blunt. Assess the sensation over the various dermatomes of the lower limb. With distal sensory impairment establish a sensory level e.g in diabetic foot. DON’T FORGET TO BIN IT IN THE SHARPS BINIHIHI01111IIH 32© PLAB Right Limited, @) PLAB Right timited 14, 15. PROPIOCEPTION © Hold the big toe of the patient and stabilise the joint distally by holding it by the sides © With the patient's eyes open demonstrate that you will be moving the toe “UP” (towards their head) and "DOWN" (in the reverse direction) © Then ask them to close their eyes © Gently move the distal joint up and down and ask the patient to report the direction of movement VIBRATION Use a 128hz tuning fork not Allow the patient to appreciate the vibration sense first over the sternum. Then hold the vibrating tuning fork over the distal interphalyngeal joint. If patient does not report appreciation, then test at medial malleoli, then knee then iliac crest if it is impaired distally. Co-ordination- ask patient to lift their leg high in the air and then touch the knee of the other leg with the heel of the raised leg by bringing it down and then they should slide leg down against the shin of the other leg. Function- ask patient if they are ok to stand and if so then ask them to take a few steps to assess the gait. Then watch him walk heel to toe. Make sure you walk with the patient to support him in case he is unsteady. Finally perform romberg’s test. Make sure you are with the patient during assessment. 33@ RLAB Right Limited @ PLAB Right timitea EXAMINATION OF DIABETIC FOOT Mr Anderson has been complaining of pins and needles in his right leg. He is a diabe' and is on insulin. Examine his foot. Greeting/Introduction Establishes identity of the patient Empathy/Checks comfort of patient Explains purpose of visit/nature of examination Asks patient to undress Asks for a chaperone Takes consent for examination Inspection: ‘a. Claw toes/ Pes Cavus b. Callus formation ¢, Ulcers/Gangrene d. Looks for ulcers between toes fe. Skin , nails and hi Feels for temperature Peripheral Pulses Sensations (find out level of sensory impairment) ‘a. Fine touch b. Pin prick c. Vibration d. Joint position Assessment of Gait Assessment of Motor functions Assessment of reflexes Checks suitability of footwear Overall approach to the task Thanks the patient Annual review of a Diabetic Patient ‘Symptoms ~ Angina, Claudication, hypoglycaemia and side effects of drugs 1. Body mass index. 2. Urine - glucose , protein ~ albumin/creatitine ratio 3. Blood Tests : HbAic; Urea and electrolytes , Cholesterol; LFT's particularly if on Metformin, TFT at 3 yearly intervals 4, BP. 5. Eyes : visual acuity and retinal assessment 6. Habits - ? Smoking ? alcohol intake ; exercise ; check for compliance including diet 7. Review diabetic diary - check for home monitoring results and hypoglycaemic episodes 8. Assessment of feet 9, Compliance - correct tablet/insulin regime (Injection sites) 10. Address any other concerns and educate 11, Discuss future targets 34a PLAB Right ine Glasgow coma scale Best Motor Response 6 Carrying out request (‘obeying command’) -patient does simple things you ask. 5 Localising response to pain. (apply over naill bed) 4 Withdrawal to pain - pulls limb away from painful stimulus. 3 Flexor response to pain - pressure on nail bed causes abnormal flexion of limbs ~ decorticate posture. 2. Extensor posturing to pain - stimulus causes limb exten: 1. No response to pain. Best Verbal Response 5 Oriented 4 Confused conversation 3 Inappropriate speech 2 Incomprehensible speech - no words uttered, only moaning. 1 No verbal response. Eye Opening 4 Spontaneous eye opening. 3 Eye opening in response to speech 2 Eye opening in response to pain. 1 No eye opening. n ~ decerebrate posture. EXAMINATION OF PATIENT WITH MENINGITIS 1. Greeting/Introduction 2, Establishes identity of the patient/rapport, 3. Empathy/checks the comfort of the patient. Offer painkillers if in pain. Is he photophobic ? Would he prefer the light to be dimmed? 4. Explains purpose of visit/nature of exam. 5, Takes consent for examination. 6. Appropriate exposure and ABC and GCS 7. Temperature 8. Check for rash. 9. Check for neck stiffness : Ask patient if it is ok to move their neck and ask them to bend their neck touching their chest with their chin 10. Kernig’s sign: Patient supine - flex the thigh so that it is at a right angle to the trunk ~ now completely extend the leg at the knee joinit. If the leg cannot be completely extended due to pain, this is Kernig’s sign. 11. Check the ear and nose for any discharge; signs of head injury 12, Ask the patient If they are sore anywhere In the face before palpating for tenderness, i.e. sinusitis, mastoiditis. 13. Examine the eyes - diplopia, Light reflexes- ask if they can manage if they refuse don’t force them. 14. Check oral hygiene to rule out any dental infection. 15. Check cranial nerves and brief neurology including plantar 16, Check Bicep, Knee and Plantar reflexes e. Systemic examination eg chest, abdomen to rule out possible infection elsewhere 35@ PLAB Right timicea 17. Thank and cover the patient. EXAMINATION OF PATIENT WITH HEADACHE Airway Breathing - respiratory rate and pattern Circulation - Blood pressure and pulse Gcs General appearance ~ ?photophobic ‘Temperature Any stigmata of head injury Eyes and periorbital areas - visual acuity , red eye (Glaucoma) i. lacrimation, flushing, red eye Cluster headache) il, pupils including light response iii. Assessment of visual fields (?space occupying lesion) iv. _ Extraocular movements ( ?opthalmoplegia) Ear, Nose and Throat assessment - also check for dental hygiene Check for sinus tenderness Check for Mastoid tenderness Check for tenderness of temporal artery Check for tenderness over cervical spine Palpate temporomandibular joint for tenderness and crepitus when patient opens and closes the Jaw. Check for Neck stiffness and kernig’s sign Do brief neurology including remaining cranial nerves and upper and lower limbs as time allows. 36© PLAB Right Limited @ PLAB Right iimea PRIMARY SURVEY Prerequisites: Trauma team, gowned and gloved. AIRWAY Protect cervical spine - maintain inline stabilisation. (Once trachea assessed, then triple immobilisation of the cervical spine (c-spine) can be done. This implies 1. Application of cervical collar 2. Head restraints eg. Blocks, sand bags 3. strapping to the spinal board Assess patency : Patient's ability to speak Look : central cyanosis, Foreign bodies Any obstruction Listen: any added sounds Deal any problems with the airway before moving on : suction simple airway manoeuvres for instance jaw thrust (Not head tilt, chin lift) airway adjuncts e.g Guedel airway( if unconscious) DO NOT DO BLIND FINGER SWEEP, Give High flow oxygen via a non-rebreathe mask at 15 Litres per minute Get patient connected to monitors (BP monitor, ECG monitor, pulse oximeter) BREATHING Asses: Rate and rhythm Tracheal position Symmetry of respiration; Use of accessory muscles Colour of patient Oxygen saturation chest expansion Percussion and auscultation. Auscultate Manage —_ according to the findings for instance in tension pneumothorax one would need to insert a wide bore needle in the 2” intercostal space in the mid calvicular line on the affected side, CIRCULATION Asses! Pulse : rate, rhythm, volume and character Blood pressure Capillary refill Look for any evidence of haemorrhage - Examine abdomen for evidence of internal bleed : inform surgeons - Pelvis ~ brusing of scrotum, bleeding from external urinary meatus. - Lower limbs for any deformity/injury Ensure that you feel for distal pulses. Manage: — Cannulate : ideally two large bore intravenous cannulae Investigate : FBC/U & E/Glucose/Group and save/Toxicology Fluid bolus : titrate to response as per trust guidelines, 37©: PLAB Right Limited @ PLAB Right timitea Pelvic binder/Thomas splint/splint depending upon the site of injury DISABILITY Assess level of consciousness with AVPU Alert Does the patient response to Voice Does the patient respond to Pain Unresponsive Pupil size and reaction Peripheral nervous system. EXPOSURE Perform head to toe examination Always maintain dignity and ensure that patient is kept warm Investigations eg X ray cervical spine, chest and pelvis. Mrs Harrison is in your clinic, Examine the cerebellar functions. CEREBELLAR EXAMINATION Greeting/Introduction Establishes identity of the patient Empathy/checks comfort of patient Explains purpose of visit/nature of examination Takes consent for examination Finger nose test Test for dysdiadochokinesia Nystagmus Assessment of Speech Heel shin test Assessment of Gait Trucal ataxia/Romberg’s sign Assessment of tone Assessment of reflexes Does relevant examination for both sides Does in a professional manner ‘Thanks the patient 38@ PLAB Right © PLAB Right Limited Limited Mr Smith is 46 yr old and was brought by paramedics to A & E. Paramedic’s report that the family members alerted because Mr Smith was not responding. EXAMINATION OF COMATOSE PATIENT 1, Checks identity of patient 2. Establishes a patent airway 3, stabilise cervical spine 4. Assess for breathing 5, Administers Oxygen 6. Establishes circulation 7. GCS 8. iv access/ECG monitoring 9. Beside Blood Glucose measurement 10. Sends blood for investigations 11. Checks for pulse, B.P, capillary refill 12. Checks for temperature 13, Skin for rashes, iv marks 14, Pupils ~ size, symmetry, reaction 415. Checks for bracelets 16. Assess for signs of Head injury 17. ENT examination 18, Smells breath 19. Checks Neck stiffness/kernig’s sign 20. Neck for swellings/tracheal position 21. Examines chest 22. Auscultation of the heart 23. Abdomen for Liver/spleen 24. Limbs for any obvious injury [Link], power and reflexes 26. mentions need for corneal/gag reflex 27. Mentions need for opthalmoscopy 28. Takes a brief history of circumstances. 29. Performs in a professional manner. 39© PLAB Right Limited @ PLAB Right timitea \n of Her . Greeting/Introduction. . Establishes identity of the patient/rapport. . Empathy/checks the comfort of the patient. . Explains purpose of visit/nature of exam. . Takes consent for examination. . Appropriate exposure. . Airway, breathing and circulation (blood sugar as well) . Take pulse (arrhythmia) and you'd also like to know the BP (?Hypertension) 9. Glasgow Coma Scale. (This would include speech as well) 10. Assess cranial nerves in particular visual fields, cranial nerves III, IV, VI and VIL 11, Test tone and power of all four limbs. 12. Check the biceps, knee and plantar reflexes. 13, Percuss bladder : if full indicates need for catheterisation. 14. Auscultate the heart and carotid arteries. 15. State you'd like to perform a full neurological assessment. 16. State you'd like to perform a fundoscopy. [Link] would like to review drug history and CVS risk factors. 18, State you'd like to have an urgent CT scan. 19. Thank and cover the patient. eNouasenpe ‘TELEPHONE CONVERSATIONS SBAR A detailed description of the steps S Situatior wolved: . Identify yourself the site/unit you are calling from . Identify the patient by name and the reason for your report . Describe your concern Firstly, describe the specific situation about which you are calling, including the patient's name, consultant, patient location, and vital signs. An example of a script would be: "This is Lou, a junior doctor on Disney Ward. The reason I'm calling is that Jack Dee, in room 6, has become suddenly short of breath, his oxygen saturation has dropped to 88 per cent on room air, his respiratory rate is 44 per minute, his heart rate is 180 and his blood pressure Is 120/50. We have placed him on 6 litres of oxygen and his saturation is 93 per cent, his work of breathing is increased, he is anxious, his breath sounds are clear throughout and his respiratory rate remains greater than 40." B Background: . Give the patient's reason for admission . Explain significant medical history . You then inform the consultant of the patient's background: admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results. For this, you need to have collected information from the patient's chart, flow sheets and progress notes. For example: “Jack was admitted ten days ago, with right side chest infection. He developed complication in form of a right empyema for which a chest tube was put in place at Sheffield. The tube was removed two days ago and his CXR has shown significant improvement. He has been mobilising and progressing well. He is on IV antibiotics, 40@ PLAB Right iimitea”” A Assessment: ° Vital signs . Contraction pattern ° Clinical impressions, concerns You need to think critically when informing the doctor of your assessment of the situation. This means that you have considered what might be the underlying reason for your patient's condition. Not only have you reviewed your findings from your assessment, you have also consolidated these with other objective indicators, such as laboratory results. If you do not have an assessment, you may say: "I think he may have had a pneumothorax." “I'm not sure what the problem is, but I am worried." R Recommendation: . Explain what you need - be specific about request and time frame . Make suggestions ° Clarify expectations Finally, what is your recommendation? That is, what would you like to happen by the end of the conversation with the physician? Any order that is given on the phone needs to be repeated back to ensure accuracy. "Would you like me get a stat CXR? and ABGs? Start an IV?" "Should I begin organising a chest drain?" “When are you going to be able to get here?"@ PLAB Right timitea Proforma for History taking Patient Details : Name DOB Address Marital Status Occupation PRESENTING COMPLAINT: Record the complaint’s in the own words of the patient. HISTORY OF PRESENT ILLNESS e.g. pain 1. When did it start? 2. How did it start? 3. What was the first thing that was noticed? 4, Progression 5. Site 6. Onset 7. Character 8. Radiation 9. Associations 10. Timing of pain/duration 11, Exacerbating and Relieving factors 12. Severity REVIEW OF SYSTEMS PAST MEDICAL HISTORY 1. Hospital admissions : No of episodes/ interventions/outcome Document in chronological order 2. Any illness: 3. Operations 4, Accidents Enquire about common medical illness like Diabetes Mellitus, Hypertension, Asthma, Heart disease, Stroke/mini stroke, Epilepsy DRUG HISTORY 1, Tablets/injections 2, Off the shelf medications 3. Alternative medications 4, Pills/Hormones 5. Allergies : Nature of allergy? FAMILY HISTORY: Details of ill health in the famity ‘Age at which illness started Deaths 42© PLAB Right Limited @ PLAB Right timitea PERSONAL HISTORY/OCCUPATIONAL HISTORY 1. Smoking : how many? Smoked?snutfed? How long Tried to stop? Pack year : 20 cigarettes/day for 1 year = 1 pack year 2. Alcohol: 1 unit = 9 gm of ethanol glass wine » pint of beer. 5 ml measure of s| 3. Recreational Drug use ? iv drug use ? share needles 4. Foreign travel 5. Occupational exposure to harmful materials SOCIAL HISTORY ~- Important particularly in elderly or disabled patients ‘Accomodation: Lives alone/Warden controlled/Nursing Home House type : number of flight of stairs? Any modifications? Housing : Location of bedroom? Where is the toilet? Family dynamics : Who is at home? Any dependants? Activities of daily living (cooking/washing/shopping/ dressing) Services : Home help/ District Nurse/ Meals on wheels/Social worker Leisure activites Any pets exer syne IMPACT 1, How has the symptoms affected the patient? 2. What can the patient not do because of the illness? 3. How has the symptoms affected work/relationships? UNDERSTANDING/BELIEFS/CONCERNS What beliefs does the patient have about their illness 43© PLAB Right Limited oO) PLAB Right Limited Practice Mock test 1 Following stations should be practiced in groups of 3. One person takes on the role of a patient, other becomes Examiner and 3" person will do the task. Examiner can use the following guide to assess the performance. Examiner should also manage the time Actor should read the “instruction to the actor” and simulate the clinical scenario given© PLAB Right iimived™” HISTORY TAKING: WEIGHT LOSS 53 Yr old Mr Rutherford Is concerned that he has been loosing weight for last 6 months. Take a history and discuss the management with the patient. Examiners Mark Sheet Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion Degree of weight loss Duration of weight loss Appetite Gastrointestinal symptoms Psychological factors a, Preoccupation with body weight/food b. Stress at home/work c. Self induced vomiting/Excessive exercise Associated symptoms Amenorthoea Skin rash/Red eyes Tremor/palpitations Heat intolerance Polyuria/Polydipsia Fever, night sweats, lethargy Cough, shortness of breath, leg swelling . Low mood, suicidal ideas Dietary history : Normal diet and eating pattern Elicits beliefs and concerns Past Medical History Drug History : Laxative abuse/Diuretic abuse Personal history : Smoking/alcohol/recreational drugs/sexual partners Occupational History : job and stresses at work Family History Ensured understanding of patients problems/concerns Made a reasoned assessment of patient's problem Summarised and clarified further actions ‘Thanks the patient yesesoge Instructions to the actor: You are 35 yr old and you have been loosing weight for 6 months. You were weight was 13 stones and now it is 11 stones. You have lost appetite and have been eating less. You do not have any other symptoms.@ PLAB Right timitea DIFFERENTIAL DIAGNOSIS Below is the DD for weight loss along with some cardinal symptoms HYPERTHYROIDISM ‘Tremors and palpitations Heat intolerance Weight loss despite increased appetite Diarrhoea CARDIAC FAILURE Dyspnoea Orthopnea Paroxysmal Nocturnal Dyspnoea Peripheral oedema Cough TUBERCLOSIS Ni Weight loss Cough Night sweats Lethargy Haemoptysis Lymph node enlargement MALIGNANCY LYMPHOMA ‘Weight loss Cough Lethargy Haemoptysit Long history of smoking Dyspnoea Night sweats Lymph node enlargement Fever ‘Weight loss Fatigue DIABETES MELLITUS Polydypsia Polyuria ‘Weight loss Tiredness Polyphagia Visual changes ANOREXIA NERVOSA Extreme weight loss Amenorrhea Constipation Fatigue Severely decreased appetite Excessive exercise 46© PLAB Right Limited @® PLAB Right timiea Low mood Decreased appetite Insomnia Guilt Suicidal thoughts Weight loss Weight loss ‘Asymptomatic Fever Myalgia Pharyngitis 47© PLAB Right Limited @ PLAB Right timitea 43 Yr old Mr Lang has coughed up blood twice in last 2 days. Take a history and discuss the management with the patient Examiners Mark Sheet HAEMOPTYSIS: HISTORY TAKING Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion Onset and Duration ‘Amount/Frequency Nature (fresh/mixed with sputum) Progression Aggravating/Relieving factors Associated symptoms Chest pain/Shortness of breath Fever, Night sweats Cough Weight loss/Appetite Bleeding gums/Easy bruising Joint pain/rash Lumps in neck Hoarseness of voice |. Pain/swelling of calf Travel History Recent Surgery/Immobility Past Medical History Drug history ~ Warfarin Personal History ~ Smoking Occupational History Family History Ensured understanding of patients problems/concerns Made a reasoned assessment of patient's problem ‘Summarised and clarified further actions ‘Thanks the patient Ferpaoge Instruction to the actor: ‘You are Mr Lang 43 yr old. You coughed up blood on 2 different occasions in last 2 days. On both the occasion the blood was bright red in colour about 5ml. It was not mixed with sputum. You have been having cough for last 3 months. You are not a smoker. 48a P LA B R i g ht ines DIFFERENTIAL DIAGNOSIS | MALIGNANCY | Weight loss Cough Lethargy Haemoptysis Long history of smoking Dyspnoea TUBERCLOSIS Weight loss Cough Night sweats Lethargy Haemoptysis * Lymph node enlargement PULMONARY EMBOLISM ‘+ Haemoptysis Chest pain (pleuritic) Dyspnoea Cough Rapid breathing CARDIAC FAILURE Dyspnoea Orthopnea Paroxysmal Nocturnal Dyspnoea Peripheral oedema Cough Weight loss Haemoptysis (pink sputum) PNEUMONIA Cough Chest pain Fever Haemoptysis Night sweats Dyspnoea_ ‘* Adaily cough, over months or years * Daily production of large amounts of sputum. * Shortness of breath and wheezing (a whistling sound when you breathe) VASCULITIS (e.g Goodpasture's syndrome ) Haemoptysis . © Chills * Fever © Chest pain * Hematuria Bleeding problems e.g Leukemia, high INR (on warfarin) 28 yr old Emma Scott is complaining for feeling tired for last 6 months. Her GP has done few investigations and they were normal. Your are SHO in medicine, take history and discuss the managements with the patient Examiners Mark Sheet 49© PLAB Right Limited @ PLAB Right timitea HISTORY TAKING ~ TIREDNESS Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Identifies the topic for discussion Clarifies nature of symptoms Elicits details of symptoms: a. Duration and pattern b. Severity of symptoms c. Rate of progression d._Exacerbating /Relieving factors Associated Symptoms Constipation/Diarrhoea Fever, night sweats, rigors Nausea, vomniting, polyuria Shortness of breath/swelling of legs Lack of energy/letharay Muscle/joint pain g.. Memory/concentration/mood Haematological symptoms Dietary intake Changes in weight Sleep: pattern, features of obstructive sleep apnoea Functional impairment Elicits beliefs and concerns. Past medical history Drug History Menstrual history (in females) Personal history: Smoking/alcohol/ Recreational drugs. Occupational history: Job, Effect on symptoms: Ensured understanding of patient’s problems/concerns Made a reasoned assessment of patient's problem Summarised and clarified further actions Thanks the patient paoge Instructions to the actor You are 28 yr old, started to feel tired 6 months ago. At that time you remember having fever for 4 days. Following that you noticed that you were getting easily tired. You don’t have any other positive symptom other than this symptom.© PLAB Right Limited @) PLAB Right timitea Mr Thompson Is in A & E. He is complaining of sudden onset of weakness of his left side of the body. Take history and discuss about the management STROKE -HISTORY TAKING AND RISK FACTORS Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion Establish nature of deficit Onset and Duration Severity of symptoms Pattern of Symptoms Progression of symptoms Associated symptoms Headache, Nausea, vomiting Loss of consciousness/fits Numbness/Weakness in other parts Visual disturbances/double vision Vertigo Swallowing / Speech problems Bowel/Bladder problems Functional consequences Past Medical History : TIA/Stroke Hypertension/Diabetes Mellitus Increased Cholesterol Heart disease Peripheral Vascular disease Bleeding/clotting abnormalities Drug History: HRT/OCP Anticoagulants/Aspirin Personal History : Smoking/Achohol Family History of Stroke/Heart disease Social History: Family/social support Ensured understanding of patients problems/concerns Made a reasoned assessment of patient’s problem Summarised and clarified further actions Thanks the patient Instructions to the actor You are 38 yr old and have attended to A & E because you have noticed weakness of left side of your body. You noticed it in the morning. The weakness is not getting worse nor getting better. You suffer from blood pressure. You have headache No other symptoms 51© PLAB Right iimices”” Mrs Smith Is 43 yr old lady complaining of racing heart beat. She is worried about her condition and feels that it is making her situation worse. Take history and discuss the management. PALPITATIONS ~ HISTORY TAKING Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion ‘Onset, Duration and frequency Nature (Constant/ Intermittent) Establishes Rate and Rhythm (asks to tap) Mode of termination (sudden/gradual) Precipitating factors Aggravating/Relieving factors Associated symptoms a. Chest pain/Shortness of breath b. Dizziness/Loss of consciousness c. Headache/sweating d. Intolerance to heat/tremors/Diarrhoea e. Feeling of impending doom Past Medical History: a. Cardiac illness b. Hypertension c. Strokes d, Diabetes Mellitus Drug History ‘a. Anti Diabetic b. Digoxin/Beta blockers c. Recent Discontinuation/ Introduction Personal History ~ smoking / Alcohol Family History of Cardiac illness Social History: Family/relationship crisis Elicits beliefs and concerns Effect on work/activities Ensured understanding of patients problems/concerns Made a reasoned assessment of patient’s problem Summarised and clarified further actions ‘Thanks the patient FEEDBACK Instructions to the actor: Mrs Smith is 43 yr old she started to feel the racing hear beats for last 3 days. She has noted that sometime it can be irregular. It occurs especially when she is excreting. History of hypertension@ PLAB Right © PLAB Right Limited Limited Mr Rateliff is 46 yr old and he is complaining of severe knee pain. He has attended the A & E. Take history and discuss about the management. HISTORY TAKING ~ JOINT PAIN Greeting/Introduction Establishes identity of the patient Empathy/Checks comfort of patient Explains purpose of visit Confirms symptom for discussion Site and symmetry of involvement Onset and Duration Radiation Periodicity Progression Precipitating factors including trauma Aggravating/relieving factors Characteristics of affected joint Diurnal variation in symptoms Associated symptoms a. Rash, mouth ulcers, photosensit b. Fever, Weight loss c. Abdominal pain d. Bowel problems e. Eye problems f. Urethral discharge/Urinary symptoms Past Medical History Drug History ~ Thiazides, Salicylates Personal History: Alcohol Dietary History Family History Functional consequences Ensured understanding of patients problems/concerns Made a reasoned assessment of patient's problem Summarised and clarified further actions Thanks the patienta PLAB Right linha DIFFERENTIAL DIAGNOSIS OF JOINT PAIN SEPTIC ARTHIRITIS ‘© Monoarthritis Joint Pain Red ‘Swollen Hot Hx of trauma? Steroid use Immunosupressed VIRAL ARTHRITIS ‘* Joint pain post infection rubella, mumps, hepatitis and enteroviruses. + Altered bowel habit Eye problems ‘+ Systemic involvement RHEUMATIC FEVER '* Post pharyngeal infection © Nodules * Erythmea marginatum Migratory Poly arthri Arrhythmia RHEUMATOID ARTHIRITIS © Smaller joints © Symmetrical involvement © Morning stiffness Eye problems ANKYLOSING SPONDYLITIS © Young males © Morning stiffness © Sacro-iliac j Eye pain * Eye redness + Photophobia OSTEOARTHIRITIS ‘* Age > 50 years unless secondary to other joint pathology ‘* Joint pain worse at end of day + Pain on movement * Loss of function REITERS DISEASE © Conjuctivitis © Urethritis * Joint pain Sexual contact involvement GouT * Excruciating sudden onset © Big toe affected © Skin changes © Precipitated by diet, alcohol and certain medications HI Mrs. Doreen Lawrenson is a 62 year old lady from Scotland. Four months ago, she had noticed that her voice had become ‘croaky’. Take history and discuss the differential diagnosis with the examiner© PLAB Right Limited @) PLAB Right timitea HISTORY TAKING ~ HOARSENESS OF VOICE Greeting/Introduction Establishes identity of the patient/Rapport Empathy/Checks comfort of patient Explains purpose of visit Establishes symptom for discussion Duration Mode of onset Severity Progression Precipitating factors Exacerbating/Reliving factors Associated symptoms a. Fever b. Cough, haemoptysis c. Weight loss d._ Difficulty swallowing e, Ear pain/throat pain [Link]/noisy breathing g. Cold intolerance h. Appetite i Lumps in neck Past Medical History: asthma, heartburn, allergies Personal history: Smoking, alcohol Drug History Occupational History Family History Ensured understanding of patient’s problems/concerns Summarised and clarified further actions Thanks the patient Instructions to the actor Mrs, Doreen Lawrenson is a 62 year old lady from Scotland. She works as a cleaner at the Royal Marsden Hospital. Four months ago, she had noticed that her voice had become a bit funny which she describes as ‘croaky’. Over time, she has not noticed any improvement in her voice and has rather noted it to be getting progressively worse. The voice remains ‘croaky’ through out the day with no particular worsening or improvement during any time. She has not noted any thing in particular that would make it better or worse, She has never had a similar episode in the past. Over the last two years she has been struggling with her breath. She initially started with cough and phlegm that was mucoid. She had two occasions of yellowish phlegm that was associated with fever and required antibiotics. A chest X ray was reported to be normal. She was subsequently started on Ipratropium inhalers which did not help her much and frequently required salbutamol inhalers, She has noted that at times she gets short of breath. She was subsequently referred to the respiratory unit and was prescribed beclomethasone Inhaler and her symptoms have eased a lot. However she does not use any spacer for the beclomethasone inhaler and does not gargle after using the inhalers. She recalls that prior to the institution of beclomethasone, her voice was normal Continues in next page She denies history of haemoptysis or shortness of breath at rest, She sleeps with two pillows. She does not have history of indigestion and heart burn. She denies any problems with swallowing and 55@ PLAB Right iimiiea” her appetite is normal. She has not lost any weight and has not noted any glands in her neck. She does not give a history of recent sore throat. Her bowels are normal and she does not have any preference for a particular type of weather. She has not had any exposure to chemicals or to smoke She has had a hysterectomy 12 years back for undiagnosed vaginal bleeding. She lives with her husband whom she describes as a supportive gentleman. She has not been overusing her voice. She has smoking 15 cigarettes a day for the past 40 years and drinks beer on the weekends. She does not have any stress at work or at home. She is trying to stop smoking but is finding it hard. She is worried about that the hoarseness might be a symptom of cancer. DIFFERENTIAL DIAGNOSIS VIRAL LARYNGITIS Fever Sore throat Loss of voice Tiredness LARYNGEAL CARCINOMA Hoarseness Sore throat Persistent cough Hx of smoking HYPOTHYROIDISM Weight gain Cold intolerance Depression Fatigue Constipation VOCAL CORD POLYPS Vocal fatigue Stridor Excessive use of voice CHRONIC LARYNGITIS ~ numerous causes including smoking Use of steroid inhalers or other drugs causing dryness of mouth and throat. Secondary to gastroesophageal reflux disease 56© PLAB Right Limited @) PLAB Right timitea Mr. Andrew Bliss is a 46 year old gentleman who works as a carpenter with the Merseyside Company. He has been referred to your clinic by the general practitioner with a history of seeing “things double” for the last one month. Take history and discuss diferential diagnosis with the examiner. HISTORY TAKING FOR DIPLOPIA Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion Elicits details of symptom a. Onset ~ sudden/gradual b. Intermittent/continuous c. Severity d. Duration e, Progression f. Aggravating/Relieving factors 8. Establishes Monocular/Binocular diplopia 9. Orientation of images 10. Vision 11. Associated symptoms: a, Droopy eyes b. Problems with speech, swallowing, Speaking c. Weakness/numbness d, Headache/vomiting/Loss of consciousness 12. Diurnal variation 13, Past medical History a. Any similar/visual problems in the past b. Diabetes/Hypertension c. Head injuries 14. Drug History 15. Family History 16. Ensured understanding of patients problems/concerns [Link] and clarified further actions 18. Thanks the patient NEURON Instructions to the actor Mr. Andrew Bliss is a 46 year old carpenter who works with the Merseyside Company. He has been referred to your clinic by the general practitioner with a history of seeing "things double” for the last one month, The double vision is intermittent and is worse towards the end of the day. He sees double in all directions and has not noted any improvement in a pai cular direction of gaze. He wife has mentioned to him that his eyes go droopy when he Is watching the television, He thinks that all his symptoms are due to excessive fatigue at work. He mentions that he feels unusually tired, more so towards the end of the day. He struggles to manage the flight of stairs that lead from the underground workshop in the company, However, he does feel refreshed and “strong” in the morning hours. Continues to next page 57© PLAB Right Limited @ PLAB Right timitea He does not have problems with swallowing, chewing, speaking or breathing and his bowel and bladder habits are normal, His eyesight is normal and he has not noted any redness or pain in his eyes. He has had not problems with his eyesight in the past. He does not have any history of headache, loss of consciousness, dizziness or unsteadiness. He has noticed some weakness in his hands and legs. He cannot work with the electric saw for a long period of time as his hands go unusually weak. After resting for a good period of time he gets his “power back in the muscles”. He does not have any pins and needles. He has not lost any weight and his appetite is normal. He does not have any significant past medical history and he is currently on Vitamin B tablets which he purchased over the counter. He does not have any allergies and there is no family history of joint pains, anaemia or thyroid problems. He doesnot suffer from diabetes and has not sustained any injuries to his head. He is a non smoker and drinks about 15 units of spirits per week. He lives with his wife. He is. concerned that he Is struggling with his work because of his symptoms, Differential diagnosi 1. Opthamoplegia - 3", 4" or 6t cranial nerve palsy ~ causes could include: Any cause of raised Intracranial pressure eg tumour Any cause of mono neuritis e.g. diabetes Cavernous sinus lesions/thrombosis Vascular eg posterior communicating artery aneurysm, stroke 2, Myasthenia Gravis 3. Multiple Sclerosis 4, Diabetes Mellitus/ Hypertension 5. Head Injury 6. Thyroid opthalmoplegia 7. Stroke. 8. Drugs 58© PLAB Right Limited @ PLAB Right timitea HISTORY TAKING - CHEST PAIN 1. Greeting/Introduction 1. Establishes identity of patient/Rapport 2. Empathy/checks comfort of patient 3. Identifies the topic for discussion 4, Elicits details of pain a. Site of Pain b, Onset/Duration of pain c.. Character and Intensity of pain d. Sites of radiation e. Progression f. Relieving/Exacerbating factors. 5. Associated symptoms a. Palpitation, SOB, dizziness, sweating b. Fever, Cough, Pain on inspiration, haemoptysis c. Bloating, heartburn, relation to meals d. Pain on movement, relation to posture 6. Sequence of symptoms 7. Risk factors for 1HD a. Smoking b. Diabetes/Hypertension cc. History of IHD/PVD/CVA d. Alcohol/Hyperlipidemia 8. Risk factors for DVT a, History of travel abroad b. Prolonged immobility c. OC pills d. Past History of clots 9. Past Medical History 10. Family History of IHD/PVD/Clots 11. Social History housing (stairs) 12. Ensured understanding of patients problems/concerns 13. Summarised and clarified further actions 14, Thanks the patient Instructions to the actor Mr, Arthur Morris is a 62 year old barman from Warrington. He gives a history of pain side of chest pain since the last three days. He describes the pain as a dull ache and is particularly brought about by exertion. The pain i mainly in the left side of his chest and lasts for 3 -10 minutes before it subsides with rest. He has noted 3 similar episodes of pain in the last three days and every episode has been brought by climbling two flights of stairs. the left The pain radiates to his neck and he has noted occasional nausea during the pain. He has not noted any problems with breathing and eating. He denies any history of cough, palpitations, syncope, indigestion, leg swelling, haemoptysis or sweating. He smokes around 23 cigarettes a day and he started it around 40 years back. He does not drink alcohol. He had been to see his general practitioner who advised him to lose weight as he was weighting 92 kilograms. His father died of heart attack at the age Of 65. He is currently on simavastatin for raised serum cholesterol. He lives with this wife who suffers from bronchial asthma. Pitfalls/Clues Chest pain is a very common condition and includes a wide spectrum of conditions ranging from acute coronary syndrome to musculoskeletal chest pain. A tailored history should be undertaken according to the symptoms to arrive at a differential diagnosis.© PLAB Right, Limited @ PLAB Right timitea Practice Mock test 2 Following stations should be practiced in groups of 3. One person takes on the role of a patient, ‘other becomes Examiner and 3” person will do the task. Examiner can use the following guide to assess the performance. Examiner should also manage the time Actor should read the “instruction to the actor” and simulate the clinical scenario given 60© PLAB Right timicea Mr, Robert Worthington Is a 75 year old retired barman. He has now been brought to the medical assessment unit complaining of shortness of breath on mild exertion. Take a detailed history and formulate. HISTORY TAKING - SHORTNESS OF BREATH 1, Greeting/Introduction 1, Establishes identity of patient/Rapport 2. Empathy/checks comfort of patient 3. Explains purpose of visit 4, Identifies the topic for discussion 5. Elicits details of symptom a, Onset /Duration b. Episodic/continuous c. Severity (exercise tolerance) d. Rate of Progression e. Aggravating/Relieving factors Diurnal variation/Weekend symptoms Associated symptoms a. Cough ~ Productive/dry b, Haemoptysis c. Wheeze d. Chest pain/orthopnea/PND e. Ankle swelling 8. Functional assessment a. Effect on Activities of daily living b. Orthopnea (Quantify number of pillows) 9. Past Medical History/Admissions 10, Personal History - Smoking/pets/hobbies. 11. History of Atopy /Allergy 12. Occupational History 13. Travel History 14, Family History 15. Social History (housing -stairs) 16. Ensured understanding of patients problems/concerns 19, Summarised and clarified further actions 20. Thanks the patient Instructions to the actor: Mr. Robert Worthington is a 75 year old retired barman. He initially presented to his general practitioner three years back with the symptoms of shortness of breath that was associated with cough, wheezing and yellowish phlegm. He was treated with antibiotics and noted a slight improvement in symptoms. Prior to that, he was a perfectly fit and healthy man and used to run a mile every morning with his dog. He attended the surgery with same symptoms after 5 months. He had not lost any weight and did not give history of haemoptysis. He was then prescribed salbutamol inhaler and beclomethasone inhaler and his symptoms had eased a lot. He has now been brought to the medical assessment unit complaining of shortness of breath on mild exertion. He gets short of breath after walking 20 meters on the flat and can hardly negotiate inclines. He struggles to go to the toilet which is situated in the 1** floor of the house. He mentions: of wheezing that has been constant. His cough has been disturbing his sleep and has been 61© PLAB Right iimiea”” bringing up whitish phlegm constantly. The symptoms are constant through out the day. He denies chest pain, fever or weight loss. He has not noticed any swelling of the ankle. He has never required hospital admission He has not noticed any particular triggers. He does not have any allergies and is on thaizide diuretics for hypertension. He has no pets at home. He lives with his wife and she does the cooking, washing and shopping. He feels uncomfortable that he has not been able to help his wife due to his symptoms. He smoked 25 cigarettes a day from the age of 16 and stopped it three years back when his chest started to bother him. He does not drink alcohol. He is concerned that his breathlessness is affecting his activities of daily living and his inhalers are not of much help. Mr. Tan Ell is a 32 year old school teacher from London. He complains of frequent episodes of loose motions take history and discuss about the diagnosis and management with Mr Ellis ALTERED BOWEL HABITS ~ HISTORY TAKING Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion Establishes Normal Bowel habits Establishes present bowel habits Onset and duration of symptoms Frequency and consistency of motions Colour of motions Presence of blood/mucus Aggravating/relieving factors Progression of symptoms Associated symptoms Abdominal pain Tenesmus Joint pain Skin rash/eye problems Vomiting f. Stress/anxiety Change in appetite/Body weight Elicits beliefs and concerns Treatment History Past Medical History Personal History ~ smoking/alcohol Drug history Family History of IBD/Polyps/Cancer Ensured understanding of patients problems/concerns Summarised and clatified further actions Thanks the patient paoge 62@ PLAB Right iimivea™ Instructions to the actor: Mr. Ian Ellis is a 32 year old school teacher from London. He complains of frequent episodes of loose motions which he describes as ‘watery’. He typically opens his bowels 2 3 times a day. The motions are watery and at times mixed with blood and mucus. He occasionally has to get up in the night to open his bowels. Since the last couple of days he has noted that he has been opening his bowels up to 5 times a day. He gives a history of nausea but has never vomited. He does not have a history of fever. He also mentions of pain in his lower abdomen which has been around for almost 3 months. His symptoms started with pain and then after a week he noticed loose motions, The pain is not continuous and can come at any time of the day and he has not noted any relationship with meals or motions. On further questioning, he describes that it is rather a discomfort than pain. He has not been outside the United Kingdom for the last year or so. He also mentions of generalised tiredness and this has been worse over the last week. His appetite has not been very good and on three separate occasions over the last 2 months he has been bothered by painful ulcers in his mouth. He had seen his general practitioner 2 weeks back for redness in his right eye which was associated with discomfort and is waiting for his appointment with the eye clinic. He does not give any history of joint pains. He mentions that he has lost about a stone during this illness. He has not taken antibiotics in the last two years and has not been in contact with anyone with diarrhoea or vomiting. There is no family history of tuberculosis or celiac disease. He has not had any surgery and does not suffer from any other medical illness. He is married to a doctor and describes his relationship as an excellent one. He is @ non smoker and drinks approximately 15 units of lager per week. He does not have any history of infections transmitted through sex. He has found his symptoms disturbing his career and is worried about it. DIFFERENTIAL DIAGNOSIS INFLAMMATORY BOWEL DISEASE © Abdominal cramps © Bloody diarrhoea © Severe urgency to have a bowel movement © Fever © Loss of appetite © Weight loss © Fatigue (Anaemia due to blood loss) © Arthiritis * Eye inflammation and irritatation Skin changes INFECTIOUS DIARRHEA Frequent watery stools sometimes bloody Fever Chills Vomiting Malaise ‘Abdominal pain MALABSORPTION PANCREATITIS © Severe upper/central abdominal pain « Abdominal swelling/tenderness © Nausea and vorniting © Fever 63@ PLAB Right timitea” © Sweating * Back or abdominal pain COELIAC DISEASE Diarrhea / constipation Chronic bloating/indigestion Poor appetite Abdominal cramping pain / distension BOWEL CANCER © Bleeding from the back passage (rectum) or blood in your stools © Achange in normal bowel habits towards diarrhea or looser stools that lasts longer than 6 weeks A lump that your doctor can feel in the right side of your abdomen, or In your rectum A straining feeling in the rectum Losing weight Pain in your abdomen or rectum Anaemia (a low level of red blood cells IRRITABLE BOWEL SYNDROME © Diagnosis of exclusion © Long periods of alternating bowel habits with no pathological cause 56 Yr old Mr Rutherford complains that his voice has changed. Take history and address Mr Rutherford’s concerns. HISTORY TAKING - HOARSENESS OF VOICE Greeting/Introduction Establishes identity of the patient/Rapport Empathy/Checks comfort of patient Explains purpose of visit Establishes symptom for discussion Duration Mode of onset Severity Progression Precipitating factors Exacerbating/Reliving factors Associated symptoms a. Fever b. Cough, haemoptysis c. Weight loss d._ Difficulty swallowing e. Ear pain/throat pain [Link]/noisy breathing g. Cold intolerance fh. Appetite i, Lumps in neck Past Medical History: asthma, heartburn, allergies Personal history: Smoking, alcohol Drug History Occupational History Family History Ensured understanding of patient's problems/concerns Summarised and clarified further actions Thanks the patient© PLAB Right iimicad”” Instruction to the actor: You are a manager in a Bank. You live with your wife. You have been smoking 20 cigarettes for ‘more than 30 years. You noticed the hoarseness 6 months back. It Is progressively getting worse. You sometime find it difficult to swallow but it is not a major problem. Ask following questions to the candidate Can this be cancer? How can you help me? Mr Baldwin is a 45 yr old gentleman who has come to see you because of red eye. You are an SHO in the accident and emergency department. Take a history and discuss the diagnosis with the examiner. RED EYE - HISTORY TAKING Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion Duration One/both eyes Mode of onset: sudden/gradual Nature of symptoms: constant/Intermittent Aggravating/Relieving factors Changes in vision Associated symptoms Pain Headache Discomfort/irritation Discharge /sticky eyes Dry/gritty eyes Itching/burning sensation Photophobia Vomiting i. Spots/haloes around light History of trauma to eye History of Urethral discharge Fever, Joint pain, Skin rashes Back pain/stiffness Bowel problems Past Medical History: Family History of similar problems/Glaucoma Similar problems in community/workplace Ensured understanding of patients problems/concerns Made a reasoned assessment of patient's problem Summarised and clarified further actions ‘Thanks the patient Fompaoge Instruction to the actor: ‘You are Mr Baldwin. You have noticed that for last 3 months your eyes are going red. You also have pain in the evening. Your father had glaucoma. You work fulltime as a teacher. 65© PLAB Right Limited ey PLAB Right timitea ACUTE GLAUCOMA, Severely painful, haloes around lights, may be systemically unwell (nausea, vorniting, headache ). Usually > 50yo. KERATITIS Photophobia, foreign body sensation + history of contact wear + previous episodes (e.g. herpes simplex infection). ACUTE ANTERIOR UVEITIS Photophobia, blurred , headache, pain on accommodating. May have been unresponsive to previous treatment for conjunctivitis. Trauma e.g. foreign body (FB) Pain depends on type of trauma, severity and location. : The acute non painful red eye” CONJUCTIVITIS Discomfort (moderate to severe pain - suspect more serious, pathology), photophobia rare unless severe from of adenoviral infection which may involve the cornea, discharge + history of contact + history of allergen exposure. EPISCLERITIS Mild discomfort, few symptoms. SUBCONJUCTIVAL May be spontaneous or traumatic, can occur after prolonged 66© PLAB Right iimivea™ Mrs Thompson has come to A & E complaining of headache. Take a history and discuss the diagnosis with the examiner HISTORY TAKING FOR HEADACHE Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion Details of Headache Site of pain Character of pain Onset and Duration Warning symptoms/aura Timing/periodicity Precipitating/Aggravating factors Relieving factors Severity Progression of symptoms Associated Symptoms: Facial pain/Neck stiffness Stress Photophobia/Phonophobia Nausea/Vomiting Blurring of vision/flashing lights Fever, rash Seizures, Loss of consciousness History of trauma Effect on daily activities Past Medical History Family History : Migraine/cerebral haemorrhage Drug History : Beta blockers/OCP Personal History : Smoking/alcohol/Recreational drugs Occupational History : job and stresses at work Ensured understanding of patients problems/concerns Made a reasoned assessment of patient's problem Summarised and clarified further actions Instruction to the actor: You are Mrs Thompson and you work in a local nursery as a child minder. You are experiencing severe headache for last 6 hrs. Acute onset and this Is the worst headache you have ever experienced. You feel sick. There is no fever. 67© PLAB Right Limited @) PLAB Right timitea DIFFERENTIAL DIAGNOSIS CLASSIC MIGRAINE @ Character: throbbing pain @ Location: hemicranial ™ Associated: preceded with visual disturbances and less often with hemi-sensory disturbances, hemiparesis, or aphasia ™ Associated: photophobia and or phonophobia; tension headache often concomitant ™ Aggravated: red wine, nuts, aged cheese, chocolate and caffeine containing beverages CLUSTER HEADACHE Character: excruciating pain often stabl Location: usually near one eye Associated: tearing, flushed face, nasal congestion, conjunctival congestion (ANS) Risk factor: males affected more than females Onset: begins at 20 - 40 years of age Attacks last 30 - 90 minutes daily for days and then disappear for months (Headache “vacation”) Alcohol can precipitate but only during an active cycle, not during "vac SUBARACHNOID HAEMORRHAGE | Character: full-blown catastrophic headache Location: Holocaine Duration: continuous | Associated: photophobia, retinal hemorrhages, nuchal rigidity, Brudzinski sign, obtunded collapse MENINGITIS ™ Headache ™ Photophobia m™ Fever Rash INCREASED ICP @ HAts severe HA occur with coughing, sneezing, valsalva effort Associated findings include papilledema, obtunded, focal neurologic signs & symptoms ‘TEMPORAL ARTERITIS Character: throbbing and sharp, burning pain Location: focal headache in the temporal or frontal-occipital region Onset: gradual and progressive Aggravated: headache worse at night and with cold Risk: most common in white females > 50 years old Associated: weight loss, fever, fatigue, polymyalgia rheumatica, monocular visual loss, jaw pain TENSION HEADCHE @ Tightness around the hat band area or squeezing or pressure pain @ Both sides of head | Radiates to and from neck @ Stress physical, mental or environmental triggers are present 9 ns’ sign, Kernig’s© PLAB Right iimiced”” Mrs Woodward has been loosing weight over the last 4 months. She says that she has no appetite. Take a history and discuss the diagnosis with the examiner. HISTORY TAKING: WEIGHT LOSS Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion Degree of weight loss Duration of weight loss Appetite Gastrointestinal symptoms Psychological factors d. Preoccupation with body weight/food e. Stress at home/work f. Self induced vomiting/Excessive exercise Associated symptoms i, Amenorrhoea j. Skin rash/Red eyes k, \ Tremor/palpitations |. Heat intolerance m. Polyuria/Polydipsia n. Fever, night sweats, lethargy ©. Cough, shortness of breath, leg swelling p. Low mood, suicidal ideas Dietary history : Normal diet and eating pattern Elicits beliefs and concerns Past Medical History Drug History : Laxative abuse/Diuretic abuse Personal history : Smoking/alcohol/recreational drugs Occupational History : job and stresses at work Family History Ensured understanding of patients problems/concerns Made a reasoned assessment of patient’s problem Summarised and clarified further actions Thanks the patient You are 35 yr old, working full time as a receptionist. You have noticed that you're feeling thirsty and have been drinking copious amount of water. You have no problem with heat. Per normal. You have a family history of diabetes ? Diabetes 69© PLAB Right Limited @ PLAB Right timitea Other Vignettes for group study@ PLAB Right iimices”” Mr Radcliff Is 26 yd old gentleman who got admitted to hospital one week back for loss of consciousness. He had one similar episode 3 months back. While he was in the hospital he has been taking sodium valproate. He is getting discharged from the hospital today. Your consultant has asked you to talk to him about the medication and life style changes he may have to do in future. ADVICE ABOUT MEDICATIONS AND LIFE STYLE - EPILEPSY 1, Greeting/Introduction 2, Establishes identity of patient / Rapport 3, Empathy/Checks comfort of patient 4. Explains the purpose of visit 5. Elicits beliefs and concerns 6. 7. 8. . Establishes patient’s understanding of his problem Advice about work ; Advice about Driving 9. Advice about sports/swimming 10. Advice about Holidays/discos 11, Advice about Recreational drugs/alcohol 12. Precautions at Home (Baths/Locks) 13. Inform people/colleagues 14, Contraception/pregnancy 15. Advice on medicines Mode of intake Frequency of dosing Duration of treatments Explains likely benefits of treatment Discusses the side effects Identifies contraindications g. Explains the importance of regular intake 16, Summarized and clarified understanding 17. Offers leaflets 18. Societies/support groups 19. Gives chance to ask questions 20. Thanks patient Instructions to the actor Ask following questions Can I drive? Can I swim? How long I need to take this medication? Is there any side effects? What a seizure? A seizure is a short episode of symptoms/ fits caused by a burst of abnormal electrical activity in the brain. Typically, a seizure lasts from a few seconds to a few minutes. What is epilepsy? If one has seizures more than once then it may be epilepsy What triggers a seizure? 71@ PLAB Right timitea There is often no apparent reason why a seizure occurs at one time and not another. However, some people with epilepsy find that certain ‘triggers’ make a seizure more likely. These are not the cause of epilepsy, but may trigger a seizure on some occasions. Possible triggers include: Stress or anxiety. Some medicines such as anti-depressants, anti-psychotic medication (by lowering the seizure threshold In the brain). Lack of sleep or tiredness. Irregular meals which nay cause a low blood sugar level. Heavy drinking, or street drugs. Flickering lights such as from strobe lighting or video games. Menstruation (periods). Illnesses which cause fever such as ‘flu or other infections Standby medicine to stop seizures In most people with epilepsy, seizures do not last more than a few minutes. However, in some cases a seizure lasts longer, and a medicine can be used to stop it. The most commonly used medicine for this is diazepam. This can be squirted from a tube into the persons anus (‘rectal diazepam’). This is absorbed quickly into the bloodstream from the rectum and so works quickly. Driving By law, people with epilepsy must stop driving. If you have a driving license, you must declare that you have epilepsy to the DVLA (Driver and Vehicle Licensing Authority). They will advise on when it may be possible to resume driving again Travel Make sure you have sufficient medication with you for your travels, Long journeys and ‘jet-lag’ may make you tired and more prone to a seizure. This should not stop you travelling. However, it may be best that someone on the trip is aware of your situation Medic~alert bracelet Consider wearing one of these bracelets (or necklets). They give an emergency phone number where details you wish to give about your condition are held. Medic-alert bracelets are often worn by people where emergencies may possibly arise. (For example, people with diabetes, severe allergies, epilepsy, etc). Contact details are given at the end. Safety The aim is to anticipate and avoid potential serious injury if you have a seizure, Below are some suggestions, but common sense will prevail in your own personal situation. ‘* Heat. Do not use open fires. Think about the design of the kitchen. A microwave oven is much safer than a conventional oven, hot plate, or kettle. Cooker guards may be advisable for conventional cookers. Always turn pan handles towards the back of the cooker. Take the plate to the pan, not a hot pan to the plate. © Water. Showers are safer than baths. If you do not live alone, tell someone if you are having a bath, turn off taps before you get in, and leave the door unlocked. Keep bath water shallow. Do not bath a baby alone. When you swim, do it with someone else, and not far away from dry ground. © Heights. Make sure there are sufficient guards or rails in any high situation. Consider a rail at the top of your stairs, It is best not to climb ladders. Electricity. Use electrical tools with power breakers. Fit modern ‘circuit breaker’ fuses. Sharp furniture. Safety corners are available to cover sharp edges. Perhaps consider soft furnishings around the home as much as possible. © Glass. Consider fitting safety glass to any glass in doors or to low windows. DRPOND EENE © PLAB Right Limited @ PLAB Right timitea Mr Wi swallowing. Take a history and discuss the diagnosis with the examiner. jams Is 45 yr old gentleman, referred by his GP because he having difficulties in HISTORY TAKING ~ DYSPHAGIA Greeting/Introduction Establishes identity of patient/Rapport Empathy/checks comfort of patient Explains purpose of visit Identifies the topic for discussion Duration of symptoms Site of food sticking Nature of symptoms: Solids/Liquids Pattern of symptoms a. Intermittent/constant b. Progression of symptoms c. Rapidity of progression 10. Associated symptoms Coughing/choking during swallowing Pain during swallowing Weakness elsewhere/Neurological symptoms Heartburn/Vomiting Bulging/gurgling of neck Repeated chest infections 11, Aggravating/reliving factors 12. Appetite 13, Weight loss: Degree and duration 14, Past Medical History (History of GI reflux) 15. Personal History: Smoking / alcohol 16. Treatment History 17. Family History 18. Ensured understanding of patient's problems/concerns 19. Summarised and clarified further actions pangs 20. Thanks the patient B@ PLAB Right iimivea”” Mr Steel is 71 yr old who lives with his daughter. He was found unconscious this morning by his daughter. He is now in the intensive care unit under the care of your team. Your consultant asks you to gather detailed history from his daughter. HISTORY TAKING - LOSS OF CONSCIOUSNESS, Greeting/Introduction Establishes identity of the patient/Rapport Empathy/Checks comfort of patient Explains purpose of visit Establishes symptom for discussion Onset/Duration Preceding symptoms/warning Precipitating factors Description of episode (any witness) Recovery time Associated symptoms: Fever, Headache Nausea, Vomiting, sweating Chest pain, Shortness of breath, Palpitation Dizziness ‘Weakness of limbs Numbness/sensory symptoms Post eve Recall Injuries sustained Muscle pains Headache . Weakness/paralysis of limbs Past Medical History: a. Similar episodes b. Hypertension/Diabetes c. Blackouts, Epilepsy d, Headache/Head injury e. Cardiovascular illness Drug History Personal history; Smoking/alcohol/recreational drugs Family History Ensured understanding of patient's problems/concerns Summarised and clarified further actions Thanks the patient paogee>gaogs 74© RLAB Right Limited @ PLAB Right timitea Mr O'Brien was admitted to hospital 2 weeks back after suffering coronary syndrome. He is now stable and ready to be discharged. Your consultant has asked you to talk to him and give relevant information about the medications he needs to take on discharge. List of his current medication 1. GTN Spray 2. Aspirin 3. Atenolol 4, Simvastatin DISCHARGE POST MI ~ ADVICE ON MEDICINES . Greeting/Introduction Establishes identity of patient/Rapport Empathy/Checks comfort of patient Explains the purpose of visit Elicits beliefs and concerns Establishes patient’s understanding of his problem Explains reasons for considering treatment Identifies the correct medicines a. GTN b. Aspirin c. Atenolol d. Cholesterol reducing drugs 10, Discusses the mode of intake 11. Discusses the frequency of dosing 12, Discusses the duration of treatments 13. Explains likely benefits of treatment 14, Discusses the side effects 15, Identifies contraindications 16. Explains the importance of regular intake 17. Summarized and clarified understanding 18. Gives chance to ask questions 19, Thank patient 20. Overall performance SON AUAWN Instructions to the actor: Ask about the side effects How long do I have to take these medications? What do these medications do? Why do I have to take several medications? 15© PLAB Right Limited @ PLAB Right timitea TIPLE SCLEROSIS It is a condition which affects the brain, spinal cord and nerves. It damages the covering of nerves called Myelin. Why does it happen? The exact cause is not known. Why me? It is a difficult question to answer. It can happen to anyone. You have done nothing wrong to bring on the disease. It is just a random bad luck. Please do not blame yourself. Can it happen to my child? Risk is there, but I can not quantify the risk. Can I smoke? It does not affect the outcome of the disease. But it is always better not to smoke because of various health risks associated with smoking. If you want to quit smoking, I may help you. Can I drink? Yes, but in moderation. Like not more than 21 units of alcohol in a week, and you should be alcohol free for at least 2-3 days a week. Can I become impotent? Risk is there, but I can not quantify the risk. If this happens, treatment is available. (papaverine injection) Can I become pregnant? Yes, but it will be better to consult the neurologist and obstetrician before conceiving. Will 1 die? It Is a difficult question to answer. It is too early to predict. We do not know how this disease will progress in future. As you know, every person is a different person, they respond differently to same medicines. Will be wheel chair bound? This is also a difficult question to answer. As you know, the course of the disease is very unpredictable. But many people, they live a very productive life for a very long time. Is it curable? No, it is not curable, but it is treatable. 16© PLAB Right iinivea™ ANT CELL ARTERITIS It is a condition in which mostly the blood vessels of the head, neck, face and chest are affected. They become swollen and painful. If the blood vessels of the brain are involved then it can cause a stroke. If the blood vessels of the heart are involved then it can cause a heart attack. When it involves the limposol blood vessels, we call it Temporal Arthritis. (Temporal region of the fore head and the sides of the fore head) Sometimes it affects the blood vessels of the eye which can sudden, irreversible and permanent blindness. Why is it known as giant cell? Because abnormal large cells are formed within the blood vessel. What is the treatment? To prevent the above mentioned problems, we are going to start high dose steroid. It is a painkiller and at the same time it reduces swelling of blood vessels. First we will start with a heavy dose, and then later on when symptoms disappear we may start a low dose of steroid as maintenance, What is the duration of steroid medicine? Usually typical duration is 2-3 years, but in some people we may have to give it for life long. We will monitor you from time to time. What are the side effects of steroids? As you know alll medicines have some side effects, steroids are no exception. Some of the side effects are -: Insomnia - it can cause difficulty in sleeping for that reason, its better to take this medicine in the morning hour. Dyspepsia - it can cause tummy problem, so please take it after eating breakfast. If necessary we will give you medicine for this tummy pain. Blood Pressure - it can increase the blood pressure. We will monitor your blood pressure regularly. If suppose it is raised, then we will start medication to bring it back to normal level. Weight Gain ~ constant, regular, high dose of steroid for a long time is associated with weight gain. So, I will refer you to a dietician for a healthy balanced diet. Gentle and regular exercise will be highly beneficial. DM - it can raise the blood sugar level. If this happens to you then we will start medicine to control it, Bone thinning (osteoporosis) - When we take steroid for a long time, it can make the bone thin, This thin bone Is known as _osteoposotic bone. Thin bones are prone to fracture. In this situation we will give you medicines like poisphosphonate to strengthen your bone. When you take steroid from outside your own body stops producing steroid. If you miss a simple dose of steroid, your blood pressure can drop dangerously to a low level which can prove fatal. So please make sure that you take medicine on time without any miss. If you have any vomiting or diarrhoea please come to us, so that we can give steroid through blood vessels. If you have any infection like chest infection, please come to us because dose may need to be increased. Please wear bracelet/necklace so that others will know that you're taking steroid. Please inform your GP and Dentist.© PLAB Right Limited @) PLAB Right timitea Gout is a condition in which the level of a chemical substance called uric acid encases in the blood. Uric acid is the end product of many reactions of cells. Excess of uric acid forms tiny crystals. These tiny crystals get deported into the joint and causes pain and swelling. Certain foods and medicines like seafood, wine and water tablets; they all increase the level of sp uric acid and brings on the gout attack. Many stressful conditions like infection, injury, operation etc can also initiate gout attack. Does it run in family? Yes, in some cases. What are the complications? It can damage joints and kidneys. What should i do? Avoid sea food, try to loose weight, do gentle and regular exercise. Do not take water tablets for high blood pressure. Drink alcohol in moderation that is not more than 21 units in 1 week. 2 or 3 days you should be alcohol free and you should not drink more than 3-4 units of alcohol in a day. Iwill refer you to a Dietician for a healthy and balanced diet. What are treatment options available? During acute attack, we will give you painkillers like Ibuprofen as with any othi advisable. Splint is required to provide rest. To prevent further attacks one medicine called allopurinol can be used. This medicine reduces the ss uric acid level. Before giving this tablet we will check your kidney function painkiller rest is PRE HIV TEST COUNSELLING Whatever we are going to talk about, normally it is going to be confidential between me and you. Actually this is a blood test. I will take out the blood from your blood vessel of your arm. This test will tell whether you are HIV negative or positive. It does not give information about AIDS. AIDS is the last terminal stage of HIV. I only will give you the result of the tests. It will take 7-10 days for the results to come. If suppose the test Is negative or positive we will do the test after 3 months to make sure that it Is a confirmed result because occasionally it gives a false report. As you know, no test is 100% accurate. Until the second test result, avoid sex otherwise practice safe sex. If the result is positive and it Is confirmed, then you must tell your GP, dentist or partner. Do you have any objection about this? Ido not want to tell my partner. We strongly advise you to inform your partner. We have one facility called partner notification service, in which after gaining consent from you, on your behalf without mentioning your name. We will contact your wife and we will tell her that she might have been exposed to some disease. In this way, we will do the test on her. will I die? It Is a difficult question to answer. It is too early to predict. We do not know how the disease will progress in future. I heard medicines are available for the HIV. Yes, medicines are available for treatment but not for cure. These medicines can delay the onset of AIDS. We will monitor you from time to time, because of this reason it is better to tell your GP about HIV status. This will be beneficial in the long term. 78© PLAB Right Limited @ PLAB Right timitea RGE MEDICATION Basically, there are 2 of 3 medicines for asthma which you have to use at home. 2 of them are in the form of inhaler. The other is tablet which is known as steroid, The 2 inhalers are (1) steroid inhaler and (2) salbutamol inhaler. Let me explain the blue inhaler which contains salbutamol. This is a reliever; use it whenever you are short of breath. Use 2 puffs each time. Do not use for more than 4 times or 8 puffs. If you are not relieved of shortness of breath, please come to hospital. However, it has got side effects as like other medicines. They are palpitation and shakiness of hands. Let me explain to you how to use an inhaler. This is the mouth piece; this is the bottom of the canister. Before using it, shake it Hold the inhaler in this way. Breathe out completely. Keep this mouth piece in below the front teeth. Make a tight seal around it with the help of lips. The moment when you are about to breath in press the canister, breathe in deeply. Hold your breathe for 10 seconds, and then slowly breathe out. Repeat if necessary, The second inhaler is a preventer which contains steroid. It is known brown in colour. Use it 2 times a day, 2 puffs each time. After use cleanse your moth to prevent oral thrush. Please use this inhaler till we say. The third tablet is a high dose steroid. It is used for 5-7 days. Please take this tablet after breakfast. Rarely S/E are seen with this tablet when used for such a short time. DIABETIC RETINOPATHY Optician has referred Mr Benjamin to you as he has noticed some changes in the Retina, Mr Benjamin is a known case of diabetes for the last 16 years. He is 65 years old. Mr Benjamin is anxious. He is having concerns. Please address his concerns. GP has mentioned that you have got certain changes in the back of your eye. These changes are known as diabetic retinopathy. This is very common in diabetics. The back of your eye is known as the retina. In the retina, blood vessels are present in diabetics. Blood vessels are affected and new blood vessels are formed. These new bloods are weak and they are prone for rupture. When they rupture, they leak blood. This blood in the eye affects the vision. These changes are permanent, but we can prevent the progression of and we can prevent the blindness also. To prevent blindness of disease progression, we have to tightly control the diabetes. At the same time controlling blood pressure along with cholesterol is equally important. We will monitor your cholesterol and blood pressure; if necessary we will give you medicine. T will refer to your diabetic nurse; she will teach you how to monitor your blood sugar level. Also, your GP will organise blood tests every 6 months to monitor your diabetes. I will also refer you to an eye specialist who will take a photograph o the back of your eye. This will be done annually. If some abnormality is there at the back of the eye, treatment is available. This treatment Is done by lasers.© PLAB Right Limited @ PLAB Right timitea FEBRII (ON This is fits that occur due to high temperature. Why him? This is difficult to answer. It can happen to any child, through genetic plays a role. Will if affect the growth of the child? No, not at all Can attacks occur again? Chances are there. If he has fever he may have fits. Whenever he is having a temperature, please give him paracetemol tablets. Keep the surrounding cool, please do liquid sponging Can it cause damage? No, but if it persists for more than 30 minutes then chances of brain damage are there. What should I do during attacks? Do not panic. Be cool and calm. Fits do not cause pain and discomfort to the baby. Do not interfere with the fits (COELIAC DISEASE The gut reacts abnormally with gluten. Gluten is a protien which is present in rye, wheat, oat, and barley. The gut thinks that gluten is a harmful substance and reacts to it like reaction to infection from organisms like bacteria or virus. Due to this inflammatory reaction the small tube like projections present in the lining of the gut, called villi, which are responsible for absorption, are lost and absorption of food is affected. Why does it happen? The exact cause is not known. But is triggered due to sensitivity to Gluten Can it happen to his brother? Will affect the growth of my child? A gluten free diet will ensure normality and development. Which foods should be avoided? Coke, pasta, bread. I will refer him to a dietician and they will be able to tell you in more detail. Gluten free food products are available in almost all supermarkets Can he eat gluten occasionally? No, not even the smallest amount of gluten in his life time, What are the complications? Complications only occur when gluten free diet is not maintained, Below are the following complications-: 1 Anaemia 2. ‘Thinning of bone 3. Failure to thrive 80© PLAB Right iimices™” What is a gastroscopy? A gastroscopy is test to look into the upper part of your gut. The upper gut consists of the oesophagus (gullet), stomach and duodenum. An endoscope Is a thin, flexible, telescope. It is about as thick as a little finger. The endoscope is passed through the mouth, into the oesophagus and down towards the stomach and duodenum. The tip of the endoscope contains a light and a tiny video camera so the operator can see inside your gut. The endoscope also has a ‘side channel’ down which various instruments can pass. These can be manipulated by the operator. For example, the operator may take a small sample (biopsy) from the inside lining of the stomach by using an thin ‘grabbing’ instrument which is passed down a side channel. What happens during a gastroscopy? Gastroscopy is usually done as an outpatient ‘day case’. It is a routine test which Is commonly done. The operator may numb the back of your throat by spraying on some local anaesthetic. You may be given a sedative to help you to relax. You lie on your side on a couch. You are asked to put a plastic mouth guard between your teeth, This protects your teeth and stops you biting the endoscope. The operator will then ask you to swallow the first section of the endoscope. Modern endoscopes are quite thin and easy to swallow. The operator then gently pushes it further down your oesophagus, and into your stomach and duodenum. A gastroscopy does not usually hurt, but it can be a little uncomfortable, particularly when you first swallow the endoscope. What preparation do I need to do? . You should not eat for 4-6 hours before the test. The stomach needs to be empty. (Small sips of water may be allowed up to two hours before the test.) Are there any side-effects or complications from having a gastroscopy? Most gastroscoples are done without any problem. Some people have a mild sore throat for a day or so afterwards, Occasionally, the endoscope causes some damage to the gut. This may cause bleeding, infection, and rarely, perforation. If any of the following occur within 48 hours after a gastroscopy, consult a doctor immediately Lifestyle treatments to lower high blood pressure Blood pressure is the pressure of blood in your arteries (blood vessels). Blood pressure is measured in millimetres of mercury (mmHg). Your blood pressure is recorded as two figures. For example, 150/95 mmHg. This is said as '150 over 95 High blood pressure is a ‘risk factor’ for developing a cardiovascular disease (such as a heart attack or stroke), and kidney damage, sometime in the future. If you have high blood pressure, over the years it may do some damage to your arteries and put a strain on your heart. In general, the higher your blood pressure, the greater the health risk. But, high blood pressure is just one of several possible risk factors for developing a cardiovascular disease. 81© PLAB Right iimivea™” Lifestyle treatments to lower high blood pressure Lose weight if you are overweight Losing some excess weight can make a big difference. Blood pressure can fall by up to 2.5/1.5, mmHg for each excess kilogram which is lost. Losing excess weight has other health benefits too. Regular physical activity If possible, aim to do some physical activity on five or more days of the week, for at least 30 minutes. For example, brisk walking, swimming, cycling, dancing, etc. Regular physical activity can lower blood pressure in addition to giving other health benefits. If you previously did little physical activity, and change to doing regular physical activity five times a week, it can reduce systolic blood pressure by 2-10 mmHg. Eat a healthy diet Briefly, this means: ° AT LEAST five portions, and ideally 7-9 portions, of a variety of fruit and vegetables per day. . ‘THE BULK OF MOST MEALS should be starch-based foods (such as cereals, wholegrain bread, potatoes, rice, pasta), plus fruit and vegetables. . NOT MUCH fatty food such as fatty meats, cheeses, full-cream milk, fried food, butter, etc. Use low fat, mono-, or poly-unsaturated spreads. . INCLUDE 2-3 portions of fish per week. At least one of which should be ‘oily’ such as herring, mackerel, sardines, kippers, pilchards, salmon, or fresh (not tinned) tuna. . If you eat meat it is best to eat lean meat, or poultry such as chicken. . If you do fry, choose a vegetable oil such as sunflower, rapeseed or olive oil. . Low in salt. A healthy diet provides benefits in different ways. For example, it can lower cholesterol, help control your weight, and has plenty of vitamins, fibre, and other nutrients which help to prevent certain diseases. Some aspects of a healthy diet also directly affect blood pressure. For example, if you have a poor diet and change to a diet which is low-fat, low-salt, and high in fruit and vegetables, it can lower systolic blood pressure by up to 11 mmbig. Have a low salt intake ‘The amount of salt that we eat can have an effect on our blood pressure. Government guidelines recommend that we should have no more than 5-6 grams of salt per day. (Most people currently have more than this.) Tips on how to reduce salt include: ° Use herbs and spices to flavour food rather than salt. . Limit the amount of salt used in cooking, and do not add salt to food at the table. ° Choose foods labelled 'no added salt’, and avoid processed foods as much as possible. Restrict your number of caffeine drinks Caffeine is thought to have a modest effect on blood pressure. It is advised that you restrict your, coffee consumption (and other caffeine-rich drinks) to fewer than five cups per day@ PLAB Right iiniied™ Drink alcohol in moderation ‘A small amount of alcohol (1-2 units per day) may help to protect you from heart disease, One unit is in about half a pint of normal strength beer, or two thirds of a small glass of wine, or one small pub measure of spirits. However, too much alcohol can be harmful. * Men should drink no more than 21 units of alcohol per week (and no more than four units In any one day). © Women should drink no more than 14 units of alcohol per week (and no more than three units in any one day). Cutting back on heavy drinking improves health in various ways. It can also have a direct effect on blood pressure, For example, if you are drinking heavily, cutting back to the recommended limits can lower a high systolic blood pressure by up to 10 mmHg. Lifestyle - in summary It is estimated that dietary and exercise interventions discussed above can reduce blood pressure by at least 10 mmHg in about 1 in 4 people with high blood pressure. Mr Rutherford is 40 yr old suffers from severe anemia. Advise him about blood transfusion Greeting, Introduction Thave come to discuss about the possible need to transfuse blood Understand patient's knowledge and concerns Can you please tell me any concerns that you may already have Explain Anaemia means reduced number of red blood cells. Red blood cells carry oxygen around the body. It is now important to transfuse the blood to maintain circulation of blood and oxygen transport Transfusion is given through a small plastic cannula (plastic pipe) in a vein in your arm. The transfusion should not be painful but having a cannula in your arm may be a little uncomfortable. Each unit of blood is usually transfused over two to four hours. Before a transfusion is given, the blood of the donor and the recipient must be tested against each other to ensure they are compatible. Risks ‘There are rare instances when a reaction might occur due to very rare minor blood group incompatibilities. There is a very low chance of getting an infection from donated blood, because blood is very carefully checked, All blood donors are unpaid volunteers who are very carefully screened and tested to make sure that the blood they donate is as safe as possible. 83© PLAB Right iimices™” CFS/ME Chronic Fatigue Syndrome / Myalgic Encephalomye Mrs Smith is 46 yr old lady. She has been feeling tired for more than a year. All investigations are normal; your consultant has reached the diagnosis of Chronic Fatigue Syndrome. Explain this to Mrs Smith Greeting, Introduction Ihave come to discuss about the results of the tests Understand patient's knowledge and concerns Can you please tell me any concerns that you may already have Explain We have now reached a diagnosis of Chronic Fatigue Syndrome, All tests done were normal. Unfortunately there is no test to confirm this condition. The cause of CFS/ME is not known. There are various theories - but non are proved. A popular theory is that a virus infection may trigger the condition Treatment: Graded exercise Graded exercise means a gradual, progressive increase in aerobic activities such as walking or swimming. It is based on the theory that a factor that helps to maintain the illness is inactivity, with subsequent physical 'deconditioning’. A very gradual increase in the level of exercise is thought to help to reverse this process. Some research studies showed that, on average, people with CFS/ME improved with a structured programme of graded exercise compared to those who did not have this treatment. 84@ PLAB Right timitea Kidney Disease/ Chronic Renal Failure Chror Greeting, Introduction Understand patient's knowledge and concerns Can you please tell me any concerns that you may already have? What is chronic renal failure? Chronic kidney disease (CKD) means that your kidneys are diseased or damaged in some way and as a result may not work properly. So, the various functions of the kidney, can be affected. Healthy kindneys have a number of fuctions. They are concerned with removal of wastes and toxins from the body by filtering the blood and production of urine. It is also involved in maintaining the balance of water and different salts in the body. A number of conditions can cause permanent damage to the kidneys and/or affect the function of the kidneys and lead to CKD. The common causes are high blood pressure, diabetes and inflammation. What are the symptoms? In the early stages patients often do not have any symptoms. However, symptoms in the late stage could include tiredness, swollen ankles and feet, poor appetite, feeling sick, shortness of breath and sometimes blood in the urine. Treatment The treatment will include treatment of underlying condition and also preventing or slowing down the progression of the kidney disease. ~ Control of blood pressure and blood sugar - Alert doctors before taking any medication as certain drugs can be harmful - Cholestro! lowering tablets may be needed ~ Stopping smoking - Regular exercise ~ Regular record of weight = Vaccination : annual flu jab and one off pneumococcal vaccine. Fluid intake: One of the major functions of the kidney is balance of water in the body. In CKD there is risk of fluid overload and this can be minimized by regulating the fluid intake. The daily intake Is different for different patients and depends on the amount of urine that one produces. The chronic kidney nurse will help us to get this balance right. Healthy diet Healthy and nutritious diet is a very important part of management and should be well balanced in carbohydrate, proteins and salt. We need to get the right balance of protein and I will put you in touch with the renal dietician who will be able to guide you further in this. Salts like potassium can increase in the body when the kidney cannot dispose these. Therefore it would be important to cut down on potassium rich food like bananas, crisps, chocolate, baked beans etc. Kidneys are also important for bone health and their balance of other minerals also becomes important. Dialysis Dialysis is an artificial method of removing toxins. If the kidneys fail, their functions to an extent can be replaced by dialysis. Not everyone needs dialysis and blood tests will be done regularly to monitor the situation, There are two different types of dialysis 1, Haemodialysis where blood is cleaned outside the body by a machine. One needs to come to the hospital usually three items a week. (haemodialysis specialist nurse) 2, Peritoneal dialysis : blood is cleaned inside the body. This can be done, at home or at work . (Peritoneal dialysis nurse)@ PLAB Right timiced™” LA’ GOLDEN POINTS = 3 types of questions can be asked viz., * Calculation only. © Calculation and preparation of the solution. * Insulin preparation. ~ In the calculation only questions, If you get a decimals in your answer, you can leave it as that because you are not going to prepare the solution. - For the second type of questions, calculate for 24 hours if you get a decimal point in your answer then calculate for 30 HOURS, to avoid decimals. And then you can discard 6 mis of the total prepared solution. 1, FENTANIL Weight of the patient is 25KG Required dose is 4 microgram/hr/kg 1 mi of Fentanil is 500 microgram A. Make a solution to administer one mi/hr for 24 hours B. How much normal saline is there in your prepared solution Calculation: Step 1: Calculate the amount of drug needed for 24 hours 24 hrs x req dose in micrograms x wt of the patient 24 x 4 x 25kg =2400 micrograms/24 hrs. Step 2: Convert to ML If 1 ml contains 500 microgram of Fentanil, how much ml is needed to get 2400 microgram im! | 500 microgram ? 2400 microgram Required Drug is (7) =2400 x 1 + 500 = 4.8 ml. Step 3: Second question is : For 24 hrs how much of normal saline should be added to the solution. We need 24 mi of the solution to administer 4.8 ml of the drug over 24 hrs, We need to dilute the drug using saline to make it up to 24ml. 24 ~ 4,8ml = 19.2 ml. We need 19.2 ml of saline to dilute the drug to make a 24ml of solution, Step 4 (only if you get a decimal point in the answer like above, if not go straight to step 5) Now calculate for 30hrs to make a solution for 30 hrs Instead of 24 (We can discard the excess of 6ml from the prepared solution at the end) 86© PLAB Right, Limited @) PLAB Right timitea Follow the same steps from 1- 3. The new answer Is 6ml of Fentanil and 24 ml of saline. If you get a decimal point in the answer for 30hrs of administration, then go to step 6 Step 5 Preparation: 1. Write the label 2. Wash your hands 3. Wear non sterile gloves 4, Get all equipments 5. Check expiry date of the drug 6. TAKE 30 mi Syringe 7. Draw the amount of drug 8. Dilute by adding normal saline to make it to 24m! 9, Stick the label, discard the waste to sharps/ yellow bin appropriately Step 6 Preparation when you have a decimal point in the amount of drug to be taken Preparation: 1, Write the label (write the amount of drug, that you have calculated for 24 hrs) 2. Wash your hands 3. Wear non sterile gloves 4, Get all equipments 5. Check expiry date of the drug 6. TAKE 30 ml Syringe 7. Draw the amount of drug nearest to the decimal 8. Use a one ml syringe to draw the fraction 9. Add the content of Iml syringe to 30ml syringe 10. Dilute by adding normal saline to make the solution to 30m! 11, Discard the 6ml to kidney tray 12. Stick the label; discard the waste to sharps/ yellow bin appropriately [Link] Weight of the patient is 12 kg Required dose is 15 micro grams /kg/hr Concentration of the drug is 1 ml = 0.5 mg ‘A, Make a solution at one mi/hr for 24 hours ? B. How much normal saline is there in your prepared solution? Drug = 24 hrs x req dose in micrograms x wt of the patient = 24 x 15 x 12kg =4320 micrograms/24 hrs. Answer: 8.64 ml. 3 PETHIDINE 87© PLAB Right iimicea™ Weight of the patient is 10 kg Required dose is 15 micro grams /kg/hr 1 ml = 500 micro grams A. Make a solution at one ml/hr for 24 hours ? B. How much normal saline is there in your prepared solution? ANSWER =7.2 ml. 4. MIDAZOLAM WEIGHT OF THE PATIENT Is 40 KG REQUIRED DOSE is 20 micro grams /kg /hr imi = 1mg. A, Make a solution at one mi/hr for 24 hours ? B. How much normal saline is there in your prepared solution? 5. Morphine Weight of the patient is 3 kg Required dose is 60 micro grams /kg /hr imi = 10mg. A, Make a solution at one mi/hr for 24 hours ? B. How much normal saline is there in your prepared solution? 6. Morphine Weight of the patient is 3 kg Required dose is 20 micro grams /kg /hr 1ml = 10mg. ‘A. Make a solution at one mi/hr for 24 hours ? B. How much normal saline is there in your prepared solution? . Midazolam Please prepare a solution of Midazolam for Mr Si hour. Prepare solution at one mi/hour for 24 hours Concentration is 1 ml = 1 mg. h. He should be given 0.5 mg of Midazolam per INSULIN Question: Weight of the patient is 40 kg Required dose is 0.05 units /kg /hr A mi of insulin is = 4 units A. Make an insulin infusion for 5 hours . Step 4: Calculate required units of insulin 5 hrs x required dose in units x wt of the patient 5 x 0,05 x 40 kg =10 units. Step 2: 88© PLAB Right iimiced”” Calculate the amount of insulin Imi = 4units ; 10 units = 2.5 mis of insulin. Step 3: Write label, wash your hands and check expiry date. Take an appropriate syringe and put needle. First take out the 2.5 ml of solution from the 500ml bag. Discard that syringe and needle. Take another set of syringe and needle. Inject 2.5 mls of insulin to the 500m! bag Special notes: If concentration of the drug or insulin (1m = xxmg) then please look at the drug vial, it will contain that information In case of insulin, if the concentration is not given on the vial as well, then please use the unit syringe. 89© PLAB Right Limited @ PLAB Right timiea Knee Joint Examination ition Hip Joint Exami Shoulder Joint Examination Hand Examination Spine Examination ‘Ankle Examination Surgery History Abdominal Examination Examination of fall outstretched arm Hematuria PR Bleeding PAIN IN RIGHT UPPER QUADRANT Lower abdominal Pain Urinary Retention Testicular Pain Hemetemesis ‘Assessment for day case surgery Intermittent Claudidation Ulcer on the back Surgery Counsel Vasectomy Colonoscopy Hernioraphy ‘Appendicectomy TURP Irritable Bowel Syndrome Hemicolectomy Testicular Lump Endoscopy ‘Telephone Conversation Post Operative infection Cancellation of surgery due to obesity Cancellation of surgery due to anaemia MRSA Nephrectomy Dysphagia: Seen in medicine Total Hip Replacement Total Knee Replacement© PLAB Right Limited @ PLAB Right timitea ABDI ‘ION. Greeting/Introduction. 2. Establishes identity of the patient/rapport. 3. Empathy/checks the comfort of the patient, 4. Explains purpose of visit/nature of exam. 5. Takes consent for examination. 6. Appropriate exposure. 7. Go to the foot end of the bed. 8, Inspect the abdomen for ; a. Skin changes/ Pigmentation b. Hair distribution ¢. Distension d. Swelling e, Scars f, Stomas g. Movement with respiration fh. Umbilicus and its shape and any discharge i. Dilated veins j. Gynecomastia 9, Then examine the hands for: a. Clubbing b. Splinter haemorrhages Erythmea ‘Sweating Dupurtyren Contracture Pigmenattion Kollonychias Leuconychia i. Radial pulse 10. Then examine the face and mouth for : a. Pallor b. Jaundice cyanosois c. Spider naevi d. Parotid swelling e. Angular stomatitis f. Glossitis 4g. Oral hygiene h. Oral ulcers 11. Then ask the patient if they are sore anywhere and if so where palpate their last. Bend down to the level of the abdomen. Begin superficial palpationand palapte all nine areas of the liver. Then perform deep palpation in all nine areas. 12, Palpate Liver. Ask patient to breathe deeply . Place your hand below the right costal margin. As the patient breathes in move your hand up the abdomen and attempt to feel the liver as the patient breathes out. If Liver is felt this indicates hepatomegally so begin percussing the right chest until percussion note changes from resonant to dull. Then measure and state the liver span. Fempas@ PLAB Right iimitca™ 13. Palpate Spleen. Begin deep palpation in the right illac fossa all the way upto the left flank you can also ask patient to roll towards you slightly making aplaption of this organ easier if enlarged. 14. Palpate Kidneys. Place one hand behind the kidney and attempt to push it up while feeling for it with the other hand placed just below the costal margin laterally. Do for both sides. 15. Palpate for any impulses. 16. Percuss ALL NINE QUADRANTS. 17. Check for shifting dullness. 18. Auscultate for bowel sounds place stethoscope over the ileocecal valve area and listen . 19. Say you would like to complete the examination by examining the hernial orifices as well as the external genitalia and perform a digital rectal examination. 20. Thank and cover the patient. EXAMINATION OF FALL ON OUT STRECHED HANI 1. Greeting/introduction. 2, Establishes identity of the patient/rapport. 3. Empathy/checks the comfort of the patient. 4. Explains purpose of visit/nature of exam. 5. Takes consent for examination. 6. Appropriate exposure. 7. Find a pillow to make patient more comfortable if possible 8. Look for the following: a. Lacerations b. Deformity c. Bruising d. Under surface of elbows 9. Feel for the following: a. Temperature b, Tenderness- feel from the top down starting at the clavicle working down towards the hand Ulnar deviation . Vascular status of upper limb including capillary refill Ask patient to push thumb against the palm of the normal hand Ask patient to bend their fingers for you 11. Xerayst 3 views ask for scaphoid view and bone scan and CT if necessary. 12. Cast: Some casts may be present choose the one that covers the thumb and starts just below the elbow, shaped in the glass holding position. Will be worn for six weeks approximately. 13. Advice: a. Keep the hand elevated by wearing a sling b. Keep the fingers moving c, Give painkillers for pain d. If the fingers swell and there is pins and needle sensation come to hospital immediately. Compartment Syndrome. 14, Thank the patient for cooperation In Plab, in orthopaedics examination, please examine the affected joint only. There is no role for tone, power and reflex. All lower limb examination begins with gait examination Gait - It is a style of walking Gait appears to be normal or gait appears to be abnormal@ PLAB Right iimied™” Always examine joint line in flexion. ‘Always begin paipation by checking the temperature first. Always palpate the tender area in the last Hematuria - Introduction: Open Question:Can you tell me more about this problem? Duratuion: Since how, have you had this problem? ‘Onset: Did it start suddenly? Did any thing significant happened around the time? (truma) Progress> Is it increasing day by day? Nature of the symptom Colour? Frequency, through the stream, beginning or end Is it mixed with the water? Is it painful or painless? Any clots? DD UTI ~ Do you have fever? Ureteric colic ~ Do you have pain on the side of tummy? Cancer bladder ~ How is your appetite? Have you lost any weight? Have you noticed any lumps anywhere in the body? Bleeding problem ~ Do you bleed from elsewhere? Medical history ~ Do you have any medical illness? Surgical history - Have you had any operations in the past? Medicine - Are you taking any medicine? Family history ~ Is there any disease which runs in your family? Is there any one in your family who had similar problem? Social history - What is your occupation? With whom do you live? Do you smoke? Do you drink alcohol? Are you able to manage your daily routine activity? Do you want to tell me anything more? Past Medical History Medications, Allergies, hospital admissions and surgeries PR BLEEDING Introduction: Open Question:Can you tell me more about this problem? Duratuion Onset: Did it start suddenly? Progress> Is it increasing day by day? Nature of the symptom Colour? Fresh? Does it get flushed easily? Quantity? Is it mixed with stool? Consistency Associated with pain DD IBD ~ Do you have tummy pain? Have you noticed any slime in your stool? ‘Anal pressure ~ Do you feel pain when you open your bowel?@ PLAB Right timitea Piles ~ Do you stain your toilet tissue? Cancer - Do you have incomplete sensation of evaluation? How is your appetite? Have you lost any weight? Have you noticed any lumps or bumps in your body? Medical history - Do you have any medical illness? Surgical - Have you had any operation in past? Drug history - Do you take any medicine? Family history - Is there any disease which runs in your family? Is there any one in your family who had similar problem? Social history - What is your occupation? With whom do you live? Do you smoke? Do you take alcohol? Are you able to manage daily routine activity? Have you been abroad any time? Do you want to tell me anymore? Past Medical History Medications, Allergies, hospital admissions and surgeries PAIN IN RIGHT UPPER QUADRANT Introduction: ‘Open Question:Can you tell me more about this problem? Duratuion: ‘Onset: How did it start? Any thing happen at the time? (Trauma) Progress> Is it increasing day by day? Nature of the symptom. Severity 0-10 Character of the pain (Sharp, Dull) Continues or episodic If episodic what brings it on? Site and Radiation ‘Aggravating and reliving factors Associated symptoms: Vomiting, Nausea, diarrhoea, Constipation, loss of appetite, Fever pp CHOLECYSTITIS - Do you have any shoulder tip pain? Is It related to eating fatty foods? Does the pain increases on breathing in? Ulcer ~ Does the pain become less after eating? Have you noticed any black coloured stool? Hepatitis - Have you vomited? Do you any itching of the skin? Pneumonia - Do you have any fever? Cancer ~ How is you appetite? Have you lost any weight? Have you noticed any lumps and bumps in your body? Medical history ~ Do you have any medical illness? Surgical history - Have you been operated any time? Drug history- Are you taking any medicine? Family history - Is there anyone in the family who is having similar problem? Social history ~ What is your occupation? With whom do you live? Do you smoke? Do you take alcohol? Are you able to manage your daily routine activity? Do you want to tell me anything more? Past Medical History Medications, Allergies, hospital admissions and surgeries© PLAB Right Limited Oy PLAB Right Limited LOWE! NAL Introduction: Open Question:Can you tell me more about this problem? Duratuion: Onset: How did it start? Any thing happen at the time? (Trauma) Progress> Is it increasing day by day? Nature of the symptom Severity 0-10 Character of the pain (Sharp, Dull) Continues or episodic If episodic what brings it on? Site and Radiation Aggravating and reliving factors Associated symptoms: Vomiting, Nausea, diarrhoea, Constipation, loss of appetite, Fever bp Common Causes Constipation Irritable bowel syndrome Diverticulitis, Lower ureteric stones, urine tract infection, Bladder infection or cystitis, Obstruction Think of the following in addition to the above in female patients Pelvic inflammatory disease, Ectopic pregnancy, endometriosis, Fibroids, Polycystic ovarian syndrome. Torsion of ovary ‘Think of the following in Male patients in addition to the above list of common causes Epidydimus Testicular Torsion UEINARY RETENTION Introduction: Open Question:Can you tell me more about this problem? Duratuion: Onset: How did it start? Sudden or gradual Progress> Where you finding it difficult to pass water? For how long? How did this problem progress?© PLAB Right Limited @ PLAB Right timitea BHP Frequency ~ How many times do you pass water? Nocturnal frequency ~ Do you wake up at night to pass water? Urgency ~ Do you have to rush to toilet once you get the urge? Urge incontinence ~ Have you passed water before reaching toil Stress incontinence ~ Do you pass water when you cough? Stream ~ How is your flow? Do you dribble at the end? Hesitancy - Do you have to wait on the toilet to pass water? Dysuria ~ Do you have any pain when passing water? Medical history ~ Do you have any medical illness? Surgery ~ Have you had any surgery in past? Drug history~ So you take any medicine? Family history ~ Is there any disease which runs in your family? Is there anyone in the family who is having similar problem? Social history - What is your occupation? With whom do you live? Do you smoke? Do you take alcohol? Are you able to manage your daily routine activity? Do you want to tell me anything more? Past Medical History Medications, Allergies, hospital admissions and surgeries TESTICULAR PAIN Introduction Open Question: Can you tell me more about this problem? Duration: Onset: How did It start? Any thing happen at the time? (Trauma) Progress> is it increasing day by day? Nature of the symptom Site, both sides? Severity 0-10 Character of the pain (Sharp, Dull) Continues or episodic If episodic what brings it on? Site and Radiation Aggravating and reliving factors Associated symptoms: Vomiting, Nausea, diarrhoea, Constipation, loss of appetite, Fever 2D TESTICULAR TORSION: Do you have tummy pain? Have you vornited? UTI ~ Do you have discharge down below? Do you have pain while passing water? Strangulated hernia - Do you have constipation? Do you have distension of tummy? Cancer of testis ~ How is your appetite? Have you lost any weight? Have you noticed any lumps or bumps in you body? Medical history ~ Do you have any medical illness? Drug history - Do you take any medicine? Surgical history ~ Have you had any surgery in past? Family history ~ Is there any disease which runs in your family? Is there anyone in the family who is having similar problem? Social history ~ What is your occupation? With whorn do you live? Do you smoke? Do you take alcohol? Are you able to manage your daily routine activity? Do you want to tell me anything more?© PLAB Right Limited @ PLAB Right timitea Past Medical History Medications, Allergies, hospital admissions and surgeries MES} MAI Introduction: Open Question: Can you tell me more about this problem? Duration: Onset: How did it start? Did any thing cause the problem? Progress> Nature of the symptom Melina: Colour? Fresh? Does it get flushed easily? Quantity? Is it mixed with stool? Consistency Associated with pain Hemetemesis: Colour? Quantity, Associated with pain? BD HEPATITIS: Have you had any blood transfusion in the past? Have you had any operation in the past? Do you take any recreational drug? Have you ever shared any needle? Do you have any tattoos? Cirrhosis - Do you have any tummy distension? Ulcer ~ Do you have any tummy pain? What is the colour of your stool? Cancer - How is your appetite? Have you lost any weight? Have you noticed any lumps or bumps in you body? Medical history - Do you have any medical illness? Drug history - Are you taking any medicine? Surgical history ~ Have you had any surgery in past? Family history ~ Is there any disease which runs in your family? Is there anyone in the family who is having similar problem? Social history - What is your occupation? With whom do you live? Do you smoke? Do you take alcohol? Are you able to manage your daily routine activity? Do you want to tell me anything more? Past Medical History Medications, Allergies, hospital admissions and surgeries Assessment for day case surgery ~ Pre anaesthetic Assessment of 3 questions 1, How is your general health? 2. Any problems with your heart or chest? 3. How is your bowel? How is your bladder? How is your appetite 4. Have you been hospitalised in any hospital, at anytime, for any reason? 5. Did you have anaesthesia in the past 6, Was there any problem during anaesthesia? 7. Is there anyone in your family who has had any problem during anaesthesia? 8, Do you have any medical illness? If yes ~ Since how long has it been controlled? 9. Do you take any medicines? If yes ~ Since how long have you been taking? 10. Are you allergic to any medicine? 11,Do you smoke? 12. Do you take alcohol?@ PLAB Right timitea 13. How far is your house from hospital? 14, Who will look after you for the first 24 hours? 15. Do you have a telephone at home? ITERMITTE! IN Introduction: Open Question: Can you tell me more about this problem? Duration: Onset: How did it start? Progress> is it increasing day by day? Nature of the symptom Site, both sides? Severity 0-10 Character of the pain (Sharp, Dull) Continues or episodic If episodic what brings it on? How long can you walk before getting the pain Aggravating and reliving factors Do you have pain at rest? Do you get relief from pain after taking rest? Do you have any ulcer in your leg? BUERGER'S DISEASE: Neurogenic cause ~ Do you have back pain? Do you have pain in the buttocks and back of thigh? Do you have weakness in your leg? Trauma - Have you injured yourself? Cellulitis - Do you have a fever? Medical history - Do you have any medical illness? Drug history - Are you taking any medicine? Surgical history ~ have you been admitted to hospital any time? Family history ~ Is there any disease which runs in your family? Is there anyone in the family who is having similar problem? Social history - What is your occupation? With whom do you live? Do you smoke? Do you take alcohol? Are you able to manage your daily routine activity? Do you want to tell me anything more? Thank you Past Medical History Medications, Allergies, hospital admissions and surgeries WOMEN WITH ULCER IN BACK Introduction: Open Question: Can you tell me more about this problem? Duration: Onset: How did it start? Any significant event (Trauma, injury, burns) Progress Nature of the symptom© PLAB Right Limited @) PLAB Right timitea Site, Size, Shape, Colour, Discharge, Pain? Is it regular? Is it spreading? pb Infection ~ Do you have any fever? Have you noticed pus from the ulcer? Skin cancer (SCC/melanoma) ~ Have you had any sun burn in the past? Do you use sun beds? Do you have any skin problem? Trophic ulcer - Have you been immobilised for a long time? Do you have any medical illness? Are you taking medicine? Lam going to examine you. I will take swab from the ulcer to see which bug is present and Lansing the ulcer. We will take some cells also for biopsy to know whether cells are normal or abnormal. VASECTOMY This is a permanent procedure. This is a minor procedure. It is done under local anaesthesia in which we will numb the area above the testis by injection. Duration of this procedure is about 10-15 minutes. We will put incision above the testis. Then we will cut the sperm tube which is known as vasdeferus and we will tie the both ends of the tube. You are not going to be sterile immediately after the procedure. We will check your semen for sperms on two occasions, after 3 and 4 months. If there is no sperm in the semen on both occasions then we will declare you sterile. This procedure does not affect virility. If patient asks, then only answer this question Reversal of the procedure can be done but results are extremely poor. Complication ~ Pain, infection, injury to surrounding structure. Do you want to ask me anything? Thank you SOLONOSCOPY What do you know about it? This is a painless procedure. This is a camera test. This is simple routine procedure. This is done under sedation. Before the procedure, we will prepare your bowel by giving medicine 2 days before. Medicine is a laxative. In this procedure, we will pass gas from back passage to distend the tummy so that visualization will be easy. We will pass one tube with camera through the back passage and we will see inside your tummy or bowel. ‘The duration of this procedure is about 10-20 minutes. Rarely may we not be able to see the bowel properly, and then we will repeat it on a later date. If we see any abnormal growth, then we will take tissue biopsy. Complication - You may bleed for a day or two if biopsy is taken. Bleeding is usually very small in quantity. Very rarely perforation of the bowel. Precaution — For the first 24 hours please do not drive, do not drink alcohol and do not work near machinery. HERNIORRAPHY Hernia Is an abnormal protrusion of an organ through normal or abnormal opening. In your case it is coming out though tummy wall and is containing small portion of bowel. This procedure is done under general anaesthesia in which we will put you to sleep. Duration of operation is 20-30 minutes. It is done by keyhole surgery. Three small hooks will be made on the tummy. One at the belly button and two at the lower tummy. Through one hole at the belly button we will put gas to distend the tummy, so that we can see the inside of the 10@ PLAB Right iimiea” tummy clearly. Through other holes at lower tummy, we will put instrument. We will push the content of the hernia back in the tummy and we will reinforce the tummy wall by putting one mesh. ‘You will wake up in the recovery room. Complication - Pain, bleeding, infection, injury to surrounding structure. Appecndicectomy: Understand the concerns, and the knowledge they already have Explain about the appendicitis (If needed) Appedicitis Is inflammation of appendix. The appendix is a small pouch that is connected to the colon (large intestine) and is located in the lower right side of the abdomen. The inflamed appendix will have to be surgically removed ina procedure known as an appendectomy. Explain only that is relevant (Question may tell if it is laparoscopic or conventional. If the question do not specify then you will have to decide on the method Traditional appendectomy, will be required in the following conditions © where the appendix has burst © people who have tumors ‘women who are in the first of pregnancy «people who have had repeated previous abdominal surgery and may have adhesions Laparoscopy We will make a number of small incisions in your abdomen, through which the we will insert a small tube that contains a light and a tiny video camera (a laparoscope). This allows us to see the inside your abdomen in great detail without having to make a large incision. The appendix can then be removed through the incisions. The advantage of a laparoscopic appendectomy is that it leaves minimal scarring and the recovery time is a lot quicker. Most people having a laparoscopic appendectomy will be able to leave hospital a few days after the operation, although it may be one to two weeks before you fully recover. Traditional appendectomy A traditional appendectomy will leave a larger scar about 4 ~ 6 inches long and it may be a week before you are well enough to leave hospital. The procedure will include removal of the inflamed appendix. Complications Peritonitis Abscess. Bleeding Pain and Infection IRRITABLE BOWEL SYNDROME Alll results are encouraging, but it does not mean that you do not have any problem. We have come to a diagnosis called IBS. What do you know about it? There is No test which can confirm IBS. It is a condition in which people get tummy problem. Exact cause is not known. However stress is closely linked to this condition. It is a treatable disease but not curable. As 1 told you the exact cause is not know, so there is no exact treatment for IBS. Simple measures can help you a lot. They are 1. Do gentle and regular exercise 2. Eat healthy and balanced diet© PLAB Right iimiced”” 3. Keep an eye on food which causes problem 4. For pain - We give antispasmodics for diarrhoea ~ anti motility drugs. 5. Attend stress management courses It does not cause Cornell, 18D and coltts. Do you have any questions? Thank you HEMICOLECTOMY ‘As you know that you have got cancer of the bowel. For this reason we are going to open your tummy, and then we will take out the portion of bowel which contains the cancer. Before the operation, we will prepare your bowel by giving you medicine and laxative. This is a major operation and is done under general anaesthesia in which we will put you to sleep. Duration of operation is 1-2 hours. In this operation we have decided to perform one procedure called colostomy. What do you know about it? In this operation, we will attach the upper end of the bowel to the front of the tummy wall skin. The opening on the skin Is called stoma. This colostomy can be permanent or temporary. It depends on the patient's condition. This stoma is an artificially back passage on the front of the tummy. Instead of passing stool from the back passage, you will pass your stool from this stoma. We will give you stoma bag which has been allocated to the stoma. In this stoma bag stool will be collected. Initially you may need to change it frequently, but later on you will get used to it and you will change it once or twice a day. Now a day, stoma bags are colourless and odourless. You can perform almost all activities with it. Our Stoma nurse will tell you more about it. What can I eat? You can eat anything, but keep an eye on food which causes problem. Can I play football? Please avoid playing any contact sports. Can I go abroad? Yes What about winds - Avoid eating foods which can cause wind formation like peas, onion etc, Any precaution - Contact us whenever there is bleeding from the stoma. Severe abdominal pain and vomiting several times. Reversal of operation - We may do it after 3-4 months if everything is fine. This operation is easy to perform and takes less time to recover. TESTICULAR LUMP On examination, I found a lump in the testis. This lump can be harmless or sinister. At the moment it is a clinical finding. Now we are going to do the scan of the testis to know whether it is arising from testis or separated from the testis. If it is separated from the testis and cystic then is a harmless condition. Then we may do surgery if it gives you pain or cosmetic reason. If it is arising from the testis and solid in consistency then it can be sinister, Then we will do some blood tests which will measure hormone levels. Hormones are chemical substance and we will take out the testis for the biopsy to know whether cells in the testis are normal or not. It is important to take the testis because of the fear of spillage of abnormal cells else where in the scrotum, If cells are abnormal, then we will refer you to a specialist doctor. Can I be a father of a child? Yes How is the prognosis? Excellent if treated in the initial stage. ENDOSCOPY This is a routine camera test in our hospital. This is a painless test and done under sedation. Please do not eat anything 4 hours before the test. You will lie on the couch on your side and a mouth guard will be applied so that you will not brush the tube. This test sees the inside of the turnmy and food pipe. The duration of this test is about 10-20 minutes. If some abnormal areas are present then we will take biopsy. Complications are rare but 1 am duty bound to tell you. 4, Bleeding ~ In small amount if biopsy is taken for a day or two 2. Perforation very rarely 12@ PLAB Right iimica” Precaution ~ Do not drink alcohol and or drive for first 24 hours. Do not work near machinery. TELEPHONE CONVERSTAION Your communication skills witll be assessed in this station. Examiner will took for clarity of the information provided and structure. This station can also turn in to viva station and examiner can ask you some questions about the management. Do not assume anything, Just provide the information given and explain what you would like to do next, Hello, may I speak to on call surgeon Dr__. 1 am Dr. . Lam sorry to bother you. Are you busy at the moment? I am going to talk to you about one patient. The name of the patient is and he is years old. He came to hospital with pain in abdomen along with distension and vomiting. He is having painful lump in the groin. Most probably he is having intestinal obstruction secondary to strangulated hernia. He is conscious at the moment vitals are stable. On examination — he has generalised destention of tummy, exaggerated bowel sounds, no rigidity and guarding. Twill request for full blood count, x-ray erect abdomen and USG of the time and ordered for cross matching. Management NBM, NG tub, 2 wide bore cannula, fluids, monitoring vitals after every 15 minutes, applied catheter, maintaining input/output chart, informed on call anaesthetist and theatre staff along with surgical registrar. Informed the patient about his condition. Do you want me to do anything? Please come and see the patient? Thank you POST OPERATIVE INFECTION MANAGEMENT Twill admit you and I will examine you. I will take a swab from the wound and send it to the lab to know which bug is causing it and we will give you the right appropriate antibiotic. At the same time we will remove sutures and when infection heals, then we will take you to operation theatre and we will put another new suture. POST OPERATIVE INFECTION MANAGEMENT ‘As you know pain after surgery or operation is of high intensity because of this reason we are not going to use Brufen or Brufen like painkillers. In your case, we will give you codeine. codeine is a member of opoid group and quite effective in controlling post operative pain. However, it can cause constipation along with drowsiness and dryness of mouth, But this disappears after some time. Suppose, if this pain does not disappear or becomes less then we may have to use morphine. what do you now about morphine? Morphine is a painkiller and belongs to opoid family. I do not want morphine? Why? Iam a teacher. morphine is an excellent painkiller if taken in the right amount. Can I become addicted? No. We are using a small dose for a short period, so chances are less If this is not working, then we will give you morphine through syringe pump called patient controlled analgesia. In this syringe morphine is kept and through a small tube morphine is injected inside the skin. Whenever patient is feeling pain he can switch on the syringe and relieves a constant dose. This is a highly effective method of pain relief. Usually almost all patients get pain relief by this method.© PLAB Right Limited @ PLAB Right timitea TOTAL KNEE REPLACEMENT: In this station, you may be asked to explain the procedure and its ‘complications and benefits fo the patient and thus take an informed consent, Or, you may be asked to talk to the patient and address his/her concems about the procedure, Its complications, duration of stay in the hospital, precautions to take after the operation, etc. Procedure: It is a major operation. An incision is given on the front of the knee and the worn out joint surfaces of the thigh and shin bone are resurfaced with metal or plastic. It is done under general anaesthesia, in which we shall be putting you to sleep. One of my anaesthetic colleagues will come and discuss the complications of anesthesia with you. All being well, the procedure should not take more than ‘one and a half hour. Complications: 1. Pain: You can have some pain after the procedure, but please don’t worry, we shall give you a ‘combination of painkillers immediately after the procedure so that you don't feel any pain. 2. Wound infection: Rarely, the wound may become infected. But, please don't worry, our surgeons use sterile techniques. And even if it does happen, we shall give you antibiotics to relieve the infection 3. Bleeding: Rarely, there could be bleeding from the wound site. Our surgeons are very competent. They shall manage any such complication if it does arise. 4. Injury to surrounding structures. 5. Clots in legs and lungs (DON'T MISS THIS COMPLICATION): There is always a risk of development of clots in legs and lungs after such surgeries. But, we shall give you blood-thinning medications, give you compression stockings to wear and shall mobilize you as soon as possible after surgery in order to minimize the risk. After the procedure: The physiotherapist will visit you on the same day of the operation and shall help you sit up in bed. He may also help you walk with a Zimmer frame. It is very important to mobilize you after ‘surgery. It improves blood circulation and reduces the risk of formation of clots. When will you discharge me? It al depends on how you recover after the operation. When you are able to bend your operated knee to 90 or more than 90 degrees; and when we are sure that you can walk independently with support and take care of yourself at home, my Consultant shall discharge you. But usually, itis about 3-5 days. Precautions at home: 1. Avoid high-impact sports like football, hockey, ete. You can swim though. 2. Donot kneel on your knees. 3, Take measures to reduce swelling of the knee by using ice packs (ice cubes packed in a towel), compression stockings and elevation of leg (do twice a day for 5 mins — by placing a few pillows beneath the foot) 4, Do exercises taught by physiotherapist regularly When can I go to work? Enquire about nature of work first! Adequate rest is very important, Sedentary work can be started after a rest of 4-6 weeks. A longer duration of rest is required otherwise. When can | drive? Give time for recovery. When you are comfortable you can make an emergency stop, you can drive, But avoid driving for 4-6 weeks, We shall be able to tell you better about this in your future follow-up appointments, Follow-up: After two weeks. Removal of sutures: One to two weeks, at GP Surgery.© PLAB Right Limited @ PLAB Right timitea TOTAL HIP REPLACEMENT: Replacement of diseased head of thigh bone and hip socket with an artificial hip joint, which is made up of either metal or plastic. HEMIARTHROPLASTY: Replacement of just the diseased head of thigh bone with an artificial head. The hip socket is not replaced In this station, you may be asked to explain the procedure and its complications and benefits to the patient and thus take an informed consent. Or, you may be asked to talk to the patient and address his/her concems about the procedure, its complications, duration of stay in the hospital, precautions to take after the operation, ete. Procedure: This is a major operation, which is done under general anaesthesia. An incision is given on the side of hip and the diseased hip joint replaced with an artificial one, One of my anaesthetic colleagues will come and discuss the complications of anesthesia with you, All being well, the procedure should not take more than one and a half hour. Complications: 1. Pain: You can have some pain after the procedure, but please don't worry, we shall give you a combination of painkillers immediately after the procedure so that you don't feel any pain. 2. Wound infection: Rarely, the wound may become infected. But, please don't worry, our surgeons use sterile techniques. And even if it does happen, we shall give you antibiotics to relieve the infection. 3, Bleeding: Rarely, there could be bleeding from the wound site. Our surgeons are very competent. They shall manage any such complication if it does arise. 4, Injury to surrounding structures 5. Clots in legs and lungs (DON'T MISS THIS COMPLICATION): There is always a risk of development of clots in legs and lungs after such surgeries. But, we shall give you blood-thinning medications, give you compression stockings to wear and shall mobilize you as soon as possible after surgery in order to minimize the risk. After the procedure: The physiotherapist will visit you on the same day of the operation and shall help you sit up in bed, He may also help you walk with crutches. It is very important to mobilize you after surgery. It improves blood circulation and reduces the risk of formation of clots. Early mobilization and physiotherapy also helps to strengthen the muscles of the legs. When will you discharge me? It all depends on how you recover after the operation. When we are sure that you can walk independently with support and take care of yourself at home, my Consultant shall discharge you. But usually, itis about 7-10 days. Precautions at home: 4. Donot bend the hip beyond an L position Do not twist on your operated leg Do not cross your legs, Do not squat, Do exercises taught by physiotherapist regularly, When can I go to work? Enquire about nature of work first! Adequate rest is very important. Sedentary ‘work can be started after a rest of 4-6 weeks. A longer duration of rest is required otherwise, When can | drive? Give time for recovery. When you are comfortable you can make an emergency stop, you can drive. But avoid driving for 6-8 weeks. The occupational therapist shall arrange for any necessary arrangements to the driving seat. We shall be able to tell you better about this in your future follow-up appointments. Follow-up: After two weeks. Removal of sutures: One to two weeks, at GP Surgery. RADICAL NEPHRECTOMY: Removal of the kidney, the adrenal gland, the tube conneeting the kidney to the water-bag and other tissues around the kidney. Procedure: This is a major operation, which is done under general anaesthesia. An incision is given on the side of belly and the diseased kidney and the surrounding tissues removed. One of my anaesthetic colleagues will come and discuss the complications of anesthesia with you. All being well, the procedure should not take more than one and a half hour. Complications:© PLAB Right ‘imi Pain: You can have some pain after the procedure, but please don't worry, we shall give you a combination of painkillers immediately after the procedure so that you don’t feel any pain. 2. Wound infection: Rarely, the wound may become infected. But, please don’t worry, our surgeons use sterile techniques. And even if it does happen, we shall give you antibiotics to relieve the infection. 3. Bleeding: Rarely, there could be bleeding from the wound site, Our surgeons are very competent. ‘They shall manage any such complication ifit does arise. 4, Injury to surrounding structures, OPERATION CANCELLED DUE TO OBESITY: In this station, you shall be asked to tell the patient that his surgery is unlikely because he is overweight. Inform the patient of the complications that surgery can pose in an overweight person and tell him about measures to take to lose weight. Surgery is safer and more effective for people with a healthy weight, Patients who are overweight are much more likely to suffer serious, sometimes life-threatening, complications as a result of surgery. + Serious breathing problems + Infections: + Heart, kidney and lung complications + Longer recovery - meaning more time in hospital + Ahhigher risk of dying whilst under anaesthetic A small weight loss can reduce these risks dramatically. The more you lose the better it will be for your long term good health. You will reduce the risk of = Diabetes + Heart disease + Stroke “Cancer + Dying early Measures to take: Referral to DIETICIAN for advise on proper diet containing less fat. Also, referral to PHYSIOTHERAPIST for advise on exercise, OPERATION CANCELLED DUE TO ANAEMIA: In this station, you shall be asked to tell the pationt that his operation has been cancelled because he has been found to be anemic. Ask him if he knows what ‘anaemia is? Anaemia is lack of pigment in the blood which we called haemoglobin. Haemoglobin carries, ‘oxygen to lissues, so anaemia is decreased oxygen carrying capacity of blood. Risks of surgery in an anaemic patient: 1. All surgeries carry a risk of bleeding. Any bleeding during surgery will put an unusual load on the heart and cause severe complications. This could be life-threatening as well 2. Delayed wound healing. 3. High risk of infection, Itis important to correct the anaemia before operating on you, Car't this anaemia be corrected by blood transfusions? Well, we shall have to find the cause of this anaemia first. And we shail treat the cause. And for that, we shall have to carry out some investigations. MRSA Infection: The scenario usually given in the exam is of a lady who has had a C-section and whose surgical wound has been found to be infected with MRSA (known as Superbug). You shall be asked to address her concerns. Beware: This lady is quite distressed. Make sure you are very clear and convincing in what you say. Where did | get this infection from? This bug is present on the skin and nostrils in normal people. Normally, it does not cause any infection. It can cause infection in patients who have underwent surgery and who have an open wound, as in your case. (MRSA can also cause infection in patients who have been admitted in the hospital for a long time, elderly patients and particularly in those patients who are immunocompromised.) Will | die? There is no reason why we may not be able to treat you successfully. This is a potentially curable infection, This superbug is not more virulent than other bugs. It is just resistant to the common antibiotics. We shall have to use stronger antibiotics to kill this bug and that means you shall have to stay in© PLAB Right iimica” the hospital for a longer period of time. Plus we shall have to keep you in a special isolated room where you shall receive special care Can my family visit me? As long as your family members are healthy, they can visit you. Children, if healthy, can attend as well. Can | hold my baby? Yes. As long as your litte one is healthy, you can hold him. Gan | breastfeed my baby? Unfortunately, you cannot. We shall be giving you strong antibiotics and there is a risk they may pass on to your baby in breast milk and cause problems to him. TURP: Transurethral resection of the prostate (TURP) is a surgical procedure that involves cutting away a section of the prostate gland. The prostate is a small gland located between the water-pipe and the water-bag, and surrounds the water- pipe. When this gland enlarges, it constricts the water-pipe and cause problems, Procedure: A TURP is usually performed using a spinal anaesthetic (epidural) so you will be awake but you will lose all feeling below your waist and will feel no pain. During the procedure the surgeon will insert a thin metal wire with a loop at the end into your water-pipe and up against your prostate. An electric current heats up the loop which cuts away a section of the prostate. Recovery: Most men can leave hospital in 2-3 days after surgery and resume most normal activities within 1 week However, it can take up to 6 weeks before you are fit enough to return to work if your job is physically strenuous. Complications: Besides pain, wound infection, bleeding, the other important complications are retrograde ejaculation and urinary incontinence. ‘[Link] disadvantage is that men lose the ability to ejaculate semen out of their penis during sex or masturbation, although they still have the physical pleasure associated with ejaculation (the climax). This is known as retrograde ejaculation and can occur in 8s many as 9 out of 10 cases. ‘Another common disadvantage Is that men lose their ability to control their water-bag (urinary incontinence), although this usually passes a few weeks after surgery. TESTICULAR LUMP: In this station, you shall be asked to talk to a patient with a testicular lump. You may be given the clinical findings in the station and asked to talk to the patient about further management. Bows his patient is naturally distressed because of the testicular lump, therefore, talk clearly and convincingly. Be empathic. We have found a lump on examination. The lump can be hamless or sinister. At the moment, itis a clinical finding, Now we are going to do a TV scan of the testis to know whether it is arising from the testis or separated from the testis.@ PLAB Right iimica” If itis separated from the testis and solid in consistency, then there is a chance that it could be sinister. We shall do some blood tests to check for any rise in tumor markers. Tumor markers are chemicals in the blood ‘which can be raised in the presence of a tumor. If tumor markers are found to be raised, then unfortunately, we shall have to remove the testis by operation and send it to the pathologist for biopsy. The pathologist shall confirm whether the cells of the testis are cancerous or not. If cells are found to be cancerous, then we shall have to refer you to a cancer doctor. Is it important to remove the testis? Yes. If our suspicion of cancer is strong, we shall have to remove the testis. Otherwise, the cancer could spread to other areas of the body. Can Ibe a father of a child? As long as your other testis is fine, you shall have no problems. Will | be cured? Testicular cancer is a completely curable cancer if in treated in early stage. HERNIORRAPHY: Hernia is an abnormal protrusion of bowel through a defect in the tummy wall. Hemiorraphy is a surgical procedure in which we give an incision on the hernia, push the bowel back into the tummy and place a mesh over the defect which reinforces the tummy wall. All being well, the procedure should not take more than 30 minutes. ce ion: 4. Pain: You can have some pain after the procedure, but please don't worry, we shall give you a combination of painkillers immediately after the procedure so that you don't feel any pain. 2. Wound infection: Rarely, the wound may become infected, But, please don’t worry, our surgeons use sterile techniques. And even if it does happen, we shall give you antibiotics to relieve the infection, 3. Bleeding: Rarely, there could be bleeding from the wound site, Our surgeons are very competent. They shall manage any such complication ift does arise. 4. Injury to surrounding structures. When can | go to work? Enquire about nature of work first! Adequate rest is very important. Sedentary work can be started after a rest of 2-3 weeks. A longer duration of rest (4-6 weeks) is required otherwise. IT IS BETTER TO STOP STENUOUS WORK ALTOGETHER FOR FEAR OF RECURRENCE OF HERNIA When can I have sex? Give time for the wound to heal. When you have recovered enough and are comfortable, you can have sex. Give a few weeks for rest and recovery. When can | drive? Give time for recovery. When you are comfortable you can make an emergency stop, you can drive. But avoid driving for 3-4 weeks, Other advice: Avoid constipation. Take more fruit and vegetables. When will you remove the mesh? Removal of mesh is not required. The mesh is there to reinforce your tummy wall and prevent recurrence of hernia,@ PLAB Right © PLAB Right Limited Limited© PLAB Right Limited @ PLAB Right timitea PERIPHI EXAM 1. Greeting /Introduction. 2. Establishes identity of the patient, 3. Empathy/ Ensures comfort of patient. 4. Explains purpose of the visit/nature of the examination 5, Takes consent for examination. 6. Appropriate exposure. 7. Chaperone. 8. Again following steps must be performed in both legs. 9, INSPECTION, ‘a. Skin Changes. b. Hair changes. . Swelling. Pigmentation. Varicose veins. Scars. Temperature. Ulcers. Nails. Capillary refill. 10. Then check the temperature of both legs and compare them . [Link] about any soreness in the calves and check for tenderness to rule out DVT |. 12. Dorsalis Pedis Pulse- felt lateral to the to the extensor hallucis longus best felt at the proximal extent of the groove between the first and second metatarsals. Comment whether they are palpable and compare both sides. Do this for all pulses. i 1 Pulse- felt 2cm below and posterior to the medial malleolus . al Pulse- feel in the popliteal fossa and say that you are unable to appreciate the popliteal pulse, This is because if it is palpable then it is an aneurysm unless proven otherwise. 15. Femoral Pulse- felt midway between the anterior superior iliac spine and the pubic tubercle. Before doing so warn them that you are going to feel their groin area and then ask them if it is ok to do so. 16. Check for radio-femoral delay. 17. Check for radio-radial delay. 18. Radial pulse should be taken quickly comment on rate, rhythm, volume, and character. [Link]’s Test k. First of all confirm that there is no soreness in the patients legs. |. Raise a leg and hold it at the angle of 45 ° and hold till the superficial veins have collapsed and the leg goes white. m. Then place the leg at the side of the couch in a dependent position and observe for an intense rubor indicating peripheral vascular disease. 20. Palpate the abdomen and auscultate to rule out abdominal aortic aneurysm. 21, Auscultate the femoral arteries as well for bruit. 22. Then auscultate the heart all four areas and the carotid arteries. 23. Then check the power of the limbs. 24, Check sensation of the limbs. 25. Finish by saying that you would like to know the claudication distance as well as the Ankle Brachial Pressure Index and that you would also like to perform a Doppler scan. 26. Thank and cover up the patient. vrsespao© PLAB Right Limited @ PLAB Right timitea 65 yr old Mrs Smith had suffered coronary syndrome 2 yr back. Now she is getting breathless. Examine the cardio vascular system 1. Greeting/Introduction. 2. Establishes identity of the patient/rapport. 3. Empathy/checks the comfort of the patient. 4, Explains purpose of visit/nature of exam. 5. Takes consent for examination. 6. Asks for chaperone. 7. Appropriate exposure. 8. Start at the foot end of the bed. 9. INSPECTION. ‘a. Scars on chest or the leg indicating any bypass surgery. b. Check the chest is moving with respiration. Chest deformity. Any visible apex beat. Pallor. Cyanosis. Malar flush. Clubbing. Splinter haemorrhage. Janeway lesions/Oslers Nodes Palmar erythmea. Sweating . m. Capillary refill. hheral /Sacral edema. pulse comment on rate, rhythm, volume, character. 11. Then ask if patient is sore before checking for the presence of a collapsing pulse by holding the patients arm at the wrist and then lifting the arm. If it collapses indicates Aortic Regurgitation. 12, Then mention that you would like to take their Blood Pressure standing and lying if possible. 13. Then ask the patient to turn their head to left and look at the JVP and mention whether it is raised or not. 14. Ask if they are sore in the chest anywhere at all. 15, Then palpate the apex beat by using the palm of the hand and then localise it with three fingers then one finger. Mention if it’s a tapping or displaced beat. Also mention the location of the apex beat with reference to the intercostals space and anatomical lines. By counting down the intercostals spaces from the angle of louis. Often located in the fifth intercostals space In the midclavicularline, 16, Palpate for any thrills by placing the palmar surface of hands on the chest. 17. Palpate for any ventricular heave by palpating along the sternal lateral borders using the ulnar border of the hand.© PLAB Right Limited @ PLAB Right timitea 18. Auscultate all four areas. ©. Mitral Area ~Apex beat. p. Tricuspid Area — -Left sternal edge 4* intercostals space. q. Pulmonary Area -Left sternal edge 2 intercostals space. r. Aortic Area -Right sternal edge 2" intercostals space. s. Comment on S1 and S2 in all four areas by timing sounds with the radial or caro [Link] comment on any added heart sounds. t. Roll the patient to the left and listen at the apex using the bell to detect the mid- diastolic and pre-systolic murmur of mitral stenosis. u, Sit the patient up and forwards and then ask patient to breathe out fully and hold their breath. Then listen over the right second intercostals space and over the left sternal edge with the diaphragm for murmur of aortic incompetence. 19. Auscultate the carotids. 20. Ausculate the lung bases and also check for sacral edema so as to avoid moving patient too much. 21, Palpate the liver for enlargement. 22. Check for aortic abdominal aneurysm: 23. Examine peripheral pulses. 24. Thank and cover up the patient. Instruction to the actor. 1. You are breathless and uncomfortable. If the doctor asks for oxygen accept it. 2. Follow the instructions given by the candidate only if it is clear and you can understand it easily. . If candidate hurts you while doing the examination you need to scream to bring this to the examiner's attention.@ PLAB Right Limited @ PLAB Right timitea 44 Yr old Mr Jones is in your clinic. Examine his lymphoreticular system EXAMINATION OF LYMPHORETICULAR SYSTEM Greeting/Introduction Establishes identity of the patient Empathy/checks comfort of patient Explains purpose of visit/nature of examination Asks patient to undress ‘Asks for a chaperone Takes consent for examination General signs: a. Pallor b, Jaundice cc. Purpura/bruising d. Lymphedema fe. Temperature Skin for scratch marks, ulceration Checks for Bony tenderness Mouth: a. Tounge b. Gum bleeds ¢. Oral ulcers d. Tonsils Lymphnodes : palpates all groups systematically a. Cervical b. Supractavicular c. Axillary d. Epitochlear e, Inguinal f. Popliteal ‘Abdomen, a. Liver b. Spleen cc. Ascitis Testis Overall approach to the task Thanks the patient Instructions to the actor 1, Follow the instructions given by the candidate only if it is clear and you can understand it easily. 2. If candidate hurts you while doing the examination you need to scream to bring this to the examiner's attention.= - 3 = = @ PLAB Right timiea 34 Yr old Mr Hopkins has come to A& E because he is feeling unwell, Examine the spiratory system and report the findings to the examiner RATOI IN 1. Greeting/Introduction. 2. Establishes identity of the patient/rapport. 3. Empathy/checks the comfort of the patient. 4. Explains purpose of visit/nature of exam. 5, Takes consent for examination. 6. Asks for chaperone. 7. Appropriate exposure. 8. Start at the foot end of the bend and comment on the following: v. Shape of chest w. Any deformities x, Scars/Sinuses y. Lumps z. Rate of respiration aa. Mode of respiration bb. Pattern of respiration cc. Use of accessory muscles of respiration dd. Symmetrical movements with respiration. 9. Then go to the hands: ee. Clubbing ff. Cyanosis 9g. Wrist pain hh. Muscle wasting li, Flapping tremor- ask patient to extend the wrists as far back and hold them there. Jj. Nicotine staining kk, Pulse BP JVP 10, Check for pallor, icterus, cyanosis and edema. 11, Then before starting palpation check for any soreness, 12. Palpate for any crepitus. 13. Palpate the trachea checking whether it is approximately central it deviates to the right slightly this is normal. 14. Check the chest expansion in upper and lower zones. Upper zone - observe the clavicles from behind during tidal breathing. Lower zone - place your hands firmly on the chest wall with fingers extending around the sides of the chest. Your thumbs should meet in the midline and lifted slightly off the chest so they are free to move with respiaration. Ask patient to take a deep breath, your thumbs should move symmetrically apart at least 5 cm, 15, Check for vocal fremitus by placing hand on the chest at the upper level then ask patient to say “99” then place hand on the left side, Compare both sides and then repeat for the middle and lower zones as well. 16. Palpate the cervical, supraclavicular, infraclavicular and axillary lymph nodes. 17. Percuss the anterior of the chest above the clavicle on the clavicle directly and down the chest along rib walls alternating between right and left comparing percussion note, 5@ PLAB Right iimiced™” 18. Then percuss the liver span. 19. Then ask the patient to sit up with arms crossed and hands placed on the shoulders. 20. Repeat the above 14,15 and 17 for the back this is done top minimise the movement of the patient for their comfort and to save you valueable time. 21. Auscultate the front and the back . 22. Vocal resonance- in the same place you auscultate for breath sounds repeat but ask the patient to say 99. 23. Look for sputum pot, inhalers. 24. Mention need to perform PEF. 25. Thank and cover the patient. Instructions to the actor 1. You are breathless and uncomfortable. If the doctor asks for oxygen accept It. 2. Follow the instructions given by the candidate only if it is clear and you can understand it easily. 3. If candidate hurts you while doing the examination you need to scream to bring this to the examiner's attention. Mr Anderson has been complaining of pins and needles in his right leg. He is a diabetic and is on insulin, Examine his foot. EXAMINATION OF DIABETIC FOOT Greeting/Introduction Establishes identity of the patient Empathy/Checks comfort of patient Explains purpose of visit/nature of examination ‘Asks patient to undress Asks for a chaperone Takes consent for examination Inspection: a. Claw toes/ Pes Cavus b. Callus formation c. Ulcers/Gangrene d. Looks for ulcers between toes e. Skin, nails and hairs Feels for temperature Peripheral Pulses Sensations ‘a. Fine touch b. Pin prick c. Vibration d. Joint position Assessment of Gait Assessment of Motor functions Assessment of reflexes Checks suitability of footwear Overall approach to the task Thanks the patient Instructions to the actor1 2. = ©. PLAB Right Limited @) PLAB Right iimiea Follow the instructions given by the candidate only if it is clear and you can understand it If candidate hurts you while doing the examination you need to scream to bring this to the examiner's attention. 45 yr old Mrs Scott has been complaining of weight gain and unable to tolerate cold. Examine her thyroid gland. Greeting/Introduction Establishes identity of patient/Rapport Empathy/Checks comfort of patient Explains purpose of visit/Explains procedure Takes consent Privacy/Chaperone Loosens clothing around the neck ‘Comments on pulse Examines hand: a, Clubbing b. Sweating/palmer Erythema c. Tremor 10. Examines Eyes: a. Proptosis (from bel b. Lid retraction/Lid Lag c. EOM for Opthalmoplegia 11. Inspects Neck (front & sides) scars, swelling 12. Inspects movement on swallowing 13. Inspects movement on protrusion of tongue 14. Palpation: Does it correctly/competently a, Feels for temperature b. Confirms movement on swallowing 15. Percussion 16. Auscultates for bruits 17. Comments on Lymph nodes 18. Feels trachea 19, Tests ankle jerks 20. Assesses speech/cough 21. Describes findings correctly 22. Thanks patient 23, Overall performance yenousene 1d) Instructions to the actor 2. Follow the instructions given by the candidate only if it is clear and you can understan easily. If candidate hurts you while doing the examination you need to scream to bring this to the examiner's attention.TRAUMA AND ORTHOPAEDICS Table of content 1, Introduction on joint examination 2, Hip Joint 3. Knee Joint 4, Ankle and foot 5. Shoulder 6. Elbow 7. Wrist and hand 8. Cervical spine 9. Lumbosacral Spine 10. Examination of spine 1. ATLS 12, Primary survey 13, Secondary survey ITR 1) IN JOINT EXAMINATIONS To be systematic we follow the following sequence for all orthopedic examinations. Look-this is inspection of the joint. We look from the front, side and the back. We comment on any of our positive findings. However if there are no positive findings we also mention the absence of some of the findings. For example there is no swelling, no bruising etc. Feel-here we feel for the temperature and palpate for tenderness. ‘Move- both passive and active. Special test-any special test that examines the particular joint. Function- range of function. REMEMBER Examine the affected joint only. There is no role for tone, power and reflex. All lower limb examinations begin with gait examination. Gait - itis a style of walking. Gait appears to be normal or gait appears to be abnormal, Always examine the joint line in flexion. Always begin palpation by checking the temperature first. Always palpate the tender area last. HIP JOINT LOOK Obvious deformity or scars One joint above and one joint below Inspect the spine Pt Supine: Leg Length discrepancy Muscle bulk and symmetry FEELLeg length discrepancy Anterior Superior iliac spine Ilac crest Pubic symphysis Greater Trocanter Sacrum Femur MOVE Flexion Extension Adduction Abduction Internal and external rotation TESTS Trendelenberg’s test ‘Thomas Test FUNCTION Walk Prepare yourself Wash your hands and explain to the patient what you are doing today. Expose patient's legs and hips while keeping underwear on, Ask patient if they have any pain. Look Look around the bed for any aids or adaptations such as a walking stick or wheel chair. ‘Ask the patient to walk for you. Comment on his gait. Gait can be antalgic, limping, Trendelenberg’s or perhaps waddling. From the front look for scars, pelvic tilt, quadriceps wasting. Comment that there is no swelling, deformity or scar marks. From the side look for lumbar lordosis. It could ether be normal, loss of lordosis or hyperlordosis. From the back look for gluteal wasting, scoliosis and any sinus or scars. ‘Ask the patient to lie on the couch with the legs straight and feet held together. Look for shortening of the leg. Feel For temperature. Comment that ‘the temperature appears to be normal’. Bony Points ~ ‘I am going to feel your hip joint’. Feel — Iliac crest, ASIS, pubic symphysis, greater trochanter, head of femur True leg length discrepancy is found by measuring from the anterior superior iliac spine to inferior margin ‘of medial malleolus. Apparent leg length discrepancy is measured from xiphisternum or umbilicus to medial malleolus. Tenderness in the greater trochanter will suggest the patient has trochanteric bursitis Tenderness in the lesser trochanter could be due to strain in the illiopsoas muscles. To feel the lesser Apparent Method? ®€272llY 2% True Method 29 the medial third of inguinal ligament.Move © ‘Lam going to do some manoeuvres on your hip joint’, Do flexion, extension, and abduction, and adduction, external and internal rotation. ‘* Flexion- Keep the patient in the supine position. Keep one hand under the patient’s lumbar spine. Bend the knee joint, and then bend the hip joint completely until it briefly touches the abdomen. © Extension- Ask the patient to lie on their chest. Stabilize the hip joint. Keep the leg straight without bending the knee joint, and lift the leg in the air. Normally; you are able to lift in the air a little. (0-10 degrees) Flexion. Extension © Abduction Stabilize the pelvis by putting your thumb over ASIS. Keep the leg straight without any bending at the knee joint. Now abduct the hip joint until ASIS moves. When ASIS moved, it means the abduction is over or finished. © Adduction- Keep the patient in the supine position. Stabilize the pelvis by keeping the thumb over the ASIS. Keep the leg straight without bending, at the knee joint. Move the leg medially across the body and over the other leg, until ASIS moves. © Internal and external rotation — Bend hip and knee at a 90 degree angle. Hold the ankle joint with one hand and stabilize the thigh with the other hand. Now rotate the leg in and out for internal and externalrotation. They are also performed with the knee flexed and by inverting the knee for internal rotation and exerting it for external rotation Comment ‘All movements of hip joint are painful and restricted. Or all movements of hip joint are painless and free’ Tests Trendelenberg’s test- Ask the patient to stand on each leg alternately. You stand behind the patient and feel their pelvis .It should remain level or rise slightly. In case of abductor muscle weaknesses the pelvis drops markedly on the side of raised leg. Thomas‘s test- place your hand under the patient's lumbar spine to stop any lumbar movements and fully flex one of their hips. Observe the other hip. If it lifts off the couch then it suggests a fixed flexion deformity of that hip. Trendelenberg’s test Thomas's test Notes © Pain in the hip may be a referred pain from the lower spine © Some causes of hip pain are -osteoarthritis , rheumatoid arthritis , ankylosing spondolysis, reiter’s disease, tumors etc. © in paediatric age group think of Slipped Femoral Epiphyis and Perthes Disease © Think of neck of femur fracture and complication from hip replacement in elderly patient © Donat forget to examine the neurovascular status © Always perform active movements before passive movements. © Make sure you mention to patient what you are doing «If patients seems to have pain always say sorry and stop.3:KNEE JOINT Prepare yourself Wash your hands and explain to the patient what you are doing today. Before you start you must ask the patient ‘Do you have any pain in your knee?’ ‘Where is the pain? Make sure both knees are appropriately exposed. The patient is asked to take of shoes shocks and pants Look This is the examination that you would do while the patient is standing. Knee should be in straight line with hip and ankle joints. Comment on any Valgus (knock knee) or Varus (bow leg) deformities. For example you can say ‘there is no valgus or Varus deformity’ Request that the patient walks and comment on his gait. You tell the examiner whether the gait is either normal or abnormal. Then you look for symmetry, redness, bruising, swelling, deformity, and scarring, muscle wasting from the front, side and back(for example baker's cyst ). If there are any positive finding describe them thoroughly. For example ‘I can see a scar in the medial aspect of the knee which is approximately [Link] long’. You will be examining the patient standing and lying down. Feel ‘Ask the patient to lie om the couch supine position, and then inform them that you will examine their knee. Look for fixed flexion deformity - The patient is positioned supine and made to relax. The examiner grasps both of the patient's heels and supports them at a height of 10 cm above the examination couch. This is the best position for screening a flexion deformity, which is a major feature of knee pathology Feel the skin temperature with the back your hand, Say ‘the temperature feels normal or hot or cold’ Palpate patella- Always examine the patella, when the knee joint is completely straight. You say ‘Please straighten your knee joint out for me’ and ‘Iam going to feel your knee cap’. Also feel the under surface of the patella by pushing it on either side, Do not forget to look at the face of the patient for any signs of pain. Also palpate the patellar tendon. Medial / lateral joint line — Please bend your knee joint at 90 degrees. Feel the fibial tuberosity. Medial and lateral condyle of tibia. Medial and lateral condyle of femur. Medial and lateral joint line palpate femur, Tibia and Fibula. Any pain in the medial joint line in knee is due to potential medial meniscus problems unless proved otherwise. Palpate the bony points. Popliteal Fossa Femur Tibia ‘Then you look for Effusion. In mild effusion look for a bulge sign, You can perform this test by forcing fluid out of supra patellar pouch with your left hand . In moderate ones Patella tap and in large ones the skin will be both tense and shiny. Check the dorsalis pedis artery (DPA) ‘T am going to feel the pulse of your foot now’. Palpate DPA in the med foot, lateral to EHL and in slight dorsiflexion of ankle joint, DPA is felt and itis a strong pulse. Move We look for Active and Passive movements. We record it in degrees. Movements are either painful or pain free, They are full or restricted. A full range of movement should be demonstrated and you should look for the cripitus. Flexion: Please bend your knee joint Extension: Please straighten your jointMcMurray- test for any damage of meniscus. Keep the patient in the supine position. Keep the hand in such a way that the fingers should be over the medial joint line and thumb should be over the lateral joint line. Through the heel, rotate the leg i internally and extemally. | ‘Apply valgus pressure on the medial side of the joint so that the knee joint faces outward. At the same time, rotate the foot externally and slowly make the knee joint align straight. A click or pop along the medial joint during the McMurry test indicates a tear of the medial meniscus. I will keep my hand over the knee joint. Then I will push your knee joint outwards. I will externally rotate your leg or foot and I will slowly straighten it out for youAnterior drawer test- Anterior drawer test: Flex the knee to 90 degrees and sit on the patient's foot. Pull forward on the tibia just distal to the knee. There should be no movement whatsoever. If there is however, it suggests anterior cruciate ligament damage. Posterior Drawer test -with the knee in the same position, observe from the side for any posterior lag of the joint. This again suggests posterior cruciate ligament damage. Medial and lateral stress test for collateral ligament. Hold the leg with the knee flexed to 15 a degree angle. Push the knee laterally and medially. Any excessive movement suggests collateral ligament damage. Thank the patient, Ask them to cover up. Lachman test Flex the knee at 20deg. Hold the thigh with one hand and calf with the other, Give a backward push to the thigh and forward pull to the calf for anterior cruciate ligament. Do the other way around for the posterior cruciate ligament. This test is done when the patient is unable to bend the knee for drawers test. ‘Muscle bulk-with both knees fully extended mark a spot about 20 com above the tibial tuberocity on both, thighs and measure their girth, Muscle atrophy is confirmed if the bulk is reduced by more than 1 em on affected side. Common presentation to A&E , GP and orthopaedics ain, laxity, knee locking, giving way are common symptoms and effusion Common conditions are arthritis, ligaments or cartilage injuries Note : In Plab I, in knee joint, patient will have pain along medial joint line Gal DS i bw © Cystic swelling seen anterior medial and lateral region of the knee can be from meniscus. © Anterior swelling in the knee is from patellar bursitis and posteriorly from baker's cyst. © Flexion of the knee is limited to 135-150 deg. © Normal knee extends to straight line and it can be hyperextended to 15 deg.4-ANKLE &QOT LOOK Ptstanding: -Obvious deformity - asymmetry = foot arch toes - swelling, Scar - Plantar surface - shoes FEEL Pt supine Temp ~ Pulse = squeeze test ~ Achilles Joint tenderness Med and lat malleolus fibular head ~caleaneum talus, Navicular, tarsal joint, subtalar joint MOVE ~ dorsiflexion - plantar flexion version and eversion -valus and Valgus - Mid tarsal and subtalar (Passive only) TESTS -Simmond’s test FUNCTION -Gait - tip toes. Preparation© Wash your hand and identify the patient correctly and explain to the patient what you are doing to them, Before you start you must ask the patient ‘Do you have any pain in the knee?’ ‘Where is the pain? © Expose the patient from the knee down Look © Gait-normal gait will be heel first and toe off. ‘* Looking for toe alignments. * Look for obvious rheumatoid disease and walking aids © Foot arch can be high arch (pes cavus) or also flat foot (pes planus). © Feel the Achilles tendon for any thickening or swelling. © While inspecting the patient's shoes we note for uneven wear and presence or absence of the insoles. Now ask the patient to lie down on the bed. Check for equal symmetry, nails, toe alignment, joint swelling and planter or dorsal calluses. bes r Squeeze the fore foot observing the patients face for any possible sign of tenderness. © Palpate over the mid foot for any tenderness. Also palpate ankle and subtalar joint. © Feel for tender areas, systematically checking, the anterior joint line ,. the lateral gutter and lateral ligaments, the syndesmosis , the posterior joint line,. the medial ligament complex and the medial gutter, © Palpate the dorsalis pedis Move © The active movements include inversion, eversion, planter and dorsiflexion. Look for toe movements as well. Subtalar Examination Inversion © The passive movements includes all of the above movements. Also we test for mid-tarsal joint movements. Here you fix the ankle with one hand and then inverting and exerting the foot with the other. Palpation of Ankle Extension FlexionFunetion: © Walking on tiptoes will test the intact of Achilles tendon. Examination of sensation in the foot © Please close your eyes and whenever you feel my finger touching your foot and finger please say yes" © Check the sensation in big, toe, small toe (Sural nerve) and first web space (Deep peroneal nerve). say “Sensation of the lower limb appears to be intact’. Ankde sprain Mr X had an ankle injury. An X ray is normal and you have ruled out fracture. Discuss the diagnosis and ongoing management with Mr X Introduce 10Identify the topic for discussion: You have got a condition called an ankle sprain, What do you know about it? General Information about Ankle Sprain This is a very common injury of the ankle joint. This usually occurs due to inversion of the foot. With this condition the x-ray will appear normal but it does not mean that everything is fine because the x-ray shows only bone, not ligaments. Ligaments are rope like structures which bind the bone. In this condition it is damaged. This condition is treated with rest and painkillers, Walk as soon as possible when the pain becomes better. We do not use cast and we do not offer crutches for walking as well. Keep your limb of the leg elevated and do active toe movements. Questions that patient is likely to ask Can I go to play football? Iam sorry to say, avoid playing any contact sport for at least 4-6 weeks because ligaments take a varying amount of time to heal. Otherwise persistent pain here if healing is not complete History for ankle sprain Pain history as SOCRATES Mechanism of Injury: Did you invert your foot during the incident? Or how did it happen? It is very important to get the mechanism of the injury correct so that we can think of possible sites of injury. For example the inversion of the foot may result in the fracture of the base of the 5" Metatarsal bone. ‘Assess loss of function: Are you able to walk OK? Do you have any swelling? Associated Symptoms System Review Past Medical History _ © Forraises, insoles, uneven wear ‘© Ask patient fo stand on tiptoes if they cant can be due to hallux rigidus 5-SHOULDER JOIN’ LOOK - Symmetry - Obvious deformity - Swelling - Wasting ~ Sears - Scapula FEEL - Temperature - Sterno-clavicular joint - AC joint - Wing of scapula - Coracoid process - Humerus: - Muscles MOVE Flexion - Extension’ Abduction- Adduction - External ~ Internal - Rotation: TESTS = Impingement test - Apprehension test ~ Scarf test FUNCTION ~ Arms behind the head ~ Arms behind the back Preparation Wash your hands and then introduce yourself. Ask the patient if they are comfortable with the examination or if they need any painkillers, Ask the patient to stand up. Tell the patient that you_are going to stand behind them. Patient needs to be exposed from waist up therefore will need a chaperone. Look Patient should be standing. Look at the level of shoulders. Comment ‘both shoulder joints are at the same level’, Look from the front, side and back, Look for symmetry, wasting and scar. Ask the patient to lean against the wall and look for the scapular position. Look for swelling, scar, deformity. Feel Feel for Temperature. A raised temperature may suggest inflammation or infection of the joint. Palpate the clavicle starting from the Sterno-clavicular joint to acromio-clavicular joint. Feel the acromion and then around the spine of the scapula. Feel for the Gleno-humoral joint from the front and then again from behind. Feel the muscles for any tenderness. Check radial pulse. ‘I am going to feel the pulse of your wrist now’ Move Start with active movements. For Flexion ask the patient to bring their arm forward. For extension ask the patient to push the arm backward while bending it at elbow. For internal rotation ask the patient to place their hand in the back, For exterual rotation ask the patient to flex the elbow, tug it by the side and then bring the hand outwards, For abduction ask the patient to bring the arm outwards and above the head. Comment on the pain of movement, restriction of movement, symmetry of movement Now do the movements passively and also feel for cripitus. Ingernal Rotation Abduction 2Tests « Impingement test- Place the shoulder out at 90 degrees with the arm hanging loosely down. Press back on the arm and check for any pain. This is the test for supraspinatus. «© In apprehension test the arm faces upward. Apprehension test is for the Gleno-humeral joint stability. © The scarf test is performed by having the elbow flexed at 90 degrees and placing the patients hand on the opposite shoulder. # Acromion clavicular joint examination-ask the patient to place their hand on their opposite shoulder. If gentle pressure on the joint elicits pain, this is indicative of acromio-clavicular joint inflammation » Arms behind the head and arms behind the back should be looked to test the functional abilities of the patient. Notes The shoulder is derived from the fifth cervical segment and therefore refers pain into the C5 dermatome. The acromio- clavicular joint is a C4 structure and refers pain into the C4 dermatome. Angina, pleuritie pain and neck pain can have referred pain in the shoulder supraspinatus (pain on resisted abduction) infraspinatus (pain on resisted lateral rotation). subscapularis (pain on resisted medial rotation), © sub-acromial bursa (pain at extremes of all passive ranges). 2BLOOK = Deformity - Swelling - Sears - Muscle wasting - Carrying angle FEEL -Temp - Joint tenderness MOVE - Extension - Flexion - Pronation - Supination TESTS - Do Cozon’s test FUNCTION Preparation; © wash your hands and introduce yourself to the patient © ask whether the patient needs any painkillers « ensure the elbows are exposed for full examination ©The patient should be standing, with shoulders slightly braced back, to display the elbow. Look: * Normal carrying angle is at about 15 degree. eo ea oe © from the side look for fixed flexion deformity © Rheumatoid nodules and psoriatic patches are some of the expected findings. Inspection may also show skin atrophy at steroid injection sites, or scars from previous surgery © Palpation starts at the posterior aspect, with the patient standing with his or her shoulder braced backwards © The three palpation landmarks - the two epicondyles and the apex of the olecranon - form an equilateral triangle when the elbow is flexed 90°, and a straight line when the elbow is in extension © Flexing the elbow allows palpation of the olecranon fossa on either ide of the triceps tendon. © Inbussitis, a boggy globular mass may be palpated; the overlying skin will be thickened. © Palpation and testing of brachioradialis, a forearm flexor 14© The ulnar nerve is palpated behind the intermuscular septum. It may sometimes sublux or roll on the epicondyle. Ulnar nerve instability is more readily demonstrated if the elbow is flexed 60° and the upper limb is abducted and externally rotated Flexing the elbow allows palpation ofthe olecranon Palpation and testing of brachiondals, a fossa on either side ofthe triceps tendon. forearm flexor @ Tennis elbow-localised pain in the lateral epicondyle mainly during the active extension of the wrist when the elbow is held at a 90 degree angle. «Golfers elbow on the other hand is the medial epicondyle particularly when the wrist is flexed firmly. ‘Tennis Elbow Golfers Elbow Move: © Ask the patient to bend their elbow (Flexion). © For Extension say; ‘Please straighten your elbow’. © For Supination and pronation keep patient's arm by the side of their chest. Bend their elbow at 90 degrees. Ask them to make a fist and rotate the arm as much as possible. Comment on whether the movements are painful and restricted or all movements are free and completely painless. © Once movements are checked actively; do the same passively. Special Test: Do Cozon's test 15,‘Tinel’s sign. Paraesthesiae in the territory of the ulnar nerve allow an assessment of the likely site of compression Since the elbow is a superficial joint, many of its disorders can be readily detected by simple inspection Normal carrying angle -9 to 14 degree ‘Any increase in, or loss of, this physiological angle is indicative either of major elbow instability or of malunion. on the side of the elbow, bulging in the para-olecranon groove will be seen; such a swelling is produced by an effusion or by synovial tissue proliferation ‘On the back, prominence of the olecranon is a sign of posterior subluxation of the elbow, a feature commonly found in RA. Counselling ~ you have a condition called Golfer's or Tennis Elbow. This is a common condition. This is not a bone problem; this is a soft tissue problem. This occurs due to excessive movement of the elbow joint. In this condition x-rays of the elbow joint will be normal. I will give you painkillers to take for 4 weeks. Please give rest to your elbow for 4 weeks. I will give you a splint and I will refer you to a 16physiotherapist for exercise. After 4 weeks we will see you again, if pain does not become less or disappear. I will then refer to orthopaedic surgeon. Do you have any questions? Thank you. 77-HAND, LOOK aration ~ Deformity © introduce yourself to the patient -Scar © explain what you would like to do and gain their full - Swelling. consent - Wasting, © Ensure that the wrist and the hands are appropriately - Symmetry ‘exposed - Nails * place the patient’s hands on the hand -Palms i pe Se FEEL - Temperature -Bony Point ~ Interphalyngeal joints of fingers PIP, DIP - Pulse - Muscle bulk h - Tendon thickening, Look = Joint tendemess © Look at all mentioned in the box above MOVE © look for operational scars for carpal tunnel and comment Flexion if there is one found - Extension © skin changes and nail pitting are other specific signs that ~ Medial could be found - Lateral flexion ¢ Comment on joint swelling, mention which joint is TESTS involved and check with the other hand and comment -Phalen’s whether the swelling is symmetrical -Tinnels © palmer erythema - Forment's FUNCTION - Nerves-Ulnar, median, radial Feel © This is the examination step It is always better to develop a pattern so that your examination looks smooth and confident overall © Compare the temperature of the joint lines with the forearm © Palpate all the joints © Palpate the thenar and the hypothenar muscles © feel for any potential tendon thickening © Squeeze the MCP joints and look at the patients face for tenderness © Palpate Radial and ulnar styloid process 18,Move Wrist flexion and extension © Fingers flexion, extension, abduction and adduction ‘Thumb flexion, extension, apposition and abduction ‘Writ lexion Wrist extension Tests © Phalen’s test ~ this is a diagnostic of carpal tunnel syndrome. Flex the patient’s wrist for 60 seconds. It will recreate the symptoms of carpal tunnel syndrome,© Forment’s sign- this test is for ulnar nerve. Ask the patient to hold a piece of paper between their thumb and the index finger. In patients with the ulnar nerve dysfunction the interphalyngeal joint of the thumb will flex to compensate pressure. © Nerve sensation- ‘I am going to touch your hand now. Whenever you feel my finger touching your hand, please say yes’. For Ulnar nerve palpate pulp of little finger. For Radial nerve it is area between thumb and index on the back of hand. For Median nerve feel the pulp of index finger. Function © ask the patient to grip your finger tightly ‘© ask the patient to perform the pincher grip NEUROLOGICAL TES! Sensory © C6-thumb and index finger © Cy-middle finger © C8 ring and little finger Median nerve ® thenar eminence-muscle wasted © sensation in palm index finger, middle finder and half of ring finger Ulnar nerve~ © hyposthenia eminence © sensation to the palm dorsum of the hand , the little finger and half of the ring finger © damage causes claw deformity in the little and ring finger because of loss of innervation to interossei and lumbrical muscles Radial nerve — © first dorsal web space © causes wrist drop 20EI PINE LOOK ; © swelling * scar © deformity FEEL © Temperature © Bony Point Spinous process © Para spinal muscle MOVE © Flexion © extension © lateral rotation © lateral flexion TESTS © Upper limb- Tone, power, reflex ® Check sensation- C5, C6, C7, C8, T1 FUNCTION «Reflexes © Look for malunion and non-union, torticollis © Anteriorly look for hyoid , thyroid * Laterally look for lordosis | ¢ With patient in sitting position | © Look from behind Move Flexion Chin to chest Extension Look up at the cielling Lateral rotation _ | Normal 60 to 90 degree ‘Motor examination | Lateral bending _| Touch the ear to the shoulder Shoulder abduction GS Elbow flexion. co Elbow extension above the | C7 headPronation C78 Supination 6 Wrist extension C6 Wrist Flexion 7 Finger extension C7-C8B Finger flexion C78 Reflexes Biceps 5,06 Triceps 7 Brachiao radialis 5-06 oS co cw cB TL Sensation [lateral | thumb | Middle | Little | Medial arm finger _| finger | arm Motor [deltoid | Wrist | Triceps | Finger | Interossei [ extension flexion Reflex Biceps | Brachio- | Triceps radialis 9-LUMBOSACRAL SPINE LOOK - Swelling, - Deformity ~Scar FEEL - Temperature - Spinous process ~Paraspinal muscle - Muscle tenderness and spasm MOVE - Lateral rotation ~ Lateral flexion. TESTS -Tone - Power - Reflex -Do SLR FUNCTION SLR tells whether or not the nerve root is compressed. 2Leseque tests ~ Tells whether more than one nerve or only one nerve root is evolved. Check sensation briefly along with dermatomes ~ L1, L2, L3, L4, L5, and SI. 239-SPI [ATION LOOK Standing: Shoulder level - Asymmetry ~ Scoliosis/ kyphosis - Wasting/ scar/ swelling FEEL - Temperature - Spinous process - Paraspinal muscle - Neurovascular and PR and perianal sensation MOVE - Flexion (sobers test) - Extension: ~ Lat flexion - Rotation - Neck flexion/extension/ lateral flexion/ rotation TESTS -Tone - Power - Reflex - Do SLR Neurovascular and PR and perianal sensation FUNCTION Preparation © Wash hand © Introduce yourselves ask whether patient is in pain and is happy to be examined © take the top off the patient © Look from side Look from behind © Comment on any finding Feel © Feel for temperature © Feel the bones ~spinous process © Feel saccro ~illiac joint © Palpate paraspinal muscles 24© Look for lumbar flexion and extension © Lateral flexion © Thoracic rotation Straight leg raise 25_10-TRAUMA. _ Concept of management of acute trauma 8 ‘Trauma teal Primary survey Secondary survey Concept of management of acute trauma Trauma is one of the major killers of modern world, It is one of killers that kills young and healthy person, Managing trauma is very important, Trauma has tri-modal pattern of mortality. The first peak is at the scene of injury. The second peak is within few hour of injury and the third peak is in weeks from injury. peed ca deaths Peet er Death due to infection Eerie nent, The first peak within minutes is at the scene. The deaths in this group are caused by lacerations of brain, aorta, spinal cord and heart. There is very little that we could do to treat these group. The focus of decreasing the mortality is on safety. Some of the things that could be done are © Education and public awareness © Strong road safety rules * Building more safe cars © Use of protective gears Regulated licencing system The second peak of mortality occurs in hours. The main killers in this group are «Epidural haematoma, subdural haematoma, © haemopneumothorax, pelvic fractures, © Jong bone fractures * Abdominal injuries. Early recognition and prompt treatment of these conditions can be lifesaving ‘The third peak occurs between two to four weeks. The main causes are sepsis and multi organ failure.‘Thus we can say that we can prevent deaths of the second peak This is what is the need of trauma teams in the hospitals. Trauma teams The concept of trauma team is to get all specialities involved early in the management of patient with trauma so that the diagnosis and treatment starts early .The trauma team comprises of A&E doctors (consultant or senior registrars) with nurses «Anaesthetic registrar and nurses © Surgical registrars © Orthopaedic registrar ‘The team is led by the AécE clinician and follows the sequence of primary and secondary survey. Primary Survey We follow ‘These are the life threatening situations assessed. The principle is to ‘find and fi © A-airway B-breathing Secondary survey The aim of the primary survey is to detect and treat immediately life threatening problems. The secondary survey aims to detect and treat ‘everything else’. Therefore the secondary survey should not be started until the primary survey is complete, repeated, and the patient as stable as possible. This is head to toe detail examination 11-PRIMARY SURVEY A Airway Oxygen Cervical immobilisation B Respiratory rate Tracheal position Chest symmetry c Blood pressure Heart rate Capillary refill time D AVPU score Pupils BM. 27E Expose the patient Cover ‘As mentioned in the previous section this is time critical and rigorous management. A-Airway This is the first and the most important step. Start by checking whether the patient has the cervical collar. Connect full flow oxygen with a rebreathing bag, Talk to the patient. If the patient can talk to you his airway is patent. If he cannot then listen for noisy breathing, If there is noisy breathing airway may be obstructed and following could be done to maintain the patency © Chin lift © Jaw thrust © Suction to clear the mouth and throat © Removing any foreign body Sometimes we may need adjuncts to keep the airway patent. They can be © Oropharyngeal or guedels airway © Nasopharyngeal airway Going further up if the airway is still not patent we can use the experts in trauma team to intubate the patient, Once airway is patent you can then fix the neck. The neck should be immobilised in collar with sand bags and tape. Remember the neck has to be manually immobilised all the time till airway was dealt with. 28B-Breathing and ventilation Look for respiratory rate. Then palpate trachea and find out whether it is in mid line or deviated to one side, Then look for chest symmetry. Chest symmetry starts with inspection. Then in percussion we confirm whether the chest is dull or normal or hyper resonant. Then we auscultate to find the air entry. In this step we are trying to pick up potentially life threatening conditions like © Tension pneumothorax - requires needle thoracotomy followed by drainage. © Insert wide bore needle in second intercostal space mid clavicular line on the affected side, © Haemothorax - will usually require intercostal drain insertion. This is one of the situations when you put cannula before putting the drain ¢ Pneumothorax - may require intercostal drain insertion. © Open chest wound- needs dressing covering it and sealed in three sides leaving one side open to act as valve. © Think of flail chest Fracture of two or more ribs at two or more sites. C-Cireulation ‘This is to assess the haemodynamic status .we look for heart rate, blood pressure and capillary refill time. Other parameters like level of conscious ness and bleeding are also important. ‘The management in C area is stopping bleeding and fluid and blood replacement. ‘Two large bore cannula need to be sited. Bloods should be send for test. Fluids should be started. Sometimes we will not be able to site a canula when we can use intra osseous accesses. Direct manual pressure should be used to stop bleeding, And also we should actively look for internal bleeding, FAST (Focussed abdominal sonography in trauma) is a tool used these days. CT scans should be used where needed, Sometimes when the bleeding is internal and very active we may have to do emergency laparotomy. This is why we have surgeons in trauma team. Fracture pelvis and long bone fractures are also the source of blood loss. [response to blood loss differs in: 29Elderly - limited ability to increase heart rate; poor correlation between blood loss and blood pressure. Children - tolerate proportionately large volume loss but then rapidly deteriorate. Athletes - do not show the same heart rate response to blood loss. Chronic conditions and medication may affect response and early on in trauma management will not be known about. D-Disability Rapid neurological assessment is made to establish: Level of consciousness, using AVPU score. A is alert, V-patient responds to verbal command, P- patient responding to pain and U- unresponsive patient. We can also assess by using GCS (Glasgow Coma Score). Pupils: size, symmetry and reaction. Any lateralising signs. Level of any spinal cord injury (limb movements, spontaneous respiratory effort). Blood glucose measurement. E-Exposure and environmental control Cut off all the clothing of the patient. This has two fold advantage. One we remove the wet, or exposed to chemical environment type of cloths. This also helps us to look for any active bleeding, injuries and drug patches that patient uses. At the end of this step we have to cover the patient. Remember that Hypothermia is one of the killers in trauma patients. Primary survey X-rays At the end of primary survey we request x rays They include-chest X ray, lateral cervical spine and pelvis, Do not forget to verbalise about airway patency If patient is lying down without collar make sure you introduce, tell patient not to move his head, hold his head and triple immobilise. Request for assistance early ‘Think of tension pneumothorax in B Make sure you mange bleeding correctly Signs like bruises, deformity, blood in external urethral meatus, scrotal or perineal haematoma may be apparent Application of pelvic binder can be one of the treatments inc Think of cardiac tamponade In C-decreased level of consciousness, cold peripheries, hypotension, and muffled heart sound-urgent pericardiocentesis is needed. Think of intra-abdominal bleed in C-distension, bruising, wounds, tenderness, rigidity, guarding, flank dullness, absent bowel sounds ete-ultrasound scan if available can help . Otherwise urgent exploration may be needed. Monitoring will include cardiac monitor, pulse oximetry and blood pressure 3012-SECONDARY SURVEY ‘The Secondary Survey 1. History 2. Head 3. C Spine & Neck 4, Chest 5, Abdomen & Pelvis 6, Perineum/Vagina 7. Arms & Legs 8, Spine & PR [Link] examination +/- Investigations Here we get quick history and do detailed head to examination, Note is made of the abnormalities and plan drawn at the end of the secondary survey. History Itis very important to understand the possible type of injuries. Following can be asked to help us: The speed, type of accident (e.g head on collision, hit from behind), type of vehicle, whether seat belt was on, whether air bags was deployed, amount of damage done to the car what happened to fellow passenger On the top of the above it is important to get the AMPLE history Allergies Medications Past medical history (& Pregnancy) Last meal Events related to accident Remember we do not need to take long history Examination of head ‘Look for lacerations bruises (remember panda eyes, battle sign etc), depression or irregularities Look for bleeding from nose and ears Nose: deformities, bleeding, nasal septal haematoma, CSF leak Remove contact lenses Eye movements Acquity 34© Eyes: foreign body, subconjunctival haemorrhage, hyphaema, irregular itis, penetrating injury, contact lenses. © Look in the mouth-remove dentures, bleeding sites from lips gums and palate. © Jaw: pain, trismus, malocclusion © Teeth: subluxed, loose, missing or fractured ¢ Palpate maxilla and mandible Cervical spine and neck © Cervical spine should have been inumobilised ‘© Senior doctor has to reassess and decide any further investigation is needed or collar can come off * Look for other injuries ® Palpate trachea Chest examination © Inspect the chest for bruises, lacerations, or flail segments © Palpate the clavicles, ribs, and sternum © Record the respiratory rate, saturations, pulse, blood pressure © Auscultate the heart and lungs Abdomen and pelvis © Inspect for flank bruising, seat belt marks, abdominal distension Inspect for bruising over the iliac crests, perineum, and pubis. Palpate the abdomen Do not apply anterior-posterior pressure on the pelvis © Remember spring test used to be done ~do this test only if there are no signs on inspection. Perineum, © inspect for bruising, lacerations, urethral bleeding, © Inspect the urine colour if a catheter is inserted. Consider placing a catheter if it is not. © Ifindicated, perform a vaginal examination and assess for the presence of blood, © Always perform a urine pregnancy test. Arms and legs © Inspect for bruising, lacerations, and deformities. © Palpate along the entire length of each limb carefully, including digits © Test sensation and power Spine © A log roll should be conducted at the end of the Secondary Survey, The lead clinician should take this opportunity to thoroughly inspect the posterior chest, pelvis and legs. * The spine should be palpated at this stage,© Finally, a digital rectal examination should be performed and the following assessed: the presence of blood, a high riding prostate, and sphincter tone. Neurological examination * GCS © Pupils ‘At the end of secondary survey consider relevant Investigations In exam situation when patient is in pain always say sorry and ask whether you can proceed with examination 33®& PLAB Right PAEDIATRICS © PLAB Right Limited Limited Pediatrics ‘Crying Baby Weight Loss Foreign Body Ingestion Delayed walking Diarrhea Chronic Diarrhea ‘Telephone Conversation: Diarrhea Fever Telephone Conversation: Fever Loss of Consciousness Uncontrolled fits me Assessment of suitability for the surgery Counselling: Ear Infection/ URTI Needle Stick Injury Irritable hip Spacer Splenectomy Meninococcal Septicemia Obesity Downs Syndrome Diabetes Hypoglycemia Unconcious Child Urinary Tract Infection Scabies Asthma Inhalers Cerebral Palsy Fever Nappy Rash Febrile Convulsions Celiac Diseas Peanut Alleroy Infantile Colic jehovah's witnesses Mock Test MMR Non Accidental Injury© PLAB Right Limited ay PLAB Right Limited Mrs Staples, mother of 9 manth old child John has come to A & E complaining of crying and passing red coloured stools. Take history and discuss the management. Examiner will later tell you the following information and may ask some questions VITALS Bp = (90/60) mm Hg Pulse = 160/ minutes RR = 28 / minutes USES OF PI Mol CHILD Causes are — Rectal polyp, piles, anal fissure, infective diarrhoea, intussusception, and trauma. Rectal polyp ~ Is stool mixed with blood? ‘Anal fissure ~ Does she cry when she opens her bowel? Infective diarrhoea ~ What is the consistency of stool? Is he having any fever? Who many times does he pass stool? Trauma - Has he injured himself? Intussusception — Does he cry in episodes? What is the colour of his stool? Is it red currant jelly like? NOTES ABOUT INTUSSUSCEPTION Intussusception Is the commonest cause of small bowel obstruction, It occurs mostly in winter season in the age group of 9-12 months. Child will cry continuously in episodes and he will draw up his legs. A mass can be felt in the left iliac fossa, which is known as empty dance sign. If thi condition is not recognised initially, then it can cause gangrene and perforation of the small bowel. Initially it is treated by conservative method that is by air enema, otherwise paediatric surgeon will operate to reduce it. Possible Different Diagnosis are: UTI, infective diarrhoea and intussusception. History Taking Open Question: Can you tell me more about the problem? HOPC: Duration, onset, progress, nature of symptom and aggravating and reliving factors. Associated symptoms How would you ask the nature of these symptoms (Crying and Red colour stolls) Crying: Pattern- continuous or episodic, duration, how does he settle? Red colour stools- pb UTI ~ Is he having any fever? Is he crying when he passes water? Infective diarrhoea ~ Did he vomit? If yes, what is the colour of vomiting? How many times has he opened his bowel? Intussusception ~ Is he drawing up his legs? Is he passing any blood in his stool? Do you think the stool looks like red current jelly? Have you noticed any lump (sausage shape) in the abdomen? Other general questions: Is he up to date with vaccination schedule? Can you tell me about his developmental milestones? Any problems during pregnancy or birth Past history Has he suffered or suffering from any health problem Is he taking any medicine? Explain the diagnosiso PLAB Right Limited Child has got a condition called intussusception. In intussusception, there is telescoping of one portion of the bowel into the other Management of Intussusception T will examine and will admit the child L will give him 02, I will keep him nil by mouth, I will put nasogastric tube, I will put 2 wide cannula, and then I will give fluid, catheter, maintain info chart, monitor vitals after every 15 minutes, inform the paediatric surgeon, operation theatre staff along with anaesthetist, tell the condition to mother. It is managed by conservative method initially, by putting air through the back passage. In later stage if it is difficult to reduce, we have to operate. WEIGHT Loss 3 yr old Edward is referred by his GP for weight loss. He has come to pediatric out patient clinic with his mother. Take history from Mrs Gilbert. Your examiner may ask your opinion History Taking Open Question: Can you tell me more about the problem? Nature of weight toss Current weight and height, How much weight he has lost and since when he has been loosing weight? Diet history - How is his appetite? Any changes noted in his diet Activity: Any recent changes to his daily activity ‘Abdominal problem ~ Is he having loose stool? Is it difficult to flush away the stool? If yes, Ask for duration, progress nature of diarrhoea and precipitating factors (any particular type of food) Nature of Diarrhoea How many times, colour, consistency, how does it flush away, any mucous or blood R/O DM ~ Does he pass lots of water? Does he drink lots of water? Have you noticed any lumps or bumps elsewhere in the body? Heart problem ~ Is he having any SOB? Is he having any chest pain? Past History Is he having any medical illness? Is he taking any medicine? How is his general health? (Any recent chest infections) Was there any problem during pregnancy? What was the method of delivery? Was there any problem during delivery? Can you tell me about his development milestone? Can you tell me about his vaccination schedule? pb Cystic Fibrosis: Recurrent chest infection Celiac Diseas Infection/ infestation Malignancy