Dr AMEH’S FREE CLASS

NOTES

compiled by

Dr MARIAM AJUGBA
(June 2023 - September 2023)
This is to show gratitude to Dr Ameh Itodo for being such a

blessing to us all. I may not have the finest words, but I want you

to know that you’re godsend and all of us, who are beneficiaries

truly love and celebrate you.

One really striking thing about you is your organization and I’m

certain others share the same sentiments. Your teaching is very

much organized and simplified and that was something that really

got me attracted.

God will honour you for taking out time and putting so much love

into teaching and guiding us for FREE. Over 90% of this note was

entirely from these teachings.

Lastly, Dr Ameh, I’d like you to know that this was not inspired by

“weed”

Thank you so much

OUTLINE
INTRODUCTION
Components/Stations in the exam ……………………………….. 10

General Approach to Stations ……………….……..……………. 11

MEDICINE
The Approach ………………….…….……..…………..………… 17

1. Fall ………………………….………….………….……..….… 18

2. Erectile Dysfunction ………….………….….……..…….…… 21

3. Pseudomembranous Colitis …….….…….…..…….………… 24

4. Iron Deficiency Anaemia …………….…...……..…………… 26

5. Vitamin B12 Deficiency …………..………….……………….. 28

6. Varicose veins …………………..……………….….……….... 33

7. Dizziness ………………………………………………….…… 36

8. Chronic Fatigue Syndrome …………..……..……………..…. 37

9. Shingles ……………………………..…….…………..………. 40

10. Infective Exacerbation of COPD ………………….…………. 43

11. Addison’s Disease …………….………….……….…..………. 45

12. Occular Toxoplasmosis ………….…..…….…………………. 48

13. Age-related Macular Degeneration …..…………….…….…. 50

14. Syphilis - result sharing ………..…………………………… 52

15. Coeliac Disease ……………………………………..……….. 55

16. Ménière’s Disease ………………..………………………….. 57

17. Multiple Myeloma - result sharing ……..………………….. 59

18. Barrett’s oesophagus - result sharing …..………………….. 63

19. Skin lesions/conditions …………..………………………….. 65

20. Giant Cell Arteritis ………..………………………………… 68

21. Peripheral Artery Disease ………..…………………………. 70

22. Diverticulitis ……………………….………………………... 72

23. Abdominal Aortic Aneurysm …….………………………… 74

24. Sepsis in the Elderly ………………….………………….….. 77

25. Hangover Headache ……….……….……………………….. 79

26. Analgesic Nephropathy ….……….…………………………. 81

27. Myocardial Infarction …….…….………….……………….. 83

28. Malaria ……………………..…….………………………….. 89

29. Intracranial Space Occupying Lesion ……...……………… 91

30. UTI - Transgender ……………………………..…………… 93

OBSTETRICS & GYNAECOLOGY

The Approach ……………….…………………………………. 96

31. Atrophic Vaginitis ………………………………….…….. 98

32. Teenage Pregnancy ……………………………………… 100

33. Pre-eclampsia ……………………………………………. 102

PAEDIATRICS
The Approach …………………….………………………….…. 105

34. Non-Accidental Injury (NAI) ….………………….……… 107

35. Asthma Emergency …………….…….…………………… 110

36. Developmental Milestones …….….………………………. 113

37. MMR Vaccine & Autism …….…………………………… 118

38. Tantrums ………………………….………….……………. 121

39. Childhood Tuberculosis ……………….……….…………. 125

40. Mumps Orchitis …………………………………………… 127

41. UTI …………………………………….…………………… 128

42. Epilepsy/ First fit ………………….……………………….. 130

43. Head Injury - Fall ……………………….………………… 132

44. Urticaria …………………………….……………………… 136

45. Recurrent Tonsillitis ………………………………….…… 139

ANGRY PATIENT/MEDICAL ERRORS

The Approach ……………………………………….………….. 143

46. Patient who was Mis-diagnosed ….………….……………. 147

47. Sample not labelled ……………………….……………….. 148

48. Missed MI …………………………….……………………. 150

49. Missed Pelvic Fracture ……………………………………. 152

BREAKING BAD NEWS (BBN)
The Approach …………………………………………………… 154

50. Oesophageal Cancer ……………………………………….. 158

51. Lung Cancer ………………………………………..……… 160

52. Post-op Bleeding; Aorto-femoral Bypass …………………. 162

53. Bilateral Ischaemic Stroke in Coma ………………………. 164

54. Sub-dural Haematoma …………………………………….. 165

55. Massive Intra-cranial Bleed …………………………….…. 167

56. Dementia - Palliative Care ………………………………… 170

OTHER ETHICS
57. Patient refusing treatment (Elderly) ….….……………….. 173

58. NAI- Domestic Violence ………….………….………….…. 175

59. NAI- Sex Trafficking ………….…………………………… 179

60. NAI- Elderly Abuse ……….…………………….…………. 181

61. Relative requesting for patient’s Diagnosis ….…………… 183

62. Breast Cancer refusing Treatment ……………………….. 184

63. Two- people/Hospital Policy ………………………………. 185

64. Change of Counsellor ……………………………………… 187

65. Euthanasia …………………………………….……………. 189

66. Gender Dysphoria …………………………….…………… 191

67. Alcohol Colleague …………………………….……………. 193

68. Rape Case - Sick Note …………………………………….. 196

69. Emergency Contraceptive - Teenager ……………………. 198

70. Refusing Colonoscopy …………………………………….. 202

71. Workplace Bullying - Lesbian ……………………………. 205

72. COPD Refusing Treatment ……………………………….. 207

73. Concerned Daughter - Cancer in Father ………………… 209

74. Sick Note - Chicken Pox in Daughter …………………….. 212

PSYCHIATRY
The Approach …………………………………………………… 214

75. Depression ………………………………………………….. 215

76. Anorexia Nervosa ………………………………………….. 217

77. Hypochondriasis …………………………………………… 219

78. Delusional Disorder ……………………………………….. 222

COUNSELLING
79. Pre-Op/Post-Op Assessment ………………………………. 225

80. Patient who wants to Self- discharge ……………………… 227

81. Cystic Fibrosis ……………………………………………… 229

82. Learning Disability ………………………………………… 232

83. Familial Obesity ……………………………………………. 235

84. Measles ……………………………………………..………. 237

85. Alcohol Withdrawal …………………….…………………. 238

86. Relative Diagnosed with Breast Cancer …….…………….. 239

87. Sickle Cell Disease in Brother ……….…………………….. 240

88. NSI - Nurse …………………………………………………. 242

89. Drug Dependency ………………………………….………. 243

90. Warfarin - Rat Poison ………………………..……………. 246

91. Pulmonary Embolism - Oestrogen ……………………….. 249

92. Epistaxis - Testosterone …………………………………… 252

DISCHARGE STATION
The Approach …………………………………………………… 255

93. Epilepsy Discharge - Paediatrics ……………….…………. 259

94. Epilepsy Discharge - Adult ……………….……………….. 262

95. Myocardial Infarction ……………….………….…………. 266

FOLLOW- UP STATION
The Approach …………………………………………………… 268

96. Autism Spectrum Disorder …………..……………………. 270

97. Ophthalmia Neonatorum (Chlamydia) …………………… 274

98. Polymyalgia Rheumatica (PMR) ………………………….. 275

99. Statins ………………………………………………………. 277

TEACHING STATION
The Approach …………………………………………………… 279

100. Epipen ……………………….……………………………. 282

101. Informed Consent ………………………………………… 284

102. Urine Dipstick …………………………………………….. 288

103. ECG …………………………………………….…………. 292

104. Patient Confidentiality …………………………………… 295

PROCEDURES
The Approach …………………………………………………… 298

105. Paracetamol Overdose - Venepuncture ….……………… 299

106. ABG Sampling ……………………….…………………… 302

GENERAL TIPS ……….……………………………………. 304

INTRODUCTION

COMPONENTS/STATIONS IN THE EXAM

1. Medicine: 65%

2. O&G

3. Paediatrics

4. Angry patient/Medical errors

5. BBN

6. Other Ethics

7. Psychiatry

8. Counselling

9. Discharge station

10. Follow-up station

11. Teaching station

13. Examination/Procedure

14. Simman (simulated mannikin)

15. Prescription
GENERAL APPROACH TO STATIONS
 GRIPS:

 G- Greet: Hello, Hi

 R- Rapport: How are you doing, etc

 I-Introduction: I’m Dr Mariam Ajugba, one of the doctors in…..

 P- Purpose: I’m here to talk to you…….

 S- Smile

 PARAPHRASE:

 I understand that you’re here……..

 I can see from my notes that you’re….

 What can I do for you today?

 How can I be of help to you today?

 How can I help you?

 SOCRATES

 S- Site: Where do you feel this pain?

 O- Onset: When did it start?

 C- Character: What kind of pain is it?

 R- Radiating: Does the pain go anywhere?

 A- Associated symptom: Any other symptom with this pain?

 T- Timing: Is it related to any particular time of day?

  E- Exacerbating/ Relieving factors

 S- Severity: on a scale of 1 to 10 with…. can you grade the pain?

 ODPARA (for symptoms other than pain)

 O - Onset: When did it start?

 D - Duration: For how long has this been ongoing?

 P - Progression: Is it getting better or worse?

 A - Aggravating factor: Is there anything that makes it better?

 R - Relieving factor: Is there anything that makes it worse?

 A - Associated symptom: Is there any other symptom associated

with this….

 You must allow patients exhaust their symptoms before asking for

differentials

 Apart from this complain, do you have any other symptom (after

SOCRATES or ODPARA)

 Apart from these things you mentioned, do you have any other

symptom

 Differential diagnosis
 PMAFTOSA

 P- Past Medical History: Any PMH of any medical condition?

 M-Medication: Are you on any medication (routine/OTC/herbal)?

 A- Allergy: Any known allergy?

 F- Family History: Any FH of any medical condition?

 T- Travel History: Any history of recent travels?

 O- Occupational History: What do you do for a living?

 S- Social History

 S- Smoking: Do you smoke?

 A- Alcohol: Do you drink alcohol?

 D- Diet: Please tell me about your diet?

 E- Exercise: Are you physically active?

 A: Anything Else: Is there anything else you would like to tell me

that I may have missed?

 …. (insert patient’s name) Thank you very much for speaking with

me. Is there anything you think I may have missed out that you would

love to tell me?

 Acknowledge the response and explore where necessary

 ICE

 I - Idea: Do you have an idea of what could be causing this?

 Have you given a thought to what the problem could be?

 C - Concerns: Any particular concerns?

Is there anything that bothers you the most?

 E - Expectations: Is there anything else you were hoping I’d be

able to do for you today?

Were you expecting something else that we haven’t talked about?

 JARSS (for chronic conditions)

 J- Job: Has this affected your job?

 A- Activities: Has this affected your activities?

 R- Relationship: Has this affected your relationship?

 S - Sleep: Has this affected your sleep

 S - Sex: Has this affected your sex life?

 EVE Protocol (use when patients show emotion): This can come

anywhere in the data gathering, but preferably early enough

 E - Explore Emotion: I can see that you’re quite disturbed about

this

 V - Validate the Emotion: Most people in your shoes would feel

the same way

 E - Empathic Response: I’m truly sorry that this has happened,

but now, we’ll do our best to help you okay?

 Examine patient (always mention chaperone): I’d like to check your

observations, examine you from head to toe and pay special attention

to your… (insert specific systems). I’ll do all of this in the presence of

a chaperone and ensure your privacy. Can I go ahead?

NOTE: Always follow “head to toe” with the specific system you want

to examine”. Don’t just say “head to toe”

 Do not make a new sentence without confirming if the patient is

following you

 Are you following?

 Are we together?

 Does this make sense to you?

 Are you with me?

 How does that sound?

 Is that something you would consider?

 Are you happy to do it?

 Does this sound like a plan?

 …..etc

 For example. Johnson from what you told me, I suspect you have a

condition we call Myocardial infarction. Do you know what that

 means? Or have you ever heard about it?

 Explain the diagnosis, then ask if the patient is following

 For most patients seen in A&E, admit.. This is an emergency and it’s

life threatening so we will have to admit you/keep you in the hospital

 Investigations: For every test you mention, explain what you’re going

to do and confirm the patient understands what you’re saying. Mention

both bedside and diagnostic investigations together. Separate bloods

from radiological investigations

 The result I have with me just confirms that……….

 Medications: explain the reason for every medication you ’ re giving

and confirm that the patient is following?

 Do you have any concerns so far?

 Inform seniors

 Safety net : always tell patient the warning signs

 Give the appropriate leaflet/reading materials

MEDICINE

THE APPROACH
 GRIPS

 PARAPHRASE

 SOCRATES/ODPARA

 History of Presenting complaints

 Differentials

 PMAFTOSA

 ICE

 JARSS

 Examine the patient

 Give provisional diagnosis

 Investigations: both routine and to confirm diagnosis

 Treatment

 Address concerns

 Inform Seniors

 Safety net

 Give leaflets/advice sheet (don’t give to suspected cancer cases to

avoid causing anxiety..etc)

PATIENT WITH A FALL (Fracture)
Anytime you see a patient with fall, look out for the following;

Mechanical fall

Chest infection

UTI

 GRIPS

 PARAPHRASE

 ODPARA/SOCRATES the symptom given

 Was it an unwitnessed or a witnessed fall?

 BEFORE

 Did you have any symptom?

 Any loose carpets?

 How is the lighting in the home?, etc

 DURING

 Did you hit your head on the floor?

 Any jerky movements?

 Did you sustain injury to any part of your body?

 Any bleeding from any part of your body?

 AFTER

 How did you feel after the fall?

 Did you lose consciousness?

 Were you confused after the fall?

 Any weakness in any part of the body?

 Do you feel pain in any part of your body?

 Has this happened before? (Explore if it’s a positive)

 Any fever?

 Any cough?

 Any chest pain before the fall?

 Any dizziness prior to fall?

 R/O UTI: increased urinary frequency

 Any use of blood thinners (especially in the elderly); do CT scan

 Relevant PMAFTOSA

 Examine patient: Check their observations, BP lying and standing (if

the difference is up to or more than 20mmHg,it’s most like Postural

Hypotension)

 Explain the diagnosis: From what you’ve told me, I suspect (always

say “I suspect” unless a diagnosis has been made)……

 What are you going to do for me (treatment)?

 Admit

 Investigations: routine

 Do ECG (R/O arrhythmias)

 DO X-ray of the pelvis; after X-ray say “ the x-ray result just

confirmed what I told you earlier”…..

 Give IV Fluids (1L till orthopedic review)

 Do a fascia iliaca block (technique to give medications to numb

pain); active for about 12hours

 Invite the orthopaedic surgeon for review

 Inform Seniors

 Safety net

 Give leaflets

 Address concerns
ERECTILE DYSFUNCTION
 GRIPS

 PARAPHRASE

 How long has this been ongoing

 How have you been coping?

 Anything that makes it better or worse?

 On a scale of 1 to 5, can you grade your urge to have sex?

 On a scale of 1 to 5, can you grade your erection?

 Are you able to penetrate and sustain it?

 Any early morning erection?

 Are you undergoing any form of stress at home or at work?

 Have you been managed for an STI in the past?

 Any instrumentation done in your penis/private area?

 Is your partner male or female?

 Any penile discharge?

 PMAFTOSA (patient will be on medications, find out who prescribed

them)

 ICE/JARSS

 Examine the patient

 Explain the diagnosis: I suspect you have a condition called Erectile

Dysfunction (ED). ED is when a you’re either unable to get an

erection or keep an erection long enough to have sex.

 How did I get it? There are different causes, but in your case, I

suspect it is because of the Bisoprolol you ’ re taking, but I’ll need to

confirm from my drug book (reach out for BNF, open to that part if

you have time)

 What are you going to do for me?

 Discontinue the medication: Please you need to return to the

specialist for a change/review of the Bisoprolol

 Reassure that as soon as the medication is changed, he’ll be alright

 Dr, can I have viagra? Give viagra if the patient asks for it (ask if

is on any nitrite containing medications and if patient is not, give

viagra). To take viagra up to 4 hours before the time for sexual

action. Tell him the viagra is a temporary treatment because the

main cause is from the medications and symptoms should resolve

as soon as the medication is changed.

 Encourage to engage in sufficient fore-play (because viagra would

work in the presence of an urge for sex and sexual excitement)

 Organize counselling session for patient and partner

 Test the underlying cause

 Counsel on lifestyle modification as required

 Refer to Sexual Health clinic

 Are there side effects of this medication? Just like every other

medication, viagra has side effects like headaches, nausea, dizziness,

indigestion, etc.. But considering that you’ll only be taking the

medication for a short time, you’re unlike to have side effects

 Inform Seniors

 Give leaflets

 Safety net: prolonged erection, etc

 Address further concerns

PSEUDOMEMBRANOUS COLITIS
 GRIPS

 PARAPHRASE

 Do you know what your dad he’s been managed for?

 What medication is he on?

 How is your dad doing now?

 Are you comfortable with his treatment?

 Relevant PMAFTOSA

 Explain the situation: One of the side effects of antibiotics in the

elderly is pseudomembranous colitis (natural protection is washed out

by the antibiotics)

 Why did you take him to another ward? We isolated him to

prevent the spread from one person to another because the condition is

contagious. Everyone in the isolation room has similar symptoms

 As soon as your dad is better, he ’ ll be brought back to the ward.

Please do not see it as a form of discrimination against your dad

 How are you going to treat? We’ll give him antibiotics

 Why are you giving antibiotics again? Reassure him and tell him

you ’ ll give him a different antibiotics that ’ s sensitive to the bug. If

antibiotics not given to treat, there may be complications like bowel

perforation

 In no distant time, your dad will be fine and he ’ ll be moved to the

 ward

 For now we’ll care for him in the best way possible and give him the

rehired treatment

 It’s important than he observes good personal hygiene so as to reduce

spread, like washing his hands with soap and water, properly disposing

used tissue, etc

 Keep reassuring

 Ask for concerns and address them

 Inform Seniors

 Give leaflets
IRON DEFICIENCY ANAEMIA (IDA)
Causes;

Poor intake

Good intake, poor absorption

Good intake, good absorption, but losing it

 GRIPS

 PARAPHRASE

 I understand that you were here.. and you carried out some tests. Has

anyone been here to explain the result of this test to you?

 I ’ m here to talk to you about your result and address any concerns

that you may have

 Why did you come to the hospital in the first place?

 ODPARA tiredness

 Intake: Do you take adequate portions of fish and meat, fruits and

vegetables?

 Absorption: any diarrhoea, vomiting, bloating..

 Loss: any passage of dark stool or blood in stool, any bleeding from

any other part of the body. Ask about Menstrual cycle for women

 R/O FLAWS

 Complications: tiredness, SOB, heart racing, dizziness

 Relevant PMAFTOSA

 ICE/JARSS
 Examine the patient

 Explain the diagnosis: From what you told me and from the

results… (state the normal ones first), but you have what we call Iron

Deficiency Anaemia. It’s a type of anaemia caused by lack of iron

 How did I get it? There are several causes, but in your case, it’s most

likely due to….(state the cause elicited in your data gathering)

 What are you going to do for me?

 Refer to Blood specialist (Haematologist), who will do the Iron

studies

 Place him on haematinics

 Refer to Dietitian if problem is with intake

 Refer for Colonoscopy if the problem is with absorption

 Refer to the Gastroenterologist if problem is with loss

 If over 60 years, refer urgently through the suspected Cancer

pathway

 Inform Seniors

 Safety net: anaemia heart failure (SOB, leg swelling….)

 Give leaflets

 Address further concerns

VITAMIN B12 DEFICIENCY
 GRIPS

 PARAPHRASE

 I understand that you were here.. and you carried out some tests. Has

anyone been here to explain the result of this test to you?

 I ’ m here to talk to you about your result and address any concerns

that you may have

 Why did you come to the hospital in the first place?

 ODPARA tiredness

 Intake: Do you take adequate portions of fish and meat, fruits and

vegetables?

 Absorption: any diarrhoea, vomiting, bloating..

 Complications:

 Heart racing

 Numbness or tingling sensation

 Weakness on any part of the body

 Problems with memory, understanding and judgement

 Problems with balance

 Confusion

 Vision problems

 Feeling of pins and needles

 Relevant PMAFTOSA

 ICE/JARSS

 Examine the patient

 Investigations: routine

 Explain the diagnosis: From our discussion so far and from your

test results (explain the result), I suspect you have a condition called

Vitamin B12 Deficiency. It occurs when a local of Vit B12 causes the

body to produce abnormally large red blood cells that cannot function

properly

 What are you going to do for me?

 Do intrinsic factor: to R/O Pernicious anaemia

 Initial Treatment: Injection Hydroxocobalamin given every

other day for 2 weeks or until your symptoms have started

improving. Your GP or Nurse will give you the injections

 Diet Related: If your Vit B12 is caused by a lack in your diet,

 You may be advised to take Vit B12 tablets everyday between

meals. Vegans may need the tablets for life, may be stopped if

Vit B12 levels have returned to normal or diet has improved

OR

 You may need to take an injection of Hydroxocobalamin twice

 every year

 For Vegetarians or Vegans, there are other foods that contain

Vit B12, such as yeast extract (including Marmite), as well as

some fortified breakfast cereals and soy products. Check the

nutrition labels while food shopping to see how much Vit B12

different foods contain

 Not Diet-related:

 If the deficiency is not caused by a lack of Vit B12 in your diet,

you’ll usually need to have an injection of Hydroxocobalamin

2 to 3 months for the rest of your life

 If you have had neurological symptoms that affects your

nervous system, you’ll be referred to the Haematologist and

may need to have injection every 2 months; duration of

treatment will be determined by the specialist

 Referral to a Specialist

 A Specialist in treating blood conditions (Haematologist): If

you have Vit B 12 or Folate deficiency anaemia and your GP is

uncertain of the cause, you’re pregnant or your symptoms

suggest your nervous system has been affected

 A Specialist in conditions that affect the digestive system

 (Gastroenterologist): If your GP suspects you do not have

enough Vitamin B12 or folate because your digestive system is

not absorbing it properly

 A Specialist in nutrition (Dietitian): If your GP suspects you

have a Vitamin B12 or folate deficiency caused by a poor diet.

A Dietitian can devise a personalized meal plan for you to

increase the amount Vit B12 or folate in your diet.

 Monitoring your condition

 A blood test if often carried out around 7 to 10 days to assess

whether the treatment is working. The test is done to check the

haemoglobin levels and the number of immature red blood

cells (reticulocytes) in your blood

 Another blood test may also be carried out after approximately

8 weeks to confirm the treatment has been here

 Most people who have had this condition may not need further

monitoring, unless their symptoms return or treatment is

ineffective

 Dr, do you think I should consider eating meat? I see you’re being

proactive about your health and I must really commend you, but the

decision to eat meat of fish is entirely up to you to make

 Dr, do you think my diet is abnormal? Don’t say it’s normal or

abnormal. I wouldn’t say your diet is abnormal, but there seems to be

some deficiencies, which is responsible for the symptoms you’re

currently having

 Inform seniors

 Safety net

 Give leaflets

 Address further concerns

VARICOSE VEINS
 GRIPS

 PARAPHRASE

 ODPARA leg swelling or pain (depending on the scenario)

 R/O DVT: calf pain/swelling

 R/O Pulmonary Embolism: shortness of breath

 R/O Trauma: Did you by any chance hurt your leg?

 R/O complications: bleeding, pain, soreness

 Menstrual history: LMP, Are you by any chance pregnant?

 When was your last pregnancy?

 Was it multiple gestation?

 Ask about prolonged standing?

 Any family history of varicose veins?

 Relevant PMAFTOSA/MSC history

 Examine the patient: including BMI

 Investigations: routine

 Explain the diagnosis: From our discussion so far and from

examination findings, I suspect you have a condition called Varicose

veins. They are swollen and enlarged veins that usually occur on the

legs and feet. They are rarely serious and do not usually require

treatment. I’m a healthy vein, blood flows smoothly to the heart and

backward flow is prevented by the valves that open and close to let
 blood [Link] veins develop when the small valves inside the

veins weaken or become damaged and this causes blood to flow

backwards and collect in the veins, causing swelling and enlargement.

 Further investigations: Doppler, etc

 Why did I get this? Certain things can increase your risk like family

history, pregnancy, obesity, standing for prolonged periods, etc; but in

your case, I think it’s because of…….. (state the risk factors elicited in

the history

 What are you going to do for me?

 Encourage to use Compression stockings

 Regular exercise

 Whenever you’re resting, try to elevate the affected leg

 Apply cold compress

 Dr, can surgery be done? There are options available for surgical

removal, but it’s unlikely you’ll receive treatment in the NHS for

cosmetic reasons. You’ll have to pay for treatment in a private facility,

is thar something you’re willing to consider?

 What if they begin to bleed or cause me so much discomfort will

the NHS do it? Yes, you’ll most likely receive treatment at the NHS,

if there is complication
 Treatment when bleeding;

 Endothermal ablation: the use of heat to seal affected veins

 Sclerotherapy (special foams to close the veins), l

 Ligation and stripping. ( surgical removal of affected veins)

 Counsel on lifestyle modification (based on the positives in the history

 Inform Seniors

 Safety net

 Give leaflets

 Address further concerns

DIZZINESS
 GRIPS

 PARAPHRASE

 Does it feel as if the room is spinning around you (from the ear)or

you are light headed(likely from the heart)?

 Ménière’s disease: hearing loss, ear fullness, tinnitus

 BPPV: dizziness worse on moving the head, movement on the bed

and standing from a sitting position

 Vestibular neuritis: any history of flu-like symptoms

 Acoustic neuroma: dizziness, progressive hearing loss, CNS

symptoms like facial weakness, wobbly gait/loss of balance, absent

corneal reflex

 Arrhythmia: any heart racing

 Postural hypotension: do you fell dizzy when you stand up from a

sitting position?

 I’d like to check your examinations, check your blood pressure lying

and standing, examine from head to toe. I ’ d also like to do a special

maneuvers called the dix hall pike maoeuvre

 Positive dix hallpike; BPPV

 If postural hypotension: admit, give Iv fluids, address possible cause

 Do ECG

 Manage accordingly
CHRONIC FATIGUE SYNDROME (CFS)
Always preceding history of viral illness

IT system also down

 GRIPS

 PARAPHRASE

 IT system is down so I can’t access your records, is it okay if I ask

some questions?

 ODPARA tiredness that has been ongoing for 6 months

 6 months is such a long time to have been experiencing this, how

have you been coping? Acknowledge response

 EVE protocol: I can see that you’re quite distressed about this and

anyone who has been experiencing tiredness for this long would feel

this same way, but it’s a good thing that you’re here now and we’ll do

our best to help you okay?

 Any fever?

 Any flu-like illness

 Any sore throat?

 Any headache?

 Do you feel sick?

 A - R/O Anaemia: heart racing, dizziness, weakness

 B - R/O Bone problems like TB, Multiple Myeloma: fever, cough,

 night sweats,back pain

 C - R/O Cancer: FLAWS

 D - R/O Depression: Grade mood, Relevant CEASAR

 E -R/O Endocrine disorders: DM (polyuria, polydipsia,

polyphasic), Hypothyroidism (cold intolerance), Addison’s (salt

cravings, pigmentation, muscle weakness, polyuria, polydipsia,

polyphagia, etc)

 Relevant PMAFTOSA

 Menstrual, Sexual & Contraceptive history: the patient is usually a

female

 Ask about support from family/friends

 ICE/JARSS

 Examine

 Do routine tests, TFT

 Explain diagnosis: Chronic Fatigue Syndrome is also called

Myalgic Encephalomyelitis (ME). It’s a long term condition with a

wide range of symptoms, of which the most common is the tiredness

that you’re currently experiencing? Are you silty me?

 How did it get this? The exact cause is unknown, but there are some

risk factors like viral infections, hormonal imbalance, family history

(more common in some families),problems with the immune system,

etc
 What are you going to do for me?

 Give painkillers if patient has pain

 Refer for talking therapy/CBT

 Refer to the Energy Management Clinic

 Relaxation exercises like yoga, massaging

 Encourage to be physically active

 Take plenty of fluids

 Listen to music

 Encourage to take walks

 Encourage to eat a balanced diet

 Support Group: ME/CFS Association; a charity that provides

information, support and practical advice for people who are

affected by the condition

 Inform Seniors

 Safety net

 Give leaflets
SHINGLES
 GRIPS

 PARAPHRASE

 ODPARA the rash

 Size

 Site

 Shape

 Symmetry

 Colour

 Any pain?

 Any itching?

 Any discharge/bleeding?

 R/O pneumonia, P.E

 History of contact with someone else with similar rash

 History of chicken pox/Immunization history?

 History of long term steroid use

 Any eye symptoms (redness, gritty sensation, pain)

 Relevant PMAFTOSA

 Examine

 Explain the diagnosis: Shingles is a reactivation of the chicken pox

virus and it causes a painful rash like what you’re experiencing.

 What are you going to do for me?

 Paracetamol 1g qds> NSAIDs> Cocodamol > Amitryptilline,

Gabapentin, Duloxetine

 Reassure patient

 Give antivirals (acyclovir) only if: the person is having signs of

immunosuppression, moderate to severe rash, moderate to severe

pain

 Commence antivirals within 3 days of onset of rash

 Keep the rash clean and dry

 Apply cold compress (a bag of frozen vegetables wrapped in a

towel or wet cloth) a few times daily

 Don’t use antibiotic creams because it slows healing

 Don’t use tight dressings or plasters that will stick to the rash

 Advice to stay away from children, pregnant women, others with

low immunity

 To stay off work if rash is oozing fluid and cannot be covered or

until the rash has dried out.

 Is shingles contagious? You can get chicken pox from someone with

shingles, but you can ’ t get shingles from someone with shingles or

chicken pox
 Is a vaccine available? Yes, vaccine is available for

 People who turn 65 on or after September 1st, 2023

 People aged 70 to 79

 People aged 60 and over with a severely weakened immune system

The vaccine helps to reduce your risk of getting shingles, but in the

event where shingles still occurs, it helps to make the symptoms

milder.

 Inform Seniors

 Safety net: feeling unwell, rash spreading, etc

 Give leaflets

 Address further concerns

INFECTIVE EXACERBATION OF COPD/
ACUTE EXACERBATION OF COPD LIKELY
DUE TO A CHEST INFECTION
 GRIPS

 PARAPHRASE

 ODPARA

 Apart from this symptom, do you have any other symptom

 Any fever?

 Any flu-like symptom?

 R/O MI: chest pain

 R/O Pneumonia: chest pain, cough productive of sputum

 R/O P.E: calf pain, calf swelling

 Relevant PMAFTOSA

 ICE

 Examine

 Investigations: routine

 Explain the diagnosis: From our conversation and from examination

findings so far, I suspect you’re having an acute exacerbation/episode

of the COPD

 What could have caused it? In your case, I suspect a possible chest

infection

 Further investigations: Chest X-ray, etc

 What are you going to do for me?

 Admit

 Give oxygen at 24-28% using a Venturi face mask. Maintain

SpO2 between 89 to 92%

 Give nebulized salbutamol

 Ipratropium bromide, 500mcg

 IV Hydrocortisone 100mg or prednisolone

 Give antibiotics based on the hospital’s protocol

 Inform Seniors

 Safety net

 Give leaflets

 Address further concerns

ADDISON’S DISEASE
 GRIPS

 PARAPHRASE

 ODPARA tiredness

 Do ABCDE of Tiredness

 Relevant PMAFTOSA (patient has Type 1 DM so R/O symptoms and

complications of diabetes)

 Menstrual history

 Sexual history

 Contraceptive history

 ICE

 Examination: Observations, hyperpigmented skin, BMI, tummy

examination

 Investigations: routine, urine dipstick, capillary glucose

 Explain the diagnosis: From our discussion so far and from my

examination findings, I suspect you have a condition called Addison’s

disease. It’s a rare disorder of the adrenal glands, which sit just on top

of the kidneys. The glands are responsible for producing some

hormones like cortisol (which helps to regulate your body’s stress

response) and aldosterone (which help to regulate your BP by

managing the levels of some salts like sodium and potassium in your

blood).
 How did I get it? The exact cause is unknown, but it could be

autoimmune since you mentioned that you have Type 1 DM and your

sister has Hypothyroidism. Does this make sense?

 What are you going to do for me?

 Arrange for immediate admission: You will need to be admitted

in the hospital immediately so they can give you some fluids to

correct the salt levels. While you’re there, you’ll also been

reviewed by the specialist. How do you feel about that?

 Is it a serious condition? Addison’s disease can be potentially

life-threatening if left untreated and it can develop into what we

call Addisonian/Adrenal Crisis

 What will the specialist do? They’ll talk to you, assess you and

carry out some further tests for some hormones (ACTH, cortisol,

aldosterone) TFT, and a special test for Addison’s disease called

the Synacthen test

 When the diagnosis is confirmed, they’ll place you on steroids;

Hydrocortisone or prednisolone … … It is important that you take

the medication as prescribed and you may need to take them

throughout life. PAUSE and acknowledge concerns

 You will need to increase the dose of this medication when

there’s an infection, illness or you’re going for surgery.

  Blue (Steroid card): Its a card to let healthcare workers who may

need to attend to you know that you’re on steroids and the steroids

cannot be stopped abruptly. It’s essential that you have this card

and carry it with you everywhere you go.

 Counsel on weight loss (if obese)

 Support Groups

 Can I drive myself to the A&E? I’m afraid you may not be able to do

so because driving may not be safe for you and other road users. We

will arrange transportation for you. To inform DVLA if patient

drives a truck, lorry or operates machineries

 Inform Seniors

 Safety net for Addisonian crisis

 Give leaflets

 Address concerns
OCCULAR TOXOPLASMOSIS
 GRIPS

 PARAPHRASE

 ODPARA blurring of vision

 R/O some eye symptoms

 Relevant PMAFTOSA

 Is there anything you think I may have missed out that you would like

to tell me?

 ICE

 Ask if they drive and involve DVLA in management

 Examine: check observations, GPE, fundoscopy

 Investigations: routine

 Explain the diagnosis: From what you told me and from my

examination findings, there seems to be something going on in your

eye which is what we call Occular Toxoplasmosis. It’s a common

infection that can be caught from the pop of infected cats or infected

meat; it’s usually harmless, but can cause serious problems in some

people

 What are you going to do for me?

 Refer to Ophthalmologist immediately

 Refer to see the Infectious Disease Specialist

  Folinic acid, Sulfadoxine-Pyrimethamine (Fansidar); for

immunocompromised, pregnant or people with eye symptoms

 Advise her that her pets (cats) have to be taken to the vet for

treatment

 She must wear gloves anytime she’s taking care of the pets

 Practice hand washing

 Inform Seniors

 Safety net: confusion, slurred speech, etc

 Give leaflets

 Address concerns
AGE RELATED MACULAR DEGENERATION
(ARMD)
Usually 70 years and above

 GRIPS

 PARAPHRASE

 History of Presenting Complaints:

 Central vision is impaired, but peripheral vision is fine

 Progressively worsening visual symptoms

 Straight lines begin to appear wavy

 Blurring of vision

 Bumping into objects

 R/O Differentials

 Relevant PMAFTOSA

 ICE

 Examine the patient

 Investigations: routine

 Explain the diagnosis: The macular is the part of the eye responsible

for sharp and clear vision and sometimes the macular undergoes

natural wear and tear, which leads to the symptoms you’re having.

This condition is what we call Age-Related Macular Degeneration. Do

you have an idea of what it is?

 How did I get it? The exact cause is unknown, but there are some

risk factors and I n your case, it’s most likely due to your age

 What are you going to do for me?

 Refer to Ophthalmologist

 Refer to Low Vision Clinic (referral made by the

ophthalmologist if patient has difficulty with daily activities)

 The ophthalmologist can refer for a type of training called

Eccentric Viewing Training if patient has poor vision in both

eyes

 Magnifying lenses

 Audio books

 Install brighter lighting in your home

 Encourage healthy diet, regular exercise, etc

 Stop driving and Inform DVLA if you drive

 Support Groups: The Macular Society

 Will I go blind? It does not cause total blindness, but it can make

everyday activities like reading and recognizing faces difficult

 Inform Seniors

 Safety net

 Give leaflets
SYPHILIS - RESULT SHARING
 GRIPS

 PARAPHRASE

 I understand that you attended the well-man clinic and did some tests

and I do have your results with me … .. Has anyone been here to

explain the results? I ’ m here to explain the results and address any

concern you may have. I would like to ask a few questions so I can get

a clearer picture of everything, is that okay?

 Why did you do the test in the first place?

 R/O UTI: dysuria,

 R/O STI: fever, penile discharge

 Sexual History:

 Are you sexually active?

 Do you have a stable sexual partner?

 Is your partner male or female?

 Have you had any sexual contact with any other person other than

your partner in the last 6 months?

 How long have you been together?

 Do you practice safe sex?

 What’s your preferred route of sexual contact

 Any previous history of STI?

 Travel history:

 Have you recently travelled out of the UK?

 How was Thailand?

 What did you do there?

 Have you had sexual intercourse with your partner since returning?

Was it protected or unprotected?

 Relevant PMAFTOSA

 Examine

 Explain diagnosis: From the results… state the normal ones first…

However, one of the tests we did to test for a bug that causes Syphilis

turned out positive. So I ’ m afraid you have Syphilis. Syphilis is a

sexually transmitted infection (STI)

 How did I get it? You didn’t mention that you’ve had more than one

partner and you don’t practice safe sex, so it’s possible that you may

have got it through sexual intercourse

 What are you going to do for me?

 Give necessary antibiotics

 Refer to Sexual Health Clinic for follow-up

 Advise to bring partner for testing and possible treatment. You

owe your partner the responsibility to get informed and treated…

 Talk about Partner ’ s Notification Programme if patient can ’ t

bring partner

 Advise to abstain from sex until treatment is complete

 Advise to practice safe sex in the future

 Offer STI screening

 Inform seniors

 Safety net

 Give leaflet

 Address further concerns

FURTHER QUESTIONS FOR HIV

 I don’t want to inform my partner: If you insist on not informing

your partner, you might be sued for an offense of grievous bodily harm

 Do I need to inform my employer: No, unless you work In a place

where you handle blood or body fluids. Inform your Manager to

switch your roles for personal reasons.

 Can I inform my insurance company: Yes, if you’re HIV positive,

your insurance company needs to know.

 Advise to practice safe sex

COELIAC DISEASE
 GRIPS

 PARAPHRASE: I understand you were here previously and had

some tests done…. Is that correct?

 Why did you come for the test?

 Has anyone explained the results?

 Any diarrhoea?

 Any bloating?

 Any feeling of indigestion?

 Any constipation alternating with diarrhoea

 R/O complications: tiredness/fatigue unintentional weight loss, etc

 Relevant PMAFTOSA

 ICE/JARSS

 Examine the patient

 Investigations: routine

 Explain the diagnosis: Coeliac disease is a condition where your

immune system attacks your own tissues when you eat gluten. This

damages your gut (small intestine) so your body cannot properly take

in nutrients.

 Why did I get it? It’s not clear what makes the immune system to act

this way, but a combination of genetics and the environment appear to

play a part.
 What are you going to do for me?

 Refer to the Gastroenterologist

 Investigation to confirm diagnosis: Endoscopy

 Encourage to maintain gluten diet until diagnosis is made

 Is there a cure? Unfortunately, there is no cure, but eating

healthy and balanced Gluten-free diet should help control the

symptoms and prevent long-term complications

 Support Group: Coeliac UK; UK Charity for people with

Coeliac disease.

 Inform Seniors

 Safety net

 Give leaflet

 Address further concerns

MENIERE’S DISEASE
 GRIPS

 PARAPHRASE

 ODPARA dizziness

 Do you feel as if the room is spinning around you or you feel lighted?

 R/O Ménière’s disease: dizziness, ear fullness, hearing loss

 R/O vestibular neuritis: flu-like symptoms

 R/O postural hypotension: do you feel dizzy when you stand up from

a sitting position

 R/O arrhythmia: any history of heart racing?

 R/O BPPV

 Relevant PMAFTOSA

 ICE/JARSS

 Examine: GPE, ear, nose and throat

 Dix hall-pike manoeuvre

 Observations: blood pressure, lying and standing (BP lying should be

higher than standing BP in postural hypotension)

 Investigations: routine,

 Explain the diagnosis: Ménière’s disease is a rare disease of the

middle ear that can affect your hearing and balancing? Are you

following?
 What are you going to do for me?

 Anti-histamines

 Anti-emetics: Prochlorperazine

 Refer to ENT Surgeon

 Do MRI (done by the specialist)

 Refer for talking therapy/counselling

 Vestibular rehabilitation to help improve your balance

 Hearing aid

 Encourage Relaxation techniques

 Keep your medicine with you at all times

 Stay well hydrated

 Consider the risk and take care when engaging in activities like

swimming, climbing ladders or using heavy machineries

 Avoid turning 360 degrees

 Inform DVLA if patient drives

 Inform seniors

 Safety net: signs of stroke

 Give leaflet

 Address further concerns

MULTIPLE MYELOMA- RESULT SHARING
 GRIPS

 PARAPHRASE

 I have your results and I’ll be sharing them with you shortly, but can I

ask you a few questions just to be sure we’re on the same page?

 Why did you have the test done in the first place?

 SOCRATES back pain

 Did you by any chance hurt your back?

 Is there any other symptom associated with the back pain?

 C - R/O Hypercalcaemia: polyuria, polydipsia, constipation, etc

 R - R/O Kidney problems: facial/leg swelling, oliguria, etc

 A - R/O Anaemia: heart racing, dizziness, etc

 B - Back pain (presenting complaint)

 R/O FLAWS

 Explore psychosocial history because patient mentioned that she lost

her husband

 Grade mood

 Relevant PMAFTOSA

 ICE/JARSS

 Examine

 Investigations: routine

 Explain diagnosis: MM is a type of bone marrow cancer. It’s called

 Multiple Myeloma because the cancer often affects several parts of the

body like the spine, skull, pelvis and ribs. It does not usually cause a

lump or tumour, it damages the bones and affects the production of

healthy red blood cells

 Could this be rheumatoid arthritis? We did a test, but the

Rheumatoid factor which is an indication for arthritis is negative so it

is not arthritis

 Will I die? I can see you’re worried….but the good thing is that you

came and now we know what’s going on….

 Is there a cure? I’m afraid there’s no cure, but treatment can help to

control symptoms and improve the quality of life in patients with

Multiple Myeloma

 What are you going to do for me?

 We will refer you urgently to a Specialist (Haematologist) via the

2 weeks referral pathway; who will do more tests and treat you

based on the results

 More tests: MRI and CT scans of the arms, legs, skull, spine and

pelvis, to look for any damage

 We’re also going to take a sample from your bone marrow (Bone

marrow biopsy) taken from the back of your hip bone. We’ll give

you some numbing medications so you don ’ t feel pain; are you
 happy about that?

 Test for immunoglobulins in the urine and blood

 Options for treatment:

 Bringing Myeloma Under Control: The initial treatment of

MM may with her be non- intensive (for older and less fit

patients) or intensive (for younger or fitter patients). Both the

intensive and non-intensive treatments involve taking a

combination of anti-myeloma medicines. But the intensive

treatment involves higher doses and is followed by a stem cell

transplant. The medicines include;

 Chemotherapy - to kill the myeloma cells

 Steroids (corticosteroids) - to help destroy myeloma cells

and make chemotherapy more effective

 Stem cell transplant - for those receiving intensive

treatment, the high doses of chemotherapy may affect

healthy bone marrow, so a stem cell transplant will be

needed to allow your bone marrow to recover

 Treating symptoms and complications:

 Painkillers - to reduce pain

 Radiotherapy - to relieve bone pain or help bone healing

 after a bone is surgically repaired

 Biphosphonate - to help prevent bone damage and reduce

blood calcium levels

 Blood transfusion or Erythropoietin - to increase RBC

count and treat anaemia

 Surgery - to repair or strengthen damaged bones or treat

spinal cord compression

 Dialysis - if patient develops kidney failure

 Plasma exchange - treatment to remove and replace plasma

(the liquid that makes up blood) if you have unusually thick

blood

 You can also mention side effects and their treatment

 Inform seniors

 Safety net

 Address concerns
BARRET’S OESOPHAGUS - RESULT
SHARING
 GRIPS

 PARAPHRASE

 ODPARA heartburn

 R/O differentials

 R/O Risk factors: obesity, smoking, alcohol

 R/O complications: difficulty swallowing, SOB etc

 R/O FLAWS

 Relevant PMAFTOSA

 ICE

 JARSS

 Examine the patient

 Explain the result/diagnosis: frequent heartburn making stomach

acid spill into the food pipe. The spillage causes changes in the cells of

the food pipe and when this occurs, it’s called BARRET’S

Oesophagus

 What are you going to do for me?

 Lifestyle modification: smoking, alcohol, weight loss, avoid

eating late in the evening, avoid tight clothing and bending

 Medication: Include PPI to suppress acid reflux

  Monitoring: Endoscopy at regular intervals

 Surgery: The consultant will discuss this with you if he feels this

would be an appropriate course of action. Surgery can be

performed to strengthen the valve at the lower end of the

oesophagus, thus preventing reflux from occurring

 Could it be cancer? Acknowledge concern. Is there any particular

reason why you think it could be cancer?. At the moment, it’s not

cancer, but in a very small number of patients, the cell changes may

develop into Oesophageal cancer

 Address further concerns

 Inform Seniors

 Safety net: FLAWS, worsening heartburn

 Give leaflets
SKIN LESIONS/CONDITIONS
 BCC

 SCC

 Malignant Melanoma

 Seborrhoiec Keratosis….. etc

 GRIPS

 PARAPHRASE

 I Understand you’ve got some concerns you would like to talk to me

about. Am I correct? I’m here to talk to you and address your concerns

 Duration: How long has it been there?

 S4 C PID FLAWS

 S - Site: where exactly is it located? Apart from this part, is it in

other parts of your body?

 S - Size: Can you describe the size of this lesion? Is it increasing in

size

 S - Shape: can you describe what it looks like?

 S - Symmetry: Can you describe the edges?

 C - Colour: What is the colour? Has it even changed colour?

 P - Pain: Is it painful? If yes, at what point did it become painful?

 I - Itching: Any itching?

  D - Discharge: Any discharge/ bleeding?

 F - Fever: Any fever?

 L - Lumps: Any lumps or bumps in any part of your body?

 A - Anorexia: How has your appetite been?

 W - Weight loss:

 S - Night sweats:

 Any ulceration?

 Number: how many are they? Have they been increasing in number?

 R/O Differentials

 Any history of sun bathing or tanning?

 Any history of recent travel outside the UK, especially to areas with

high sunlight?

 Any family history of any skin condition? What about skin cancers?

 Relevant PMAFTOSA

 ICE

 JARSS

 Examine the patient

 From the assessment, it could be…. (Explain the diagnosis). Ensure

to give warning shots if you suspect a cancer

 Management

1. Seborrhoic ketratosis: shave excision, freeze with nitrogen

2. Mole: shave excision, freeze with nitrogen, laser

3. Cherry Angioma: Reassure

4. Non-melanoma (SCC, BCC etc):Referral through the cancer pathway

5. Molluscum contagiosum: Reassure

6. Malignant Melanoma: Excision biopsy, Wide local excision, referral

through the suspected cancer pathway

7. Etc……….

 Refer to the Dermatologist

 Wear protective clothing to cover yourself when out in the sun

 Use sun screens

 Inform Seniors

 Safety net

 Give leaflets (except in suspected cancer cases)

 Address concerns
GIANT CELL ARTERITIS/TEMPORAL
ARTERITIS
 GRIPS

 PARAPHRASE

 SOCRATES headache

 Did you by any chance hurt yourself?

 Any eye symptoms?

 Any pain on chewing?

 Any pain on combing your hair?

 Any joint stiffness, pain or inflammation in the muscles of the

shoulders, neck and hips?

 Relevant PMAFTOSA

 Examine

 Investigations: routine bloods, ESR, CRP, Temporal artery biopsy

 Explain the diagnosis: Giant Cell Arteritis/Temporal Arteritis refers

to an inflammation in the blood vessels on the temporal region/at the

side of the head called the temples. It’s a serious condition and

requires urgent treatment

 How did I get it? The actual cause is unknown, but it’s believed to

be due to a faulty immune response; It’s an autoimmune condition,

which causes the body’s defence (immune) system to mistakenly

attack your own blood vessels

 What are you going to do for me?

 Admit

 Give High dose steroids

 Give Low dose aspirin

 Once symptoms have improved, commence low dose steroids

 PPI and Biphosphonate: because of long term steroid use

 Immunosuppressants

 Invite Ophthalmologist for eye symptoms

 Inform Seniors

 Safety net

 Give leaflets

 Address concerns
PERIPHERAL ARTERY DISEASE
(PERIPHERAL VASCULAR DISEASE)
 GRIPS

 PARAPHRASE

 SOCRATES bilateral leg pain

 Positive history of intermittent claudication

 Any hair loss on your legs and feet?

 Any numbness or weakness in the legs?

 Any changes in the colour of the skin on your legs?

 Any non-healing ulcers on your feet and legs?

 Any shiny areas of the skin?

 Any brittle or slow-growing toe nails?

 Ask about low libido (erectile dysfunction) if patient is a male

 R/O Differentials: DVT, etc

 R/O Risk factors: smoking, DM, HTN, high cholesterol, etc

 R/O complications: Stroke, Acute Limb Ischaemia, etc

 Relevant PMAFTOSA

 ICE/JARSS

 Examine the patient

 Explain the diagnosis: It ’ s when build up of fatty deposits in the

arteries restrict blood supply to the muscles of the leg.

 Investigations: routine
 What are you going to do for me?

 Ultrasound scan of the leg (Doppler)

 Give painkillers

 Refer to the Vascular Surgeon

 Counsel in lifestyle modification: Smoking, blood sugar control,

BP control, Cholesterol control, Diet, Exercise

 Treat the underlying cause

 Inform Seniors

 Safety net: worsening pain, stroke, Acute limb ischaemia, etc

 Give leaflets

 Address further concerns

DIVERTICULITIS
 GRIPS

 PARAPHRASE

 SOCRATES left lower abdominal pain

 Any fever?

 Any blood in stool?

 Any mucus (slime) in stool?

 Do you feel sick?

 R/O Differentials

 Relevant PMAFTOSA

 ICE

 Examine the patient

 Investigations: routine, stool M/C/S

 Explain the diagnosis: There are small bulges/pouches in the walls

of the large intestine called diverticula; Diverticulitis occurs when

these bulges become inflammed

 What are yo going to do for me?

 Investigations to confirm diagnosis: Colonoscopy

 Give painkillers (Paracetamol); don’t give NSAIDs or opioids as

they can increase the risk of constipation and bowel perforation

 Give antibiotics
  Eat a healthy, balanced diet

 Drink plenty of water

 Regular exercise to maintain a health weight

 Counsel on other lifestyle modifications as indicated

 Inform Seniors

 Safety net

 Give leaflets

 Address concerns
ABDOMINAL AORTIC ANEURYSM (AAA)
 GRIPS

 PARAPHRASE

 SOCRATES back pain

 Is there any other symptom associated with this?

 R/O Trauma: Did you by any chance hurt your back?

 R/O Slipped disc: Any lifting of heavy objects?

 R/O Cauda Equina: Any difficulty passing stool or urine?

 R/O AAA: Any tummy pain? Any swelling/lump in your tummy?

 Has this ever happened before?

 R/O Risk factors: smoking, positive family history, male, high blood

pressure, high cholesterol levels, COPD, have coronary or peripheral

artery disease, etc

 R/O Complications: dizziness, shortness of breath, palpitations,

cyanosis, loss of consciousness, etc

 Relevant PMAFTOSA: Elicit risk factors here

 ICE

 Examine: check observation, examine the tummy, do straight leg

raise test, DRE

 Investigations: routine

 Explain the diagnosis: From our conversation so far and from my

examination findings, I suspect you have a condition called AAA.

 AAA is a swelling in the aorta (the artery that carries blood from the

heart to the tummy). It happens when the main artery that carries

blood from the heart to the tummy becomes weakened

 How did I get it? It’s not always clear what causes it, but some

people are more likely to get it due to some risk factors. In your case,

it’s mostly like due to…….(state the risk factor elicited in the history)

 Is it a serious condition? Most aneurysms do not cause any

problems, but they can be serious because there’s a risk trust they

could burst (rupture)

 What are you going to do for me?

 Further tests: tummy scan

 Small (3cm to 4.4cm or smaller) and Medium (4.5cm to 5.4cm)

Aneurysm:

 Lifestyle modifications such as quitting smoking, healthy diet,

exercise, etc

 Medicine to lower blood pressure, cholesterol levels

 Yearly scan to monitor the size

 Large (5.5cm and bigger) Aneurysm:

 Surgery is done to reduce the risk of rupture. Surgery can also

 be done if it’s quickly getting bigger or painful

 If it bursts; Arrange admission for emergency surgery

 Screening: an ultrasound is offered to all men when they turn 75, as

they are most at risk of getting AAA

 Inform Seniors

 Safety net

 Give leaflets

 Address further concerns

SEPSIS DUE TO SUSPECTED UTI
(ELDERLY)
 GRIPS

 PARAPHRASE

 ODPARA confusion

 R/O chest infection: fever, cough, chest pain, etc

 R/O UTI: tummy pain, dysuria, frequency, etc

 R/O falls/trauma

 Do you feel sick?

 Any discharge from your penis/private area

 R/O BPH: Urgency, nocturia, hesitancy, terminal dribbling, etc

 Any pain or swelling in your private area?

 Relevant PMAFTOSA

 ICE

 Examine patient: high temperature, low bp, low SPO2

 Examine the specific system of focus

 Investigations: routine, urine dipstick

 Explain the diagnosis: From our conversation and examination

findings, I suspect you’re having sepsis and the most likely cause is a

UTI (a condition where bugs grow in your bladder (cystitis), urethra

(urethritis), kidneys (kidney infections) and causes the symptoms that

you’re having
 What are you going to do for me?

 Admit patient

 Take 3: Routine tests, serum lactate, blood culture,

urinalysis/urine m/c/s

 Give 3: Oxygen, IV fluids, antibiotics

 Give anti-sickness medication if patient feels sick

 Pass urethral catheter to monitor input/output

 Close vital signs monitoring

 Inform seniors

 Safety net

 Give leaflets

 Address further concerns

HANGOVER HEADACHE
 GRIPS

 PARAPHRASE

 SOCRATES headache

 Any eye symptoms?

 R/O differentials: Sub-arachnoid haemorrhage, migraine, etc

 R/O risk factors

 Relevant PMAFTOSA

 ICE

 Examine the patient

 Investigation: routine

 Explain the diagnosis: From my assessment so far, I suspect you’re

having a Hangover Headache

 How did I get it? It occurs when you drink more than your body can

handle and it’s quite common in people who are beginners or new to

alcohol intake

 What are you going to do for me?

 Give painkillers

 Drink plenty of fluids

 Sugary foods may help you feel less trembly

 Adequate rest
  To avoid drinking more than he can handle

 To avoid drinking on an empty stomach

 To drink water, soda or non-fizzy drinks in between alcohol

 Drink plenty of water after drinking alcohol

 Counselling to cut-down on alcohol intake if patient is a regular

drinker

 Inform Seniors

 Safety net

 Give leaflets

 Address further concerns

ANALGESIC (NSAIDs - INDUCED)
NEPHROPATHY
 GRIPS

 PARAPHRASE

 SOCRATES left loin pain

 Any changes in your urine (e.g blood)

 Have you been using the loo more often (frequency)?

 Does urine come out before you get to the loo (Urgency)?

 Do you feel sick?

 Any facial, leg swelling? Any swelling in any part of the body?

 R/O Pyelonephritis: any fever, do yo feel sick, etc

 R/O Trauma: did you by any chance hurt your back?

 R/O other differentials

 R/O Complications: Epigastric pain, Oliguria, etc

 Relevant PMAFTOSA

 ICE

 Examine the patient

 Investigations: routine, urinalysis

 Explain the diagnosis: Analgesic Nephropathy is a chronic kidney

disease caused by regular use of analgesics such as acetaminophen,

aspirin, ibuprofen, etc. Taking one or a mix of these daily, over a long

time may cause chronic kidney problems.

 Further investigations: non-contrast CT scan, etc

 Why did I get it? It’s most likely due to the prolonged use of

painkillers you’ve been taking for the back pain

 What are you going to do for me?

 D/C the analgesic

 Give an alternative pain killer like Paracetamol

 Refer to the Nephrologist (They will assess and treat any

existing kidney failure)

 Behavioural changes and/or counselling to help control pain

 Inform seniors

 Safety net

 Give leaflets

 Address further concerns

MYOCARDIAL INFARCTION
 GRIPS

 PARAPHRASE

 SOCRATES chest pain

 Any jaw pain?

 Any pain in other parts of the body?

 Do you feel sick?

 Any sweating?

 Any overwhelming feeling of anxiety?

 R/O differentials: Pneumonia, Pulmonary embolism..etc

 R/O risk factors

 R/O Complications: Arrhythmia (fluttering feeling in the chest), etc

 Relevant PMAFTOSA

 Do you drive?

 ICE

 Examine the patient

 Investigations: routine

 Explain the diagnosis: From our discussion so far, I suspect you’re

having a condition called Myocardial Infarction. MI (heart attack) is a

serious medical emergency in which the supply of blood to the heart is

suddenly blocked, usually by a blood clot. Lack of blood to the heart

may seriously damage the heart muscle and can be life-threatening

 Further investigations: Troponins, Chest X-ray, ECG (usually shows

ST elevation MI (STEMI)

 What are yo going to do for me?

 Arrange for Admission in the hospital: patient will most likely

decline, but emphasize that it’s an emergency and possibly life

threatening

 Give Aspirin

 Give GTN spray

 Give Morphine, Oxygen when patient gets to the hospital

 Review by the Cardiologist

 Lifestyle modification such as eating healthy, stop smoking,

regular exercise, etc

 Talk therapy: Having a heart attack can be frightening and

traumatic and it’s common to have feelings of anxiety afterwards.

For many people, the emotional stress can cause them to feel

depressed and tearful for a few weeks after returning home from

the hospital.

 When can I go back to work? The time it takes to recover from a

heart attack will depend on the amount of damage to your heart.

Usually, in about 4 to 6 weeks, you should be able to return to work.

 Most people can go back to work after having a heart attack, but how

quickly they do so depends on their health, the state of the heart and

the type of work they do.

 When can I have sex? You’ll usually be able to start having sex

again once you feel well enough, usually about 4 to 6 weeks after

 When can I start driving?

 Don’t inform DVLA: If you drive a car or motorcycle, you don’t

have to inform the DVLA. Many people can now return to driving

1 week after a heart attack, as long as you don’t have any other

condition or complication that would disqualify you from driving.

But in some cases, you may need to stop driving for 4 weeks

 Inform DVLA: If you drive large goods vehicle or

passenger-carrying vehicle, you must inform the DVLA. Your

license will be temporarily suspended for a period of 6 weeks, until

you have adequately recovered. Your license will be re-issued if

you can pass a basic health fitness test and you do not have any

other condition that would disqualify you from driving

 Inform seniors

 Safety net/Give leaflets

TREATMENT OVERVIEW

The treatment options for a heart attack depends on whether you’ve had an

ST segment Elevation MI (STEMI) or another type of Acute Coronary

Syndrome (NSTEMI or unstable angina)

STEMI

It requires emergency assessment and treatment and it’s important to treat

quickly, so as to minimize damage to the heart after ST segment Elevation

Myocardial Infarction (STEMI).

If you have symptoms of a heart attack and the ECG shows STEMI, you’ll

be assessed for treatment to unblock your coronary arteries.

The treatment used will depend on the duration of symptoms and how

soon treatment can be accessed

 If your symptoms started within the past 12 hours; you’ll usually

be offered coronary angiography (this is done to assess your suitability

for PCI) and Percutaneous Coronary Intervention (Primary PCI),

which is a procedure that is done to widen any blocked coronary

arteries. You may also be given Low dose dose Aspirin to prevent

further clots. You may need to continue taking medicines for sometime

after PCI.
 If your symptoms started within 12 hours, but you cannot access

PCI quickly; you’ll be offered medicine to break down blood clots,

known as thrombolytics or fibrinolytics, usually given by injection.

Thrombolytics and fibrinolytics target and destroy a substance called

Fibrin. Fibrin is a tough protein that blocks blood from gong through

the coronary artery. You may still need to do the coronary angiography

and PCI once your condition is stable or if thrombolytics does not

work.

 If symptoms started more than 12 hours ago; you may be offered a

different procedure, depending on your symptoms. The best course of

treatment will be decided after an angiogram and may include

medicine, PCI or bypass surgery

 If a PCI is not suitable for you; you may be offered a combination of

medicines to prevent blood clots and they’re called Antiplatelet

medicines (usually Aspirin and one other medicine). Both antiplatelet

medicines usually need to be taken for up to 12 months

NSTEMI and UNSTABLE ANGINA

If an ECG shows you have a non-ST segment Elevation MI (NSTEMI)

and unstable angina, medicines to prevent blood clots, including Aspirin

and other medicines, are usually recommended.

In some cases, further treatment with coronary angioplasty (also called

PCI) or Coronary Artery Bypass Graft (CABG) may be recommended

after initial treatment with these medicines.

Medicines to thin the blood may need to be taken for up to 12 months

MALARIA
 GRIPS

 PARAPHRASE

 SOCRATES generalized body pain

 Any fever?

 Any joint pain?

 Any muscle weakness?

 Any headache

 Any shyness to light

 Any rash

 Any neck stiffness?

 Any yellowish discolouration in your eyes?

 How’s your appetite?

 Do you feel sick?

 Recent history of travel

 Any prophylaxis for malaria before you travelled

 Relevant PMAFTOSA

 ICE

 Examine the patient

 Investigations: routine

 Explain the diagnosis: From our conversation so far and

examination findings, I suspect you’re having a condition called

 Malaria. Malaria is a serious infection spread by mosquitoes. If it’s not

diagnosed and treated quickly, you can die from it

 Investigations to confirm diagnosis: Thick and thin blood film

 What are you going to do for me?

 Admit the patient (if In GP, send to the Hospital for admission)

 Antimalarials

 Painkillers

 Notify the Local Health Protection Team because Malaria is a

notifiable disease

 Inform the Infectious Disease Unit

 How did I get it after taking prophylaxis: Malaria prophylaxis

doesn’t offer 100% protection against Malaria

 Inform seniors

 Safety net

 Give leaflets

 Address concerns
INTRACRANIAL SPACE OCCUPYING
LESION (ICSOL)
 GRIPS

 PARAPHRASE

 Ask questions of before, during and after the fit?

 Ask about last meals

 Any other symptom

 SOCRATES persistent headache

 Did you by any chance hurt your head?

 Any vomiting?

 Any progressive weakness in any part of your body?

 Any vision problems

 Any memory problems?

 Any changes in personality?

 Has this ever happened before

 R/O FLAWS

 Relevant PMAFTOSA (family history of seizure disorders)

 ICE/JARSS

 Examine the patient

 Investigations: routine, CT scan of the brain

 Explain the diagnosis: From what you told me, that you ’ ve been

having a persistently worsening headache and you had a fit this

 morning, I suspect there’s something serious going on like an

Intracranial space occupying lesion (ICSOL). Lesions could be benign,

malignant, tumours or abscesses

 What are you going to do for me?

 Give painkillers

 Refer to First Fit Clinic (if it’s the first fit)

 Refer to the Neurologist

 Treatment will depend on the cause

 Inform Seniors

 Safety net

 Give leaflets

 Address further concerns

UTI - TRANSGENDER
 GRIPS

 PARAPHRASE

 ODPARA burning sensation

 Any tummy pain?

 Any fever?

 Have you been using the loo frequently?

 Any discharge from your private area?

 Do you think your fluid intake has also increased?

 Does it seem like the urine comes out before you get it the bathroom?

 Do you by any chance hold urine? Yes because there ’ s no gender

neutral toilet at his work place

 Relevant PMAFTOSA

 TRANSGENDER HISTORY

 O - Orientation:

 Were you born a male or female?

 What gender do you identify as now

 S - Sexual History:

 Are you sexually active?

 Do you have a stable partner?

  What’s your preferred route of sexual intercourse?

 Do you practice safe sex?

 S - Support:

 Are your family and friends aware that you’re transitioning?

 Are they supportive?

 Have you heard about any support group like the LGBTQ

groups?

 Have you attended any of their meetings?

 D - Discrimination: Are you facing any form of discrimination

based on your new sexual identity?

 T - Treatment: Have you officially commenced treatment?

 ICE

 Examine the patient

 Investigations: Routine, Urine dipstick, Urine M/S

 Explain the diagnosis: UTI

 Give Painkillers

 Give Antibiotics

 Encourage adequate fluid intake

 Encourage her to speak to her boss, to create a gender neutral

bathroom

 Encourage her to use whichever toilet she is most comfortable with

 Quote the equality act of 2010 if patient is being discriminated. The

Equality act criminalizes all forms of discrimination against anyone,

on the basis of their sexual identity

 Support Groups: LGBTQ (if patient doesn’t already belong to one)

OBSTETRICS & GYNAECOLOGY

THE APPROACH
 GRIPS

 PARAPHRASE

 SOCRATES/ODPARA

 R/O Differentials

 R/O Risk factors

 Relevant PMAFTOSA

 M - Menstrual History:

 When was the last time you saw your period?

 Are they regular?

 S- Sexual History:

 Are you sexually active?

 Do you have a stable partner?

 Is your partner male or female?

 What’s your preferred route of sexual contact?

 Do you practice safe sex?

 Have you been diagnosed/treated for STIs in the past?

 Ask about the partner where necessary

 C - Contraceptive History:

 Are you aware of contraceptives?

 Have you ever used any contraceptive?

 How long did you use it?

 When did you stop using it?

 Why did you stop using it?

 Any side effects?

 ICE

 JARSS

 Examine the patient

 Investigations: routine

 Explain the diagnosis

 Investigations: to confirm diagnosis

 Treatment

 Inform Seniors

 Safety net

 Give leaflets
ATROPHIC VAGINITIS
 GRIPS

 PARAPHRASE

 When did the bleeding start?

 What could have caused the bleeding?

 What’s the quantity?

 Is this the first time?

 Fresh blood, clot, brown?

 Anything that makes it better?

 Anything that makes it worse?

 Any other symptom associated with this bleeding?

 R/O cancer: FLAWS

 R/O endometrial CA: HRT, family history of cancer, pregnancy,

contraceptives

 R/O STI: any discharge from front passage

 R/O UTI: dysuria, frequency, etc

 Any history of trauma?

 When was the last time you saw your period?

 How long have you been with this partner

 How long have you been sexually active with him

 Have you ever had a Pap smear done? When was the last time? What

was the result?

 Menopausal symptoms: hot flushes, mood changes, low libido, etc

 R/O complications: lightheadedness, heart racing, etc

 Relevant PMAFTOSA

 Examine: GPE, tummy exam, speculum exam

 Investigations: routine, TVS, STI screening

 Explain the diagnosis: From our discussion so far, I suspect you

have a condition called Atrophic Vaginitis. It’s thinning, drying and

inflammation of the vaginal walls that may occur when the body has

less oestrogen; this is most often around or after menopause

 What are you going to do for me?

 Advise to use a water-based lubricant

 Topical oestrogen

 Non-hormonal treatments like moisturizers and lubricants if

there’s a history of breast cancer

 Pain killers (where necessary)

 Safety net

 Inform Seniors

 Give leaflets

 Address concerns
TEENAGE PREGNANCY (16yr old vomiting)
 GRIPS

 PARAPHRASE

 ODPARA vomiting

 R/O differentials: gastroenteritis, food poisoning etc

 R/O complications: excessive thirst, etc

 Psychosocial history

 Relevant PMAFTOSA

 Menstrual history

 Sexual history

 Contraceptive history

 ICE

 JARSS

 Examine patient

 Investigations: routine, urine PT

 Explain the diagnosis: From all we’ve discussed and from your test

results, I suspect you may be pregnant

 PAUSE and Give her some time to react

 I can see that you’re quite distressed about the news and being

pregnant as a teenager can be daunting, especially when it’s unplanned,

but we’re here to support you……

 Encourage her to speak with a trusted person; family/friends

 Offer confidentiality where necessary

 Counsel on the possible options:

 keep pregnancy, commence ANC and keep the baby

 have the baby and give up for adoption

 abortion

 Encourage her to think about the options and discuss with someone

e.g mum before making a decision. When decision is made, encourage

her to contact her GP with the feedback

 Dr, my mum will kill me? I’m so sorry you feel this way and I wish

o had better news. You mum may be surprised, but I don’t think she

will kill you. Give her sometime to process things and I’m sure she’ll

support you

 Dr, I feel so stupid: Sometimes we make certain decisions that we

may not be proud of, but that doesn’t mean we’re stupid. I really don’t

want you to feel that way

 Offer counselling sessions where necessary

 Address concerns

 Inform seniors

 Safety net

 Address further concerns

PRE-ECLAMPSIA
 GRIPS

 PARAPHRASE

 Talk about current pregnancy;

 How is your pregnancy going so far?

 How far gone are you?

 Any bleeding?

 Any tummy pain?

 Ask of headaches?

 Any blurring of vision?

 Any body swelling?

 What’s your EDD?

 What’s your planned mode of delivery?

 Elicit risk factors: first pregnancy, new partner, last pregnancy over

10 years, family history, obesity, etc

 R/O Complications: fits, yellowish discolouration of the eyes,

stroke, pulmonary oedema, liver/kidney failure, DIC, etc

 Talk about previous pregnancy;

 Have you been pregnant before?

 How many times have you been pregnant in the past?

  Did you have any problem during that pregnancy?

 What was the outcome of the pregnancy?

 Relevant PMAFTOSA

 Contraceptive history

 Examine

 Investigations: routine, urine dipstick

 Explain the diagnosis: Pre-eclampsia is elevated blood pressure

with protein in urine. It occurs during the second half of pregnancy

(from 20 weeks) or soon after the baby is delivered

 What could have caused this? The exact cause is unknown, but it’s

thought to occur when there is a problem with the placenta, which is

the organ that links the baby’s blood supply to that of the mother).

There are a few things that can increase your risk of getting it and in

your case, it’s most likely due to…… (mention the risk factors

elicited)

 What are you going to do for me?

 Admit

 Further investigations: tummy scan, CTG

 Why do you want to admit me? Emphasize that it’s a

life-threatening condition and can cause harm to mother and baby

  Give anti-hypertensive; Labetalol

 Give MgSO4 if BP > 160 systolic

 Regular monitoring of BP, urine protein levels, etc

 Can I have water birth; you require close monitoring during

and after delivery because of the condition so water bath won’t be

in your best interest….

 For 36 weeks: keep BP until control and monitor till term (37

weeks) and do IOL. However, if we encounter complications, we

may need to deliver you through the quickest and safest option,

which is usually a C/S

 For 38 weeks: admit, optimize BP and aim to deliver within 24 to

48 hours

 Address other concerns

 Inform seniors

 Safety net: fits, reduced foetal movement, etc

 Give leaflets when she is stable or at the point of discharge

PAEDIATRICS

THE APPROACH
 GRIPS: I’m Dr Mariam Ajugba, one of the doctors in…….

 PARAPHRASE

 SOCRATES/ODPARA

 Differentials

 R/O Risk factors

 PAMGUDU (ask these if the patient has fever)

P- Pneumonia : cough, chest pain..etc

A- AOM : ear tugging, ear discharge…etc

M- Meningitis : shyness to light, neck stiffness, body rash..etc

G- Gastroenteritis : stooling, vomiting…etc

U- UTI: tummy pain, burning sensation, frequency…etc

D- Dehydration: excessive thirst, oliguria…etc

U- URTI: runny nose, cough, shortness or breath…etc

 PBINDS

P-Pregnancy: How was the pregnancy?

B-Birth history: How was the delivery?

I-Immunization history: Is he up to date with his jabs?

 N-Nutrition history: What do you feed him with?

D-Developmental history: Are you satisfied with his red book?

S-Social history: Who takes care of him?

 FMAM

 F - Family History: Any FH of any medical condition?

 M - Medical History: Has he been diagnosed with any medical

condition in the past?

 A- Allergy: Any allergy?

 M - Medication History: Is he on any medication?

 ICE

 Examine the patient

 Routine investigations

 Give provisional diagnosis/ Explain the diagnosis

 Investigations to confirm diagnosis

 Treatment

 Inform seniors

 Safety net

 Give leaflets/advice sheet

 Address concerns
NON - ACCIDENTAL INJURY (NAI)
 GRIPS

 PARAPHRASE … you had x-ray done for your child. Has anyone

been here to explain the results to you……

 I’m here to explain the results to you and address your concerns, but

would you mind if a I ask a few questions so I can better understand

what’s going on?

 Can you tell me why you came for the x-ray in the first place?

 When did you notice it?

 How did you notice it?

 Any bluish discolouration of the eyes?

 Any bone problems?

 Any fever

 Has the is ever happened before?

 What did you do when you noticed it?

 Apart from you, who takes care of him?

 Who was the last person with the child before you noticed this

injury?

 What was the person’s account of what happened?

 Is this the first time your boyfriend will be taking care of him?

 Do they get along well?

 Is he the biological father of the child?

 Is there any other child at home?

 Does he sometimes get angry at this child?

 Has he ever kicked or physically hurt your child?

 Risk factors for abuse: alcohol, drugs, stress, financial challenges

 FMAM history

 PBIND

 Examine the child

 Investigations: routine

 Explain the diagnosis: From our discussion so far and from the

X-ray result, …. has a spiral fracture. Most times when this kind of

fracture occur, it is as a result of a twisting force and that’s what we

call a Non-Accidental Injury (NAI) OR

From our discussion so far and from the X-ray result, …. has a

spiral fracture. Whenever we see this kind of fractures, we just want to be

sure, it ’ s not a NAI, meaning that the injury was not from an accident.

This sort of injury doesn ’ t just happen from a simple fall. It usually

suggests an external force, such as a twisting force

 Do you mean my boyfriend caused this? Do not confirm or deny it;

We are not sure but it’s a possibility, I encourage you to have a chat

with your boyfriend. It’s possible someone close to the child may have

caused it
 What are you going to do for him?

 We will need to admit the child and observe closely

 We also need to do X-ray of other parts of the body to be sure

there are no fractures anywhere else

 Give pain killers

 Invite the orthopaedic surgeon, who will treat the fracture.

 Inform the social services. We will inform the social services

who will come and have an assessment follow your house to be

sure it is safe for the child to return

 Will social services take my son away? The social services will

only come and have a chat with you and your partner, to see how safe

the house is for the child to return to. They may offer suggestions to

you, issue warning or take custody of the child temporarily. Be rest

assured that whatever decision they take will be in the best interest of

you and your son.

 Dr, I feel like a terrible mum? PAUSE Encourage her and tell her

she is a wonderful mum who cares for her son.

 Inform seniors

 Give leaflets
ASTHMA EMERGENCY (TELEPHONE)
 TELEPHONE GRIPS: Normal GRIPS +

 Can you confirm your date of birth?

 Can you confirm the first line of your address?

 Is this a good time to talk? (Ask if you’re the one calling)

 If this call ends abruptly, can I reach you on this number?

 Can you confirm that you can hear me clearly?

 Scenario 1: I have been asked to speak to you about……

 Scenario 2: I understand you booked an appointment to speak to

us today… Is that correct?

 Acknowledge her concerns: I can see this is a troubling moment for

you…….

 Try as much as possible to calm the patient

 The ambulance is going to be on its way to your house immediately

 What happened to him?

 Was he playing with toys before this happened?

 Is he being managed for any medical condition? Asthma

 Is he on inhalers?

 Is he taking the medications a prescribed

 Do you have the inhalers there? Please give him 2 puffs

 Reassure her that the ambulance is coming

 Tell her to sit the child upright on the couch

 You can give up to a maximum of 8 to 10 puffs

 Always ask how the child is doing after each puff

 Has he been unwell in the last few days?

 Any fever?

 Any cough?

 Do you have any pet at home?

 Any flu-like symptoms

 Any vomiting?

 Dr, he is struggling to breath again. I’m so sorry please take a deep

breath. Give him another 2 puff now. The ambulance is already on its

way and I’m here with you

 FMAM

 Relevant PBINDS

 When he arrives at the hospital, I’m going to examine him, his chest,

I ’ ll be doing this in the presence of the chaperone and ensure his

privacy

 From what you told me and from the examination findings I see here

(may be given in the cubicle), I suspect he is having what we call acute

exacerbation of asthma, likely due to a chest infection

 Oh he’s having difficulty breathing again… Reassure and continue

 This is actually an emergency, so when he gets here, we will need to

 admit him. Is that okay with you?

 We’ll do routine blood tests, chest X-ray

 Give oxygen (where necessary)

 We will give him a special medication called salbutamol and it will

really help with his breathing

 Give antibiotics based on the hospital protocol (if you suspect a chest

infection).. ensure to ask about allergies

 I will inform my seniors so they can see him as well when he gets

here

 Keep reassuring/addressing concerns

GENERAL TELEPHONE TIPS

 You’re not expected to touch the telephone

 Whether the prompt says “ the patient has called you ” or “ you ’ ve

been asked to call the patient ” , you ’ re the one to initiate the

conversation
DEVELOPMENTAL MILESTONES
Always R/O Autism in any developmental milestones scenario

1. Gross motor (sit, crawl, stand, walk)

2. Fine motor

3. Speech

4. Social/autism

A 14 - month old who can’t walk

 GRIPS

 PARAPHRASE

 Gross motor

 Can he sit, crawl, stand without support?

 Can the child reach out for an object?

 Fine motor

 Can he pick an object with 2 hands?

 Can he drink from a cup unaided?

 Speech

 Does he talk?

 How many words can he say?

  Do the words have meanings?

 Social

 Does he smile

 Does he maintain eye contact?

 Does he play with other kids

 When you cuddle him, does he cuddly back?

 Does he have any particular repetitive behaviour

 Does he have preference for any particular colours or toys

 Siblings

 Does he have siblings?

 How are they doing?

 Did any of them experience similar symptom when they were at

his age?

 Differentials: R/O dumbness, deafness, blindness

 Dumbness: does he communicate when he is hungry?

 Deafness: does he answer his name when called?

 Blindness: does he see?

 PAMGUDU
 PBINDS

 FMAM

 Examine

 You can do routine tests

 Explain the diagnosis: this is a Normal Development

 Reassure her. Any mum will be worried, but from the medical point

of view, we do not worry for now. We only worry when the child

doesn’t walk at 18months

 Is there a way I can help him for now?

 Ensure someone can hold the child and support him to walk

towards you

 Try to encourage the child to walk barefooted; It gives the

child’s feet perfect grips to the ground

 Toddler’s truck

 Inform Seniors

 Safety net: If he’s unable to walk at 18 months, well refer him to the

Paediatrician

 Give leaflets on Developmental Milestones

 Give her a short appointment (depending on the child’s age) e.g a 14 -

month old should come for follow-up in 4 months (at 18 months).

SPEECH DELAY
One twin cannot speak, but the other twin can speak at 15 months

 GRIPS

 PARAPHRASE

 Commend her for coming?

 Does he speak at all?

 How many words can he say?

 Do they make sense? OR Do they words have meaning

 Ask about the twin:

 How about his twin?

 How is she doing?

 How many words does she say?

 Do the words have meaning?

 Is she able to interact with him?

 Ask about social, fine motor and gross motor

 R/O deafness, dumbness, blindness

 PAMGUDU

 PBIND

 Examine

 You can do routine tests

 Explain the diagnosis: At the moment, from our discussion so far,

your child has a Normal Development…….

 Reassure mother

 How can I help him for now?

 Tell everyone to speak to them differently

 Give individual instructions in simple and clear language

 Everyone should speak the same language to them

 Call him by his name

 Try to spend more time with the twins individually

 Try to interact with him both verbally and non-verbally

 Give him time and be patient with him

 Inform Seniors

 Safety net: If he’s unable to speak at 18 months, well refer him to the

Paediatrician/Speech and Language Therapist

 Give leaflets on Developmental Milestones

 Follow- up in 3 months
MMR VACCINE AND AUTISM
 GRIPS

 PARAPHRASE

 I read somewhere that MMR Vaccine causes autism.. I can see why

you’re worried and anyone in your shoes who has read it has a right to

believe it’s true..

 I must also commend you for making this research yourself and

coming to seek [Link] we go on, is it okay if I ask a few

questions?

 Do you have any concern with other vaccines?

 Is she up to date with her other vaccines?

 When she took these other vaccines, did she have any problem?

 Does she have siblings? Did they also receive their own

vaccines?Did you notice any problem when they received the

vaccines?

 Did they also receive their own MMR vaccine? Yes

 Did you notice any problem when they received their MMR vaccine?

 R/O contraindications to vaccine; any acute illness (PAMGUDU),

any allergy to Neomycin in you or Jenny’s father?

 R/O autism: does she play with other kids? Does she maintain eye

contact? When you cuddle him does he cuddle back?

 PBINDS
 FMAM

 Offer to examine patient

 You mentioned that you read somewhere that MMR vaccine causes

autism and that’s why you came for clarifications.. am I correct?

 I must commend you once again for coming to seek clarity

 Of a truth, there was a publication that linked MMR vaccine and

autism, but other superior publications have been made to debunk

this?

 You must clearly state that MMR vaccine is safe and does not cause

Autism

 Why is this vaccine important? It offers protection to 3 conditions

(Mealses, Mumps, Rubella), all of which have the potential to cause

complications if not properly handled. Complications like deafness,

blindness, etc

 Dr, is there an alternative to the MMR vaccine? At the moment,

there is no alternative to the MMR vaccine

 Is Measles, Mumps or Rubella still present in the UK? They’ve

largely been eradicated, but there’s been some outbreaks in recent

years. Also, there are people from other nations coming into the UK

and they may not be vaccinated, which will increase the spread. You

may also need to travel to other countries or regions where MMR are

still present so it’s important that your child is protected.

 Can she get each component of the MMR separately? Yes it ’ s

possible to get each component separately, but it is not given in the

NHS and the reason is because no one would like the child to be

exposed to repeated trauma/pain from vaccination.

 How many time will she have to take the vaccine? Two times; the

first is at the age of 12 to 13 months and the second is at the age of 3

years and 4 months.

 If I allow the MMR vaccine, does this mean my child will never

have Measles, Mumps or Rubella? The vaccine may not confer

100% immunity, but it’ll definitely make the symptoms milder if your

child has measles, mumps or rubella.

 Any Side effects? Just like every other vaccine, the MMR vaccine

has some like effects like Pain at injection side, mild inflammation,

fever; these are usually mild and go away spontaneously but if they

don’t, we’ll give the necessary treatment

 Inform Seniors

 Safety net

 Give leaflets

 With this new information you have, would you consider bringing….

for the vaccine? Thank you for accepting to give it a thought

 We look forward to having you and…… for the vaccine

TANTRUMS
Between 18months and 4 years of age

 GRIPS

 PARAPHRASE

 ODPARA

 R/O Autism

 R/O ADHD

 Is he facing and form of stress?

 Any recent changes around the home?

 Is he in school?

 Has his teacher made similar complaints?

 Is he being bullied?

 R/O Risk factors: Hunger, dehydration, attention, parental

problems/challenges, etc

 Relevant PMAFTOSA: similar history in mother or father

 PBINDS

 FMAM

 Examine the patient

 Do routine investigations

 Explain the diagnosis: From our discussion so far, I think he has

Temper Tantrums and this is common in children of his age group.

This happens because they’re unable to express their emotions at that

 age. They feel frustrated and the frustration comes out as a tantrum

 How can it be managed?

There are ideas that may help you cope with tantrums when they

happen. Would you like to hear them?

 Find out why the tantrum is happening: Your child may have a

tantrum because they’re tired amor hungry, in which case the

solution could be simple. They could be feeling frustrated or

jealous, maybe if another child. They may need time, attention and

love, even though they’re not being very loveable.

 Understand and accept your child’s anger: You probably feel

angry yourself at times, but unlike your child, you can express it in

other ways.

 Find a distraction: If your child is starting a tantrum, find

something to distract them with straight away. This could be

anything, even something you can see out of the window.

 Wait for it to stop: Losing your temper or shouting back will not

end the tantrum. Ignore the looks you get from people around you

and concentrate on staying calm.

 Do not change your mind: Giving I’m will not help in the long

run. If you’ve said no, do not change your mind and say yes just to
 end the tantrum. Otherwise, your child will start to think that

tantrums can get them what they want. For the same reason, it does

not help to bribe them with sweets or treats. If you’re at home, try

going to another room for a while, but make sure you child cannot

hurt themselves first before you leave.

 Be prepared when you’re out shopping: Tantrums often

happen in shops. This can be embarrassing and the embarrassment

makes it harder to stay calm. Keep shopping trips as short as

possible. Involve your child in the shopping by talking about what

you need and letting them help you.

 Try holding your child firmly until the tantrum passes: Some

parents fine holding their child while they’re having a tantrum

helpful, but it can be hard to hold onto a struggling child

 Hitting, biting, kicking and fighting: Most young children

occasionally bit, hit or push another child. Toddlers are curious

and may not understand that biting or pulling the hair hurts and

this behaviour doesn’t mean they’ll grow up to be aggressive. Do

not hit, bite or kick back because it could make your child think

it’s acceptable to to this. Instead, make it clear that what they’re

doing hurts and you will not allow it.

 Talk to them: Children also go through phases of being upset or

insecure and express their feelings by being aggressive. Talking to

 them and finding out what worries them is the first step to being

able to help them.

 Show them you love them, but not their behaviour: Children

may be behaving badly because they need more attention Show

them you love them by praising good behaviour and giving them

plenty of cuddles when they’re not behaving badly.

 Help them let their feelings out in another way: Letting your

child know that you recognize their feelings will make it easier for

them to express themselves without hurting anyone. Find a big

space, such as a park and encourage your child to run and shout

 Support groups: parents who have children also going through this

particular phase

 Reassure mother that he’ll outgrow it

 Follow-up

 Inform Seniors

 Give leaflets

 Address further concerns

CHILDHOOD TUBERCULOSIS
 GRIPS

 PARAPHRASE

 ODPARA cough

 Is the cough productive (haemoptysis)

 Any fever?

 Any night sweats?

 How is his appetite?

 Any weight loss/poor weight gain?

 History of contact with persons with chronic cough (20 hours of

exposure is enough)

 R/O other possible causes of cough: pneumonia, etc

 R/O complications: any lumps or bumps on any part of the body,

constipation, neck stiffness, rash, etc

 FMAM History

 PBIND: missed the BCG vaccine

 Examine the patient

 Investigations: routine bloods, sputum AFB, CXR

 Explain the diagnosis: Tuberculosis (TB) is an infection that usually

affects the lungs. It be treated with antibiotics, but can be serious if not

treated

 How did he get it? There’s a vaccine that helps protect some people
 who are at risk from TB and from our conversation, you mentioned

that he missed that vaccine. Also, you mentioned that he just started

nursery so he may have been exposed there

 What are you going to do for him?

 Refer to Infectious Disease department

 Give antibiotics for at least 6 months; It’s important that

medications are taken as prescribed, otherwise, TB will come back

if medications are stopped abruptly

 Further tests: Mantoux test (a skin test where a small amount of

liquid is injected under the skin in your arm, the liquid will cause a

small reaction on your skin if your have TB), for family/friends

who have no symptom, but have been in close contact with the

infected person

 Address concerns

 Inform Seniors

 Safety net

 Give leaflets
MUMPS ORCHITIS
Mother says her son in school called her with some concerns

Son has testicular swelling

 GRIPS

 PARAPHRASE

 ODPARA testicular swelling

 When your son spoke to you, did he mention…..

 R/O testicular torsion: duration

 R/ O Epididymo-orchitis

 Positive history of parotid swelling

 Find out the last time the boy was home

 Relevant PMAFTOSA

 If your son was here, I would have loved to examine him…

 Inform public health department of the city where the boy goes to

school

 Inform the city where the family resides

UTI IN A CHILD
 GRIPS

 PARAPHRASE

 SOCRATES abdominal pain

 Any pain/burning sensation when peeing?

 Has he been using the loo frequently?

 Any changes in the colour of the urine?

 Any fever?

 Any vomiting?

 is he as active as usual?

 Does he feed well!

 R/O Risk factors: constipation, poo coming in contact with urethra,

holding pee, etc

 FMAM

 PBINDS

 Examine: GPE, tummy

 Investigations: routine

 Explain the diagnosis: From our conversation so far and from my

examination findings, I suspect she has a Urinary Tract Infection

(UTI)..UTI is a condition where bugs grow in the bladder (cystitis),

urethra (urethritis), kidneys (kidney infections) and causes the

symptoms that your child is having

 What are you going to do for me?

 Diagnostic test: Urine M/C/S

 Give pain killers

 Give antibiotics: based on hospital protocol

 Encourage fluid intake

 General advise: clean from front to back, basic hygiene, stay well

hydrated)

 Inform Seniors

 Safety net

 Give leaflets

NOTE: As a precaution, babies under 3 months and children with more

sever symptoms are usually admitted to the hospital for a few days to

receive intravenous antibiotics.

EPILEPSY/FIRST FIT
 GRIPS

 PARAPHRASE

 Dr my daughter had a fit…I can only imagine what it feels like for a

mum to see her own daughter have a fit in front of her.. you must have

gone through a lot, but I’m glad you’re here…..

 When did it start?

 What exactly happened?

 BEFORE

 Did he make any complaints before?

 Any fever?

 Was there any symptom at all?

 DURING

 Was there upward rolling of the eyes?

 Was there any tongue-biting?

 Did he fall?

 Did he hit his head on the ground?

 AFTER

 Was there post-ictal sleep?

  Was there post-ictal urinary incontinence

 Was there faecal incontinence?

 Was he drowsy?

 Did he start talking/behaving irrationally

 R/O meningitis: fever, shyness to light, headache, neck stiffness

 R/o hypoglycemia: excessive sweating, hunger…

 Has this ever happened before?

 Any family of seizure disorders?

 FMAM

 Examine the patient

 Investigations: routine

 Explain the diagnosis: From our discussion so far, I suspect you had

a Seizure. Seizure is a sudden burst of electrical activity in the brain

that temporarily affects how it works.

 What are you going to do for me?

 Refer to the First Fit Clinic to see the specialist (Neurologist)

 Do EEG

 If EEG confirms epilepsy, we will place him on medication

 Inform Seniors/ Safety net/ Give leaflets

HEAD INJURY - FALL
 GRIPS

 PARAPHRASE

 BEFORE

 Did he make any complaints before?

 Any fever?

 Was there any symptom at all?

 DURING

 Any jerky movement?

 Was there upward rolling of the eyes?

 Did he hit his head on the ground?

 Any trauma to any part of the body?

 AFTER

 Was there post-ictal sleep?

 Was there post-ictal urinary incontinence

 Was there faecal incontinence?

 Any vomiting?

 Was he drowsy?

 Did he start talking/behaving irrationally

 FMAM

 PBIND

 Examine

 Investigations: routine

 Explain the diagnosis: From our conversation so far, I suspect she

sustained a Head Injury following the fall

 Dr I want CT scan of the brain: We don ’ t like to unduly expose

children to the radiation that comes with CT scans so we usually

observe for a while before considering that

 Can we go home now? I can see you’re eager to go home, but I’m

afraid we may have to keep him for now. Every child who has had a

head injury should be kept under observation for at least 4 hours

 Inform seniors

 Safety net

 Address any other concern

 Head injury advice sheet or leaflets

CRITERIA FOR PERFORMING CT SCAN
Category 1: For children who have sustained a head injury and have

ANY of the following risk factors, perform a CT scan of the head

within 1 hour;

1. Suspicion of NAI

2. Post-traumatic seizure, but no history of epilepsy

3. On initial assessment, GCS less than 14, or for children under 1 year

with GCS less than 15

4. 2 hours after the injury, GCS less than 15

5. Suspicion of basal skull fracture or tense frontanelle

6. Any sign of basal skull fracture

7. Focal neurological deficit

8. For children under 1 year, the presence of bruise, swelling or laceration

of more than 5cm on the head

Category 2: For children who have sustained a head injury and have

MORE THAN ONE of the following risk factors (and none of those in

category 1), performance CT scan of the head within 1 hour of the

risk factor being identified;

1. Loss of consciousness of more than 5 mins

2. Abnormal drowsiness

3. 3 or more discrete episodes of vomiting

4. Dangerous mechanism of injury (high speed RTA either as a

pedestrian or cyclist or vehicle occupant, fall from a height of greater 3

metres, high speed injury from projectile opt other object)

5. Amnesia (retrograde or anterograde) lasting more than 5 minutes.

NOTE

Children who have sustained a head injury and have only 1 of the risk

factors should be observed for a minimum for 4 hours after head injury

If during the observation, any of the risk factors below are identified, a CT

scan of the head should be performed in 1 hour

1. GCS less than 15

2. Further vomiting

3. A further episode of abnormal drowsiness

URTICARIA
 GRIPS

 PARAPHRASE

 ODPARA the rash

 How many times has he had the rash?

 What was he doing when he got the rash?

 S - Site

 S - Size

 S - Shape

 S - Symmetry/surrounding

 C - Colour

 P - Any pain?

 I - Any itching?

 D - Any Discharge/bleeding?

 F - Any fever?

 L - Lumps or bumps in any part

 A - Anorexia

 W - Weight loss

 S - drenching Night sweats

 R/O Anaphylaxis: wheeze, lip swelling, difficulty breathing,

cyanosis, difficulty swallowing, confusion, someone who faints and

cannot be woken up, etc

 Elicit risk factors/Triggers:

 Eating certain foods

 Contact with certain plants, animals, chemicals and latex

 Extremes of temperature

 A reaction to certain medicines, insect bite or sting

 Scratching or pressing on your skin, such as wearing itchy or tight

clothing

 An infection

 A problem with your immune system

 Water or sunlight (but this is rare)

 FMAM history

 PBIND

 Psychosocial history: Who takes care of the child? Do you have

support?

 Examine the patient if he’s there

 Investigations: routine

 Explain the diagnosis: From our conversation, I suspect h has

Urticaria/Hives. Its is a form of allergic allergic reaction…

 Dr, is it a serious condition? It ’ s not a serious condition, but the

mainstay of management is to identify and avoid the triggers. It

usually gets better within a few minutes to a few days

 What are you going to do for him?

 Do patch test or skin prick test if unable to identify the triggers

 Give a non-sedating anti-histamine

 Menthol cream

 Do patch test or skin prick test if unable to identify the triggers

 Keep an urticaria diary: frequency of the episodes, severity,

duration; bring the diary to the next appointment

 Counsel to recognize and avoid triggers

 Refer to the Dermatologist if urticaria doesn’t go away with

treatment/ chronic (lasting more than 6 weeks) and requires oral

steroid treatment

 Refer to the Psychologist if affecting child’s mental health

 Inform Seniors

 Safety net: rash spreading, not disappearing, fever, etc

 Give leaflets

 Follow-up in 1 month
RECURRENT TONSILLITIS
 GRIPS

 PARAPHRASE

 Acknowledge mother’s concerns and address them

 When was the last time he had an episode?

 How many episodes has he had in the last year?

 Any fever?

 Any sore throat?

 Does he eat well?

 Does he drink well?

 R/O Complications: difficulty swallowing, difficulty breathing,

drooling of saliva. difficulty speaking, etc

 FMAM history

 Social history: Who takes care of him? Apart from you, who else

takes care of him?

 Examine if the patient is there

 Investigations: routine

 Explain the diagnosis: Tonsillitis is an infection of the tonsils at the

back of your throat

 I’m afraid the tonsillectomy was not done because there is a criteria

we follow and he doesn’t actually meet the criteria. Would you like to

know the criteria?

 The Criteria:

 The episodes are disabling and prevent normal functioning e.g

there has been significant, severe impact on the quality of life and

normal functioning like absence from school, failure to thrive,

insomnia, daytime sleepiness, etc

AND THERE HAS BEEN

 Seven (7) or more well documented, clinically significant,

adequately treated sore throat in the preceding (1) year OR

 Five (5) or more well documented, clinically significant,

adequately treated sore throat in each of the preceding two (2)

years OR

 Three (3) or more well documented, clinically significant,

adequately treated sore throat in each of the preceding three (3)

years

AND

 There has been a discussion with patient/parents or carers in

relation to the benefits and risks of tonsillectomy

 What are you going to do for him?

 We will give him painkillers to relieve the pain.

 Encourage to drink cool drinks to soothe the throat

 Please ensure he is taking plenty of rest.

 Also ensure he gargles with warm salty water

 Ensure to tell the mother that each episode must be documented

at the GP, so she should bring him whenever he has tonsillitis

 So why did he refer me to ENT? The referral may have been made

by the GP because there was pus discharge and some enlarged lymph

nodes were found during one episode OR whatever you’re given in the

prompt

 So why don’t you remove it if they don’t meet the criteria? The

tonsils help to protect against infections. Surgery also has risks and it’s

better not to expose him if it’s not otherwise indicated

 So the NHS is just trying to save money? I’m so sorry you feel this

way. But NHS has planned those surgeries and set those criteria for

delivering the best possible care to the patients.

 He had 6 episodes last year and 4 this year, will he have

tonsillectomy? I can see you ’ re quite concerned, but it has to be at

least 5 each year for 2 years before he can be considered for a possible

tonsillectomy
 Inform Seniors

 Safety net: condition gets worse, neck stiffness, can’t swallow, etc

 Give leaflets

 Inform seniors

 Address further concerns/keep reassuring the mum

ANGRY PATIENT/MEDICAL ERRORS

THE APPROACH
 GRIPS

 PARAPHRASE: I can see from my notes that you’ve got some

concerns that you would like me to address and I’m here to talk to you

and address those concerns. But first can I ask a few questions so as to

have a better understanding of what’s going on?

 Why did you come to the hospital in the first place?

 What were you told was wrong?

 What has been down for you?

 Any symptom? Explore if any

 Relevant PMAFTOSA

 I’m afraid, there’s been an error and that’s what I’m here to talk to you

about

 DUTY OF CANDOUR: As doctors, we owe it to our patients to be

completely honest with them in every situation….

 Explain the situation: Well, you did mention that you came here on…

and……was done for you…. Am I correct?

 Explain the error as given in the prompt

 PAUSE and allow the patient to react

 Apologize as much as you can

 Document it in the patient’s notes

 Incident report form

 Inform Seniors

 Root-Cause-Analysis-Meeting (RCAM): for Medical Errors: a

monthly meeting where all the consultants, nurses and other health

care workers discuss cases, find out what was done wrong and set up

measures to make them better moving forward….

 Patient Advise and Liaison Service (PALS): an independent body

where patients can go to complain when they feel their care has been

compromised. PALS carries out investigation on the matter; they’ll

keep you abreast every step of the way and will vary out the

appropriate disciplinary actions at the end of the investigation

 Address concerns

NOTE:
Every medical error would be an angry patient, but not every angry patient

is a medical errors

For solely angry patients with no medical errors, no need for RCAM
OVERVIEW FOR MEDICAL ERRORS

CONES Protocol

 C - Context:

 Prepare for what you want to say and anticipate their reaction

 Have the conversation in a quiet area

 Seat the patient closest to you and have no barrier between you

 Sit down, try to be calm, maintain eye contact

 Have a box of tissue available

 O - Opening Shot:

 Alert the patient/family member of the important news. For

instance, I need to talk to you about an update In your condition,etc

 N - Narrative:

 Explain the chronological sequence of events

 Avoid assigning blames and/or making excuses

 Emphasize that you’re investigating how the error occurred

 Offer a clear apology

 E - Emotions:

 Address strong emotions with empathic responses

  Use the EVE protocol as soon as strong emotion occurs

 Beware of being pushed to make promises you can’t deliver

 Avoid reassuring the person that there’s going to be a good

outcome or that no harm was done

 S - Strategy & Summary:

 Summarize the discussion and make specific plans for follow up

 Let them know the situation is a priority

 If you don’t know the answer, say so and that you will attempt to

find out

 Disclosing medical errors is now a standard, it’s not optional

 Sensitive disclosures have a favourable impact on malpractice

claims
ANGRY PATIENT FOR MIS-DIAGNOSIS
 GRIPS

 PARAPHRASE

 Why did you come in the first place?

 What were you told was wrong?

 What was done for you?

 When you took these antibiotics, any side effect

 Any new symptom?

 Relevant PMAFTOSA

 Examine the patient

 I’m here to talk to you about an error that occurred with your care….

 Narrate the whole story again (when you came in, we saw you , did

x-ray and told you you had pneumonia. Ami correct? We later found

out that someone ’ s x-ray was read as yours and you were mistreated

for pneumonia.

 PAUSE/ Apologize

 Tell him the ideal thing that should have been done. “Ideally when we

do…. We tend to …., but unfortunately this was not done for you”

 Keep apologizing

 Fill an incident report form

 PALS
ANGRY PATIENT-SAMPLE NOT LABELLED
(TELEPHONE CONVERSATION)
 TELEPHONE GRIPS

 PARAPHRASE

 Do you have an idea why I’m calling you

 I called to speak to you, give you updates with regards your sample

and address your concerns. But before then, can I ask a few question..

 Why did you come to the hospital in the first place

 What were you told was wrong

 What was done for you?

 Relevant PMAFTOSA

 You know you had samples taken yesterday.. has anyone told you the

outcome

 Duty of candor.. as a doctor….

 Unfortunately the sample taken was not labelled properly so the lab

was not able to process it

 I’m really sorry that this has happened… it’s totally unacceptable…

 Does this happen a lot…keep apologizing

 Keep apologizing…don’t say what’s not given in your prompt

 How do you make sure it doesn’t happen again? We’re going to take

necessary steps

 Document what has happened in his notes

 Fill an incident report form

 Inform your Seniors/Consultants

 RCAM (root cause analysis meeting)

 PALS

 Dr, will the person be punished? Necessary disciplinary actions

will be carried out based on the outcome of investigations

MEDICAL ERROR - MISSED MI
 GRIPS

 PARAPHRASE: I Understand that you were here 2 weeks ago and

you were managed for…. Can you tell me why you came in the first

place?

 I also understand that before this current admission, you presented a

few days prior … . Am I correct? What symptoms did you come in

with?

 What were you told was wrong?

 What was done for you?

 Are you still having those symptoms?

 Any new symptoms?

 Relevant PMAFTOSA

 Examine

 Well I ’ m here to talk to you about an error that occurred in your

management during your last visit..

 Well, the last time you came with…… unfortunately, the consultant

came in and reviewed your results … you actually suffered a heart

attack the last time

 PAUSE

 I ’ m truly sorry you feel this way, anyone in your shoes would feel

same way…
 Because this has happened, I ’ ll fill and Incident Report Form and

Inform my Seniors

 Root-Cause Analysis Meeting: I ’ ll ensure your case comes up and

will be discussed thoroughly to ensure this doesn’t happen again

 Keep apologizing

 PALS (Patient Advise and Liaison Service): it’s an independent body

that will investigate the matter and carry you along while the

investigation is ongoing. They’ll decide what to do after investigation

 Inform the Practice Manager if you’re in the GP

MISSED PELVIC FRACTURE
 GRIPS

 PARAPHRASE

 Is it okay if I ask you a few questions…

 Why is your mum in the hospital?

 What was done for her?

 What were you told was wrong?

 Relevant PMAFTOSA

 The reason we ’ re having this conversation is to update you about

your mum’s condition

 I’m afraid there was an error…

 You ’ re aware that your mum had a fall 5 days ago and she was

brought here. We did…… Are you following me?

 The physiotherapist examined your mum and found she was still in

pain so a CT scan was requested

 Unfortunately, the CT scan returned and showed that…

 The consultant radiologist took a look at the first x-ray and we

realized the first X-ray actually shows the fracture.. I’m truly sorry that

we missed it..

 PAUSE

 Apologize profusely

 Incident form
 Inform your Senior

 RCAM (Root Cause Analysis Meeting)

 PALS
BREAKING BAD NEWS (BBN)

THE APPROACH
 GRIPS

 PARAPHRASE

 Why did you come to the hospital in the first place?

 What were you told was wrong?

 What was down for you?

 R/O differentials

 R/O risk factors

 R/O FLAWS (where necessary)

 Relevant PMAFTOSA

 ICE/JARSS

 Examine the patient

 I’m sorry I do not have good news for you

 Narrate the story leading to the bad news, but don’t break the bad news

 Are you sure you’re able to continue with this conversation or is there

someone you would like to be here with you today?The reason I’m

asking is because I don’t have good news for you

 Break the bad news

 PAUSE

 Treatment (based on the scenario give)

Use the SPIKES PROTOCOL when breaking bad news to patients

and/or their relatives

 S - Setting: Secure an appropriate area for the discussion

 Have the conversation in a quiet, undisturbed area

 Prepare for what to say and anticipate the patient/family reaction

 Have the key people (whom the patient wants) in the room

 Seat the patient closest to you and have no barriers between you

 Sit down, try to be calm, make eye contact

 P - Perception: Assess the patient’s understanding of the

seriousness of the condition

 Ask what the patient and family already know

 Assess the patient and family member’s level of understanding

 Take note of discrepancies in the patient’s understanding and what

is actually true

 Watch for signs of denial

 I - Invitation: Get permission to have the discussion

 Ask patient if they want to know the details of the medical

condition /treatment

 Accept the patient’s right not to know

 Offer to answer any questions the patient/family member may have

 K - Knowledge: Explaining the facts

 Avoid medical jargons by explaining the facts in a manner that the

patient will understand

 Fill in any gaps that were evident in the “Perception” stage

 Present the information in small chunks

 After each chunk, verify the patient’s understanding

 E - Emotions: The Empathic Response - Be Supportive

 Deal with/attend to the emotions as they come

 Use open/ended and direct questions to explore what the patient is

feeling

 Respond to emotions with empathic and affirming statements

 Use “tell me more” statements

 Try to keep your own emotions from taking over

 Avoid responding with false reassurance

 NOTE: You don’t have to have the same feeling as the patient nor

do you have to agree with the patient

 S - Strategy and Summary: Closing the interview

 Strategy:

 Decide what the best medical plan would be for the patient

 Appraise in your mind or clarify with the patient what their

 expectations of treatment and outcome are

 Recommend a strategy on how to proceed

 Collaborate and agree on the plan

 Ask the patient to repeat to you their understanding of the plan

 Have a clear treatment plan in writing for the patient to take

home with them

 Summary:

 Summarize the conversation

 Offer to answer the questions (be prepared for tough questions)

OESOPHAGEAL CANCER
 GRIPS

 PARAPHRASE

 ODPARA difficulty swallowing

 Weight loss: when did you notice the weight loss? How much weight

have you lost? What was your weight before and what is it now

 Ask about feeling or being sick

 Ask about symptoms of indigestion: burping a lot, heartburn, etc

 R/O differentials: corrosives, strictures, achalasia, etc

 R/O FLAWS

 Relevant PMAFTOSA (elicit risk factors, smoking, work…)

 ICE/JARSS

 Examine the patient

 Investigation: routine

 Explain the diagnosis: From what you told me and from my

examination , I am quite concerned. Giving your age and the fact that

you mentioned that you have been having problems swallowing and

this has progressively worsened, the fact that you ’ ve been losing

weight and have been smoking cigarettes for the past 40 years. I ’ m

afraid we may be dealing with something as serious as a cancer and

the cancer that usually present this way is called the Oesophageal

cancer (cancer of the food pipe). PAUSE and allow patient to react
 What are you going to do for me?

 Again, this is a suspicion so we’ll be referring you urgently to see

the specialist through the cancer pathway. This does not definitely

mean you have cancer

 Gastroscopy (a type of endoscopy): A long, thin, flexible tube

with a small camera inside (endoscope) will be put into your

mouth and down your oesophagus (food pipe). The specialist will

use the camera in the endoscope to look out for problems. A small

sample of cells (biopsy) may be collected during the procedure;

these cells will be sent to a laboratory to check for cancer. The test

typically takes about 10 to 15 mins and results for a gastroscopy

and biopsy will be ready within 2 weeks

 It can help to bring someone with you to any appointments you

may have

 Treatment: If it is indeed a cancer, the treatment will depend on

the size, type, location, level of spread and your general health. It

may include surgery, chemotherapy, radiotherapy, targeted

medicines and immunotherapy

 Inform Seniors

 Safety net

 Address further concerns

LUNG CANCER
 GRIPS

 PARAPHRASE

 ODPARA cough

 R/O lung cancer: cough, weight loss

 R/O TB: drenching night sweats, weight loss ,cough

 R/O Bronchietasis: copious sputum, recurrent chest infections

 Relevant PMAFTOSA: smoking…

 Examine the patient

 Investigations: routine

 Explain the diagnosis: From what you told me, you mentioned that

you’ve been SOB, you’ve been coughing, lost weight and you’ve been

smoking for the last 32yrs…With all of these, I suspect you might be

having a form of cancer called Lung cancer ………………………OR

From what you told me , I’m quite concerned because you told me you’

ve been….. I’m afraid we may be dealing with a lung cancer here

 What are you going to do for me?

 Again, this is a suspicion so we ’ ll be referring you urgently to

see the specialist through the cancer pathway. This does not

definitely mean you have cancer.

 Chest X-ray: Usually the first test to diagnose lung cancer,

 however, cannot give a definitive diagnosis

 CT Scan: Contrast CT. The next after chest X-ray

 Bronchoscopy and biopsy: Done if CT scan shows there might

be a cancer in the central part of the chest. A thin tube with a

camera at the end (bronchoscope) is passed through your mouth or

nose, down your throat and into your airways, biopsy is taken and

sent to the lab. A newer procedure is called an Endobronchial

Ultrasound Scan (EBUS), which combines a Bronchoscopy with

an ultrasound scan

 It can help to bring someone with you to any appointments you

may have

 Treatment: If it is indeed a cancer, the treatment will depend on

the size, type, location, the stage and your general health. It may

include surgery, chemotherapy, radiotherapy and immunotherapy.

Depending on the stage of the cancer center you may receive a

combination of these treatments.

 Inform Seniors

 Safety net

 Address any other concern

POST-OP BLEEDING; AORTO-FEMORAL
BYPASS
 GRIPS

 PARAPHRASE

 Can I ask a few questions….

 What do you know about your wife’s condition

 Why was she here in the first place?

 What have you been told

 Relevant PMAFTOSA

 Is she on any medications, like blood thinners?

 I’m afraid I don’t have good news for you

 Is there anyone you would like to be here with you?

 As you know, she had…. And was scheduled for surgery

 While in recovery room, the nurse discovered she was bleeding into

the drain

 6 units of blood has been given and all staff have scrubbed in for her

surgery to find out why she may be bleeding

 She ’ s in a critical condition, but in safe hands and we ’ ll do our

best….

 Was there an error in surgery? Show empathy … . There was no

error in surgery, this is one of the complications of surgery and we

usually inform our patient and obtain consent before surgery

 Why did you go ahead with surgery when you knew this

complication could arise? Before we do any surgery, we weigh the

benefits and risks; if the benefit outweighs the risk, we go ahead with

surgery. We discuss everything with the patient and get their consent

before proceeding

 Should I invite my children? You can invite your children to come

around and show their love and support

 Always show empathy

 Address further concerns

 Inform Seniors
BBN - BILATERAL ISCHAEMIC STROKE IN
COMA
 GRIPS

 PARAPHRASE

 Do you know why he was here in the first place?

 What is he being managed for?

 What have you been told?

 Take brief history

 Relevant PMAFTOSA

 I’m afraid I don’t have good news for you

 Are you sure you want to continue with this conversation is there

anyone (either a family member or a friend) you would like to be here

with you? I’m asking because I don’t have good news for you?

 From our discussion so far, he had a stroke 2 weeks ago, he was

initially recovering but he suffered another stroke and is now in coma

 PAUSE

 Acknowledge their concerns

 The MDT has decided that only palliative care will be in his best

interest

 Explain palliative care

 Inform Seniors

 Address further concerns

SUB - DURAL HAEMATOMA
 GRIPS

 PARAPHRASE

 Dr where is our son? I can see you’re really worried about your son.

Is it okay if I confirm a few details from you to be sure I’m speaking

with the right people?

 Show empathy

 Can you please tell me what happened… Explore the history

 You know while you were in the garden, he ran across the road and

was knocked by a fast moving vehicle

 When he was knocked downs what happened

 Any convulsion?

 Any vomiting?

 Any bleeding?

 Relevant you PMAFTOSA

 You know while you were in the garden, he ran across the road and

was knocked by a fast moving vehicle

 When he arrived, the team of doctors attended saw him and did a

special scan of the brain called the CT scan

 I’m afraid I don’t have good news for you

 Are you sure you want to continue with this conversation is there

anyone (either a family member or a friend) you would like to be here

 with you? I’m asking because I don’t have good news for you?

 So the result of the CT scan revealed bleeding in the brain and this

kind of bleeding is called sub-dural haematoma

 PAUSE

 How is he now? Right now, the surgeons are preparing to take him to

theatre to try to remove some of the bleeding in the brain, through a

bore hole craniotomy

 Dr, are there complications of this surgery? The surgery will be

down by experts so the risk of complications will be low, however,

some common complications that occur with surgery are pain,

bleeding, infection. Talk about each one and profer a solution

 Dr, will there be a long term complication? At this point it’s

difficult to say; the team of Dr handling the case are experienced.

Some possible long term complications associated with this surgery

include memory problems, speech problems, seizures, etc. If you

notice any of these or anything abnormal, please let us know and we’ll

refer him to the appropriate specialists.

 Dr I think I’m a bad mother, I blame myself completely; it’s okay

if you feel this way, but I’d like to let you know this is not your fault.

For calling the ambulance to bring your son to the hospital, you ’ ve

shown clearly that you’re a good mum

 Address further concerns

MASSIVE INTRA-CEREBRAL BLEED
 GRIPS

 PARAPHRASE

 What do you know about his condition?

 Why did he come in the first place?

 What have you been told?

 Relevant PMAFTOSA

 Before now, has your husband been complaining of headaches?

 Was there weakness in any part of his body?

 Is he on any medications, like blood thinners?

 Narrate all that has been given to you in the prompt

 So your husband is as brought in today because he collapsed and was

brought in by an ambulance unconscious

 When he came, the team of doctors saw him and did a special scan of

the brain called the CT scan

 I’m afraid I don’t have good news for you

 Are you sure you want to continue with this [Link] there

anyone (either a family member or a friend) you would like to be here

with you? I’m asking because I don’t have good news for you

 So the result of the CT scan showed that your husband has suffered a

massive bleed in his brain; a condition we call intra-cerebral

haemorrhage
 PAUSE

 I’m so sorry this happened; this is too much for you to bear. Anyone

in your shoes will feel this way…..

 What are you going to do for my husband? Ideally, whenever we

see situations like this, we usually take our patients to the theatre to

remove the bleed, but in your husband’s case, the team of doctors have

reviewed and decided your husband will not benefit from any active

treatment, only palliative treatment?

 Dr what is palliative treatment? Means no surgery will be done,

because surgery won’t be of any use

 Are you giving up on my husband? I can see that this is very

challenging you, however we ’ re not giving up on your husband, we

don’t give up on our patients. It’s against our ethics and principles to

give up on our patient.

 There’s a lot we will be doing for him; wound you like to know?

1. We will ensure that your husband is properly hydrated

2. If he’s in pain, we’ll ensure that we give him pain killers

3. We’ll turn him regularly to prevent bed sores

4. We’ll ensure he doesn’t soil himself; in the event where he does, we’ll

clean him up

5. ….etc
 Dr please can you take him to ICU? Validate her concerns. We can’

t take him there because he doesn’t need it. ICU is for people who are

unable to breathe on their own

 Dr is my husband going to die? Don’t confirm or deny it, to avoid

litigation… I can see this is a very challenging time for you, however,

people with this condition are not expected to make full recovery

 Dr can I see my husband? Of course you can, I ’ ll speak to my

seniors and we’ll make arrangements for you to see him

 Dr please can you keep him alive (if you’re speaking to daughter)?

Is there any particular reason you want him to be alive for 2 weeks…..

Get her response … . Congratulate her and wish her well but tell her

you can’t guarantee her wish because his condition is quite serious

 Dr I have kids who are in.. can I invite them to come back? Yes,

he needs all the support he can get because his condition is very

serious

 Address further concerns

DEMENTIA - PALLIATIVE CARE
 GRIPS

 PARAPHRASE

 Could you please tell me what you know about your mum ’ s

condition?

 ODPARA the weight loss

 I can see that your mum is also being managed for Dementia; can you

please tell me more about that?

 Daughter’s social history:

 Who takes care of her?

 How have you been coping with taking care of her alone?

 Do you have a job?

 How have you been coping financially? (Ask is she’s not working)

 Relevant PMAFTOSA

 Explain all the examinations and investigations that has been done…

all of this has come out normal, how do you feel about that?

 I’m afraid I don’t have good news for you

 Are you able to continue with the conversation? How much of your

mum’s condition would you like to know? Would you like someone to

be here with you? I’m asking because I don’t have good news for you
 Explain the diagnosis: Dementia is a progressive condition and

sometimes can become advanced and give symptoms like what you

mum is having. The only reason for the weight is the Dementia

 The team has decided that your mum will not benefit from any active

treatment, but palliative care

 Do you know what palliative care is? Palliative care involves

supportive treatment to make the patient comfortable; it can be done in

the hospital, hospice, day care

 PAUSE

 Can I take my mum home? Long stay in the hospital can predispose

her to having opportunistic/hospital acquired infections and we

wouldn’t want that. So you can take your mum home

 Would you like some support? We have carers, Dementia nurses

that can come and support you at home

 How do I feed her?

 Make her meals in semi-solids or purée form,

 Let her take small portions per time

 Eat with her

 Be patient and give her time to eat

 Avoid distractions like tv when it’s time to eat

 Oral care
 Can you take her to the ICU? The team has decided that aggressive

treatment will not be in her best treatment and she does not need ICU

care

 Is she dying? At the moments it ’ s difficult to say, but people with

this condition are not expected to make full recovery

 Refer to the Citizen’s Advice Bureau so she can get some financial

benefits/assistance

 Inform Seniors

 Safety net: further questions

 Address concerns
OTHER ETHICS

PATIENT REFUSING TREATMENT -

ELDERLY
 GRIPS

 PARAPHRASE: I can see from my notes that…..

 I’m here to talk to you and address all of your concerns

 How can I help you?

 Any particular reason why you want to stop your treatment?

 Acknowledge his concerns. I can see it’s challenging. Is it okay if I

ask a few questions…..

 Assess Capacity

 Are you aware of the condition you’re being managed for?

 Are you aware of the treatment?

 Are you satisfied with the treatment?

 Which of the treatments are you uncomfortable with? Address

side effects and talk about the treatment

 If we change or make adjustments to treatment, will you

re-consider?

 Are you aware of the consequences of not continuing with

treatment?
  Have you discussed with any member of your family and friends?

What did they say?

 How is your mood? Can you grade your mood from 1 to 10?

 Ideally, I would have loved you to continue with your treatment. I can

only imagine what you must have gone through for you to decide to

stop. I have assessed you and seen that you have capacity so I will go

ahead and grant your wish

 Lasting Power of Attorney (LPoA): Now that you ’ ve decided to

discontinue your treatment, In the coming days or weeks your health

may deteriorate and you may not be able to make decisions regarding

your own health. In situations like that , we depend on LPoA. Have

you appointed anyone like that?

 CPR: Chest compressions to bring our patient back to life. Would

you want this?

 DNAR: I’m going to inform my seniors about this conversation and

they’re going to come with a form called the DNAR form for you to

sign in order to make our conversation legally binding. In the event

where you wish to change your mind, we’re more than willing to help

 Give leaflets

 Address further concerns

NAI - DOMESTIC VIOLENCE
 GRIPS

 PARAPHRASE.. I understand that I understand that you did an

ultrasound scan… Is that correct? Has anyone been here to explain the

result of your ultrasound scan

 When they don ’ t maintain eye contact; I can see you ’ re

uncomfortable, is everything okay?

 Why did you come in for the test in the first place

 I must commend you for being prompt and coming to the hospital

 Are you still having pv bleeding at the moment?

 When did you notice this pv bleeding?

 How much blood did you use?

 Did you by chance fall down?

 Did it have any clot in it?

 Any bleeding from any other part of the body?

 What did you do when you noticed it?

 Any tummy pain?

 Is this the first time of bleeding from your front passage during this

pregnancy

 Is this your first pregnancy?

 Relevant PMAFTOSA

 Examine
 Explain the result: So the ultrasound scan returned normal and it

shows your baby is fine. How do you feel about that?

 However, when the nurse was examining you, the nurse noticed

some bruises on your wrist, which she was quite concerned about. Can

you tell me how the bruises came about?and she was quite concerned.

Can you tell me how this happened?

 Offer confidentiality

 Please know that this is a safe space and you can tell me

everything. Whatever you say will remain confidential between me

and our team

 Ist level confidentiality: Make open/non-specific statements;

whenever we see things like this, we just want to be sure that

everything is fine at your home and place of work and be rest

assured that whatever we discuss remains confidential between us

 2nd level confidentiality: Whenever we bruised like this, we just

want to be sure that someone either at home or your place or work

is not responsible for it

 3rd level confidentiality: Whenever we see something like this,

we just want to be sure that your partner at home or your boss at

your place of work has not caused this.

 When patient opens up, applaud her and encourage her

 Condemn it completely: no one is meant to go through this… it is a

crime for anyone to treat you this way…….

 HARK

 H- Humiliate: Does he humiliate you when you’re around him?

 A- Afraid: Do you feel afraid when around him?

 R- Rape: Does he sometimes force himself to have sex with you

even when you don’t consent?

 K- Kick: Does he sometimes kick or get physically violent with

you?

 Risk factors for abuse

 Alcohol: Does he drink alcohol? Was he under the influence of

alcohol?

 Drugs: Does he do recreational drugs? Was he under the influence

of drugs?

 Stress: Is he by chance facing any form of stress?

 Finance: Is he facing any form of financial challenge? What does

he do for a living?

 Forensics: Has he even been in trouble with the law?

 Apart from you and your partner, is there anyone else (a child) in the

house. Inform social services if there is a child in the house

 Condemn again. it is a crime for anyone to treat you this way and the

police are empowered by law… I’d encourage you to inform the police

 Link her up with various support groups

 Encourage her to inform trusted family/friends

 Encourage her to move her finances to a separate place/account just

incase she needs to move out of the house

 Refer to MARAC (Multi-Agency Risk Assessment Conference)

 Inform Seniors

 Give leaflets
NAI - SEX TRAFFICKING
 GRIPS

 PARAPHRASE

 Ensure to observe for non-verbal cues

 Offer confidentiality

 How did you sustain this injury?

 I ’ m not doubting you, but from examination, scalded injury on the

tummy doesn’t seem likely from the story you told me. When things

like this happen, we just want to be sure everything is fine at home

 Offer the 3-level confidentiality

 When she opens up, reassure/commend her. I appreciate you giving

this information to me and we’ll do our best to ensure you’re safe

 Any pain/ Taken pain killers?

 Has this happened before?

 When it happened, what did you do?

 Commend her for coming

 How are you related to him?

 What exactly does he do for a living?

 What do you do for him?

 Where do you live? Who do you live with? Are you related to them?

What exactly do they do?

 Ask of risk factors for abuse: stress, alcohol, drugs, financial

 challenges, problems with the law

 HARK history

 Have you ever tried to escape?

 Ask about her family/friends

 Relevant PMAFTOSA

 Ask about her international passport/relevant documents

 Examine the patient

 Admit her

 Inform Seniors

 Inform the police yourself

 Inform Social Services

 Refer to the Sexual Assault Referral Centre (SARC)

 Also mention that the team will try to rescue the other girls

 Keep reassuring

 Address concerns
NAI - ELDERLY ABUSE
She is being abused by her daughter and her two grandkids

 GRIPS

 PARAPHRASE

 What happened?

 Can you tell me more about this?

 Commend her for bringing her mum to the hospital

 Did your mum hit her head when she fell down?

 How did she fall?

 Is this the first time your mummy will be falling?

 What do you think might have caused this?

 Relevant PMAFTOSA

 How long has she had dementia?

 Dementia can be quite challenging and difficult; How have you been

coping taking care of your mum?

 Apart from you, who else takes care of your mum?

 Do you think you will need some help?

 Do you sometimes feel overwhelmed or frustrated?

 Sometimes, when people feel overwhelmed they can get irritable and

raise their voice; has that been the case with you?

 Explain..Can you tell me how she sustained this injury…

.
 I ’ m asking because the bruises are of difficult ages and cannot be

sustained/ explained by a simple fall

 Offer confidentiality. Not to worry, whatever is discussed here is

strictly going to be between you, myself and the entire team

 Sometimes when we see bruises like this, we just want to be sure that

no one has done this to her

 Sometimes when we see bruises like this, we just want to be sure that

someone close to her has not done this

 Examine the patient when she is back

 Admit her

 Do x-ray of all other parts of the body

 Inform social services who will check the condition of the house to

see that it is safe for the patient to return

 They will come and double check that the house is safe for your mum

to return. Sometimes when they come, they can issues warning, offer

suggestions and sometimes take custody of your mum

 Inform Seniors

 Give leaflets on Elderly Abuse and all the laws guiding it

RELATIVE REQUESTING FOR PATIENT ’ S
DIAGNOSIS
 GRIPS

 PARAPHRASE

 Dr, do you know who I am? I’m sorry I don’t know who you are, but

I’ll be more than willing to get to know you

 Dr, I’m….. Oh nice to meet you, it’s my pleasure speaking with you…

 How much do you know about your mum ’ s condition? TAKE

HISTORY

 Is your mum aware we’re having this conversation? No

 Are you the next of kin?

 Do you have Lasting Power of Attorney?

 I understand … .. but as doctors, we cannot disclose information of a

patient who hasn’t given consent. I totally understand that you’re her

son and you wish the best for her, but we have a duty to keep a patient’

s medical records confidential

 I ’ m so sorry I won ’ t be able to help you the way you would have

wanted me to, however, if you have any other concerns, I’ll be more

than willing to address them

 Inform Seniors

 Address further concerns

BREAST CANCER REFUSING TREATMENT
 GRIPS

 PARAPHRASE

 What can I do for you?

 What has been done?

 What have you been told?

 Assess capacity

 Hair loss: option of wigs, hats

 Vaginal dryness: there are some creams that can be given to help

 Why are they not removing only the area where the tumour is?

The thing with removing only tumour is that there is a chance that if

not removed properly, it can spread and it may be noticed really late.

Encourage to use silicon bra, breast reconstruction

 Convince to continue treatment

 Inform Seniors

 Give leaflets on treatment options, side effects:treatments… etc

 Address concerns
TWO - PEOPLE/HOSPITAL POLICY
 GRIPS

 PARAPHRASE

 They will praise you. PAUSE. I’m glad you’re happy we’re doing the

right thing. It’s our desire to give patients and their relatives the best of

treatment

 Is It okay if I ask a few questions?

 What symptoms did she come with?

 What is she being managed for?

 So far, are you comfortable with the treatment?

 Have the staff been nice to you?

 How often do you visit your grandmom?

 What time of the day do you visit your grandmom?

 When you come to the hospital, what exactly do you do?

 We encourage relatives to come around to see….as it……

 Well there is actually a recent development with regards the hospital

policy I would like you to know. Are you aware of it?

 The hospital stipulates that not more than…..

 Patients are complaining that whenever you come you…. I’m letting

you know from other patient ’ s point of view that the hospital is

supposed to be quiet to help with their mental state and improve their

health condition
 I’d encourage you to reduce……...based on the hospital policy

 Clearly state these policies

 You mentioned to me that you visit your grandmother in no particular

order of time. Am I correct? The new hospital policy states that there

is a quiet time from 2 to 5pm and no one should be allowed in the

hospital

 We appreciate that your family is large and supportive, but the

hospital policy states that only 2 to 3 relatives are allowed per time;

other members of the family can pray virtually e.g via zoom call

 Dr is it possible to get my grandmom a private room? Yes it is

possible and I will discuss with the ward manager

 Dr can we get our priest to come and pray? Every hospital has a

chaplain and we can make that arrangement within the local chaplain,

if that ’ s okay. If they insist on personal priest, tell him you ’ ll speak

with seniors and give him feedback

 Can the Bible be put under her pillow? Yes

 Address other concerns

CHANGE OF COUNSELLOR
 GRIPS

 PARAPHRASE

 What are you being managed for?

 What medications are you on?

 How has the treatment been so far?

 Are you satisfied with your treatment?

 How long has this person been your counselor?

 Why do you want a change of counsellor?

 Offer confidentiality

 Commend her for speaking up

 Was it consensual?

 Grade her mood

 Relevant PMAFTOSA

 Examine the patient

 We’re going to thoroughly investigate this matter and if he is found

guilty, appropriate disciplinary measures will be taken up against him

 Dr, do you mean you don’t trust me? I’m not saying I don’t trust

you, but the necessary thing to do is that a panel has to be set up and

investigations carried out

 Dr, I want to change my counsellor and I prefer a female: Offer

another psychiatrist, let her know being a male psychiatrist isn ’ t the
 problem. If she doesn’t agree, offer to talk to your seniors to make an

arrangement for a female psychiatrist

 Is he going to be punished? I don’t know what will happen, but it

will be dependent on the outcome of the investigation.

 Inform his supervisor

 Inform Seniors

 Address further concerns

EUTHANASIA
An elderly lady with a terminal illness; only palliative care. Son is either

in Sweden, Switzerland or Any other country where euthanasia is

[Link] puts a call across to you and tell you; thank you for all you’ve

done for my mother

 GRIPS

 PARAPHRASE

 Son says I want you to help me do something and I was hoping you

could help me.. whatever problems you have, we ’ ll see how we can

help

 My mum has been here for a long time….. I was hoping you could

withdraw her treatment or twitch the medication

 When you say twitch your mum ’ s treatment, what exactly do you

mean

 Dr I would want you to stop her medications or give her an overdose:

So you would want me to…

 Establish what the mum is being treated for

 Establish what has been done for her

 Establish her present status

 It must be challenging…. How has the family been coping

 Have you got siblings? Are they aware you ’ re having this
 conversation me? I haven ’ t spoken to my siblings because they may

not accept it

 Are you the next of kin? Yes

 Are you the Lasting Power of Attorney?

 Recap what patient has told you and confirm that is exactly what they

said… Am I correct?

 This is what is called Euthanasia

 I’m afraid I may not be able to do that because Euthanasia is a crime

and it’s punishable under the UK Law

 Dr, you need to help me … I ’ m afraid I may not be able to do it

because it’s a crime under the UK Law

 Suicide act of 1961: criminalizes all forms of Euthanasia and it is

punishable by a maximum of life imprisonment

 Dr, it’s just between us………. Acknowledge him, but reject him

 Dr I live in Sweden or Switzerland where Euthanasia is legal and I’

m the LPoA, can I organize for my mum to be flown into this place

where it’s legal? Acknowledge him (EVE’s protocol), but refuse

 Assisted Suicide Act of 1961: also criminalizes every form of

assisted suicide and it’s punishable by up to 14 years imprisonment

 Dr you’ve not been helpful…. I’m sorry I was not able to help you

in the way you would have loved me to , but I’m open to helping with

 Send him a leaflet that contains all relevant laws about Euthanasia
GENDER DYSPHORIA
 GRIPS

 PARAPHRASE

 Commend him for opening up

 For how long have you been feeling this way?

 Anything worsen the feeling?

 Have you discussed this with anyone (family/friends, teacher)? Were

they supportive?

 Explore sexual history:

 Are you sexually active? No

 Are you in a relationship?

 In the event that you become sexually active, do you see yourself

being involved with a man or a woman

 Grade mood

 R/O Suicide and self harm: sometimes when people feel this way,

they may want to harm themselves or think of taking their own lives.

Has this ever been the case with you?

 Are you facing any form of discrimination/bullying

 Have you commenced any form of treatment?

 Relevant PMAFTOSA
 ICE/ JARSS

 Examine the patient

 Investigations: routine

 Explain the diagnosis: Gender Dysphoria describes a sense of

unease that a person may have because of a mismatch between their

biological sex and their gender identity. Or a person feels

uncomfortable in his body

 What are you going to do for me?

 Refer to Gender Identify Development Service (GIDS): it ’ s a

multi specialist clinic. They’ll see you, talk to you and follow you

up till you get to 18

 When you get to 18 and you still feel this way, you’ll be referred

to the Gender Dysphoria Clinic (GDC), where the surgery will

be performed

 Refer for talking therapy

 Encourage to speak to trusted family members/friends for support

 Offer support groups

 Inform Seniors

 Give leaflets

 Address other concerns

ALCOHOL COLLEAGUE
 GRIPS

 PARAPHRASE and Establish rapport

 Are you aware why I’ve asked to see you?

 There ’ s something I ’ ve noticed for a while now and it ’ s quite

concerning to me and as your colleague, I feel important to speak to

you about it

 I would like you to know that whatever conversation we have today is

going to remain confidential.. I’m not here to judge you

 For sometime now, I noticed you ’ ve been smelling of alcohol.. is

everything okay

 Dr I think you may be mistaking: when people are confronted with

stuff like this, it’s okay for them to deny. But like I told you, I’m not

here to judge you, I’m only here to help you

 Offer confidentiality again

 Well it will interest you to know that even the nurses have noticed

this and are making comments about it. You know what that means if

it gets to gmc. I’m only here to help you…..

 Well I’ve been drinking alcohol for a while……

 Any particular reason why you’re drinking alcohol? How much

 Is this a usual habit or is it recent

 Any recreational drugs?

 Any smoking?

 Any drinking of alcohol?

 Since coming to the hospital, have you seen any patient?

 Have you prescribed any medication

 Have you discharged any patient?

 I ’ m not doubting your judgment, but sometimes alcohol can cloud

our judgement. I just need to double check that the right thing was

done. Like I told you, I’m here to help [Link] know the nhs places

emphasis on patient safety

 Advise to stop taking alcohol both for his health and professional

outlook

 Please take the day off

 Encourage him to speak to the consultant. It ’ s important you do so

yourself because if they hear from you first, it’s better than if they hear

from someone else. They ’ re here to help you and give you all the

support you need.

 Counselling/ Support groups

Use the SPIES Protocol for colleagues

 S - Seek information: Find out what’s going on (based on the

scenario)

 P - Patient/Person:

 Patient: - How many patients have you seen today?

- What did you do for them?

 Person: - How are you doing?

- Is everything okay at home?

-Are you facing any form of challenge at home/work?

 I - Initiative: Offer to review the patients already seen

 E - Escalate: Inform Senior, Educational Supervisor etc

 S - Support: Offer to assist at work where necessary

RAPE CASE - SICK NOTE
 GRIPS

 PARAPHRASE

 Why do you want a sick note?

 Once he opens up, condemn the act completely

 When this happened, did you inform anyone?

 Please can you tell me exactly what he did?

 Was this a mutual consent?

 Who organized the party?

 What happened in the party?

 Did you go alone or with someone?

 Were they under the influence of alcohol or recreational drugs?

 What’s your relationship with this person?

 Was this culprit under the influence or alcohol or recreational drugs?

 Were you by any chance giving mixed signals to the culprit?

 Any pain or bleeding from the passage?

 Sexual history : STI in the past, sexual orientation….

 Relevant PMAFTOSA

 Ask him to come to the GP (if phone conversation); GP then sends to

the hospital

 Examine: only inspection

 Investigate: baseline, STI screening

 Explain the diagnosis: Sexual Assault/Rape

 Offer him the sick note: include the rape issue if he wants you to or

omit it based on confidentiality

 Offer post-exposure prophylaxis within 72 hours of occurrence,

regardless of the result of the STI screening

 Refer to Sexual Assault Referral Centre (SARC)

 Give him support; totally condemn the act

 Encourage him to inform his family

 Encourage him to inform the police: This is against the law and it has

to be reported

 Ask for further concerns and respond

 Inform Seniors
EMERGENCY CONTRACEPTIVE -
TEENAGER
 GRIPS

 PARAPHRASE

 Is there any particular reason why you are here alone? The hospital

policy states that anyone under the age of 16 ought to come with their

parents or guardian.

 Dr, I want contraceptives. Not to worry I will see you and ask some

questions to see if I may be able to give you the contraceptives

 Offer confidentiality: our conversations will remain between us

except there’s a situation that needs to be escalated?

 Why exactly do you want this contraceptive?

 GILLICKS competence;

1. What do you know about this contraceptive pills?

2. What do these pills do?

3. Do you know if these pills sometimes fail?

4. Are you aware these pills may have side effects?

5. Apart from pregnancy, do these pills protect against STIs

 FRASER competence;

1. Have you spoken to your parents about this? Why haven’t you spoken to

them?

2. How will you feel today if we do not give me the pills?

3. Are you likely to continue having sex if we don ’ t give you the pill

today?

4. Do you know the consequences of having unprotected sex? If she tries

to apologize, tell her not to do so

 Menstrual history: LMP

 Sexual history: you mentioned you had sex yesterday, how long

have you been sexually active? Is your partner male or female? Can

you tell me more about him? How is he doing? How is he (24hrs)?

What does he do for a living?

 Contraceptive history: have you used any in the past? What

happened this time?

 R/O Abuse and cohesion: does he sometimes have sex with you

even when you don’t consent to it?

 Who do you live with? Do they know about your relationship?

 Relevant PMAFTOSA : smoking, alcohol, recreational drugs

 Examine

 Investigations: STI screening

 Explain the situation;

 SCENARIO 1: You mentioned at you had unprotected sex last night

and that’s why you want emergency contraceptives today, am I correct?

I have assessed you and I can see that you have very good

understanding contraceptive pills and your relationship is not an

abusive one so I will go ahead and give you the pill (appropriate

relationship)…. If the relationship is appropriate (her partner is within

similar age range), give contraceptive

 SCENARIO 2:You mentioned to me that you had sex and that’s why

you’re here for emergency pills, am I correct? I have assessed you and

I see you have good understanding of contraceptives, however you

mentioned your partner is your teacher, gym instructor…. that means

he occupies a position of authority over you and this makes your

relationship with him inappropriate so I’m afraid I will not be able to

give you the pill and I will have to inform the relevant authorities

( Safeguarding team). The authorities will look into this to make sure

the relationship is appropriate and someone is not taking advantage of

you….If relationship is inappropriate ( her partner is far older than her

and in a place of trust), don ’ t give contraceptives; refer to the

necessary panels within the hospital to give the contraceptives.

 Give the Ella-one pill or levonelle pill. Give within the first 72hours

of sexual intercourse. The earlier you take the pill, the better

 If you take the pills and you vomit within 2 hours, the pill must be

repeated

 Encourage to inform parents

 Inform Seniors

 Safety net: if your period delays for more than 2 weeks, you must

come back for a pregnancy test

REFUSING COLONOSCOPY
 GRIPS

 PARAPHRASE

 I have your test result with me, but would you mind if I ask a few…..

 Why did you do the test in the first place?

 What have you been told?

 Any dizziness?

 Any heart racing?

 Do you feel weak?

 Any tiredness?

 Explore history, R/O FLAWS

 Relevant PMAFTOSA

 Examine the patient

 Has anyone been here to explain there results to you?

 Explain the findings: Thank you for being patient with me thus far,

we did a sigmoidoscopy which showed a benign (harmless) polyp; the

sigmoidoscopy shows only a part of the bowel

 We also did a biopsy which shows an adenoma

 You have been requested by the consultant to come for a colonoscopy

(a flexible tube with a camera will be passed through your back

passage to visualize your entire gut/bowels and care given as required)

 Dr, I don’t want the colonoscopy: I can see you’re not really keen
 on having the procedure, but may I know why?

 Assess capacity

 You already passed a flexible tube, why repeat it? Last time, we

did a sigmoidoscopy, which doesn’t show all of your bowels and

there’s a possibility that since we found a polyp, there may be others as

well. So this time, the consultant has planned that you have a

colonoscopy to look further into the bowel to see if there are other

polyps and get them removed at one go

 Dr, why can’t you just leave it there since they are benign? Well,

as much as they ’ re benign , there are possibilities they can become

cancerous so we don’t want to take chances

 Dr, the last time was painful: I’m truly sorry you had to go through

that, but this time we ’ ll give you medications to ensure you feel

minimal to no pain

 So with all this information you have, will you consider having the a

colonoscopy? Briefly talk about bowel preparation for colonoscopy if

patient agrees

 Inform Seniors

 Give leaflets

 Safety net

 Address further concerns

GETTING READY FOR COLONOSCOPY

2 DAYS BEFORE:

Eat only plain foods like

 plain chicken, not in sauce

 white rice, pasta or bread

 clear soup

Your letter will tell you what you can eat or drink

1 DAY BEFORE:

You’ll need to drink sachets of laxatives to empty your bowels in

readiness for the test

Most people:

 need to drink few sachets

 need to drink the sachets at different points throughout the day

 get diarrhoea a few hours after taking the first sachet

Stay at home and be near a toilet after starting the laxatives

ON THE DAY:

 When you arrive, you’ll give consent

 You may be offered painkillers, sedation (requires you to have a

caregiver and not drive for at least 24 hours), breathing n gas and air

 The Colonoscopy
WORKPLACE BULLYING - LESBIAN
 GRIPS

 PARAPHRASE

 Offer confidentiality

 Commend her when she opens up and condemn the act completely

 Explore bullying

 Have you told anyone about this?

 Have you informed your boss?

 Is your partner aware? Is she supportive

 Are you family/friends aware of what ’ s going on? Are they

supportive?

 Sexual history

 Grade mood: R/O depression if mood is low

 Relevant PMAFTOSA

 ICE

 JARSS

 Examine the patient

 Quote the Equality Act of 2010: The Equality Act of 2010 is against

any form of discrimination solely on the basis of a person ’ s sexual

identity/ orientation.

 Explain the diagnosis: From all we’ve discussed, I suspect what

you’re going through is called Workplace Bullying

 Encourage to talk to the colleague in question, as they may not be

aware of the impact of their behaviour towards others

 Encourage her to speak with her employer if she doesn ’ t want to

speak to the colleague; it ’ s the duty of your boss to have a space at

work

 Encourage her to speak to her family/friends, partner for support

 Counsel on her alcohol intake

 Refer for Talking Therapy/Counselling

 Refer Support groups: LGBTQ

 Safety net: suicidal ideation, self-harm etc

 Give leaflets one different support groups

 Crisis card

 Give 1 week follow-up

COPD REFUSING TREATMENT (ELDERLY)
 GRIPS

 PARAPHRASE..I ’ m here to talk to you and address all of your

concerns. Is that okay?

 How can I help you

 Is there any particular reason why you want to stop treatment ?

 Acknowledge his concerns: I can see it ’ s challenging. I can only

imagine being managed for several conditions and taking so many

medications? Is it okay if I ask a few questions

 Are you aware of the condition you’re being managed for?

 Are you aware of the treatment?

 Are you satisfied with the treatment?

 Which of the treatments are you uncomfortable with? Address side

effects and talk about the treatment

 If we change or make adjustments to treatment, will you re-consider?

 Do you know the consequences of not continuing with treatment?

 Offer home-care: Are you open to taking the treatment at home?

 Have you discussed with any member of your family and friends?

What did they say?

 How is your mood? Can you grade your mood from 1 to 10?

 Ideally, I would have loved you to continue with your treatment. I can

only imagine what you must have gone through for you to decide to
 stop. I have assessed you and seen that you have capacity so I will go

ahead and grant your wish

 Lasting Power of Attorney: Now that you’ve decided to discontinue

your treatment, In the coming days or weeks your health will likely

deteriorate and you may not be able to make decisions regarding your

own health. In situations like this, we depend on LPoA. Have you

appointed anyone in this capacity?

 CPR: In the coming days or weeks you health may deteriorate and

when this happened, we perform a certain maneuver called [Link]

compressions to bring our patient back to life. Some patients give

advanced directive with regards this; What will be your case with this?

 External breathing: In the coming days or weeks, you health may

deteriorate and we may need to connect you to a breathing machine.

Sometimes, some patients give advanced directive regarding this; what

will be your case?

 DNAR: I’m going to inform my seniors about this conversation and

they’re going to come with a form called the DNAR form for you to

sign in order to make our conversation legally binding. In the event

where you wish to change your mind, we’re more than willing to help

 Have you made any funeral arrangements?

 Give leaflets

 Address concerns
CONCERNED DAUGHTER - CANCER IN
FATHER
 GRIPS

 PARAPHRASE

 Dr, I don’t want my father to know he’s been diagnosed of cancer:

I can see you’re quite concerned about this, would you mind if I ask

you a few questions so I can better address your concerns?

 Assess her knowledge of her father’s condition

 What is he being managed for?

 When was the diagnosis made?

 Relevant PMAFTOSA

 Is there any particular reason why you don’t want your father to

know of his cancer diagnosis? Acknowledge her concerns

 I ’ m sorry we have to inform your father of his cancer diagnosis

because as doctors, we owe it to our patients to be true to them at all

times and in every situation

 We spoke to your brother earlier because your father didn ’ t have

capacity, but now he has capacity and we ’ re duty bound to explain

everything that has to do with his diagnosis and treatment

 We’re bounded by the ethics of our profession to carry our patients

along with their diagnosis and treatment

 Can you tell him another diagnosis, I don’t want you to mention
 cancer to him: Cancer diagnosis is a serious diagnosis and patients

have to be involved from the start

 Just treat him for infection, don’t tell him it’s cancer: Cancer

treatment comes with a lot of complications/side effects and it ’ s

unethical not to involve patients in their care

 When we start giving medications to your dad and he asks us what

medications we’re giving him, we can’t lie to him and it’ll be unfair

for him to find out only at that point

 Dr, my father will not be able to handle the news: It’s beautiful to

see that you care so much about your father, however, we’ve been

trained on how to break such sensitive news to our patients. We’ll ask

him how much he would like to know about his condition and give

him the news in the most sensitive way possible

 Dr, can I be present when you’re telling him? It’s possible, but we

need to gain consent from your dad first….

 Dr, my father doesn’t really understand English, I’d love to be

your interpreter? Thank you so much for the effort, but we have an

interpreter here in the hospital and it’s our practice to use the hospital

approved interpreter

 Dr, can I interrupt you when you’re speaking to him? Is there any

particular reason why you would want to interrupt us? I want to

interrupt you because I would like to stop you before you say some
 sensitive things that my father may not be able to handle, you know

he’s old and weak. I appreciate you concern, but it would not be proper

for you to interrupt us when we’re speaking to him and I’d like to

reassure you that we’re trained professionals and we will break the

news to him in the best way possible

 Dr, you were really not helpful: I’m sorry I couldn’t help you in the

way you would have wanted, but be rest assured that if you have any

other question or concerns, we’ll be more than happy to help

 Inform Seniors

 Address further concerns (if any)

SICK NOTE - CHICKEN POX IN DAUGHTER
 GRIPS

 PARAPHRASE

 Dr, my daughter has chicken pox? How is your daughter doing

now?

 FMAM History

 PBIND

 Social history: Who takes care of her? Who else takes care of her?

 Brief history about mum:

 Ask about symptoms of chicken pox

 Are you up to date with your jabs?

 Have you had chicken pox in the past?

 Ask how she’s coping

 What do you do for a living, etc

 Examine if patient is there

 Dr, I want a sick note? Why do you want a sick note? My husband

is very busy and my other child needs to go to school. I’m afraid I can

not give you a sick note

 Speak to your boss, explain the situation and your boss may consider

giving you compassionate leave from work

 Can your husband get some time off work to help? No, he just started

a project and he’s the team lead

 Encourage her to put in an emergency leave request to get your leave

and take care of her child

 Encourage to get another relative/family member to come help out

 Encourage to get the services of Child Minders

 Dr, I may lose my job and source of livelihood: I’m so sorry you

feel this way, but I’m afraid I can’t give you a sick note

 Refer to the Citizens Advise Bureau if mother is insisting

 Inform Seniors

 Address further concerns

PSYCHIATRY

THE APPROACH
 GRIPS: I’m Dr Mariam Ajugba, one of the doctors in……

 PARAPHRASE

 HPC

 FAMISH

F- Family, Friends, finance, forensics

A- Alcohol/smoking, recreational drug

M- Mood, Medications

I- Insight

S- Suicide, Sleep

H- Hallucinations (visual/auditory)

 ICE

 JARSS

 Examine the patient

 Give provisional diagnosis

 Investigations to confirm diagnosis

 Treatment

 Inform seniors

 Safety net

 Give leaflets/advice sheet

DEPRESSION (Failed CBT)
 GRIPS

 Ask the patient to bring you up to speed with regards what happened

 Empathize (IPS)

 Any major incident happened before the diagnosis of depression?

 How are you feeling generally?

 So this treatment you’re on, are you taking it as prescribed?

 How many sessions of CBT have you had?

 Is it a group or an individualized session?

 CEASAR

C - Concentrate: Are you able to concentrate?

E - Energy: What’s your energy levels like?

A - Appetite: What’s your appetite like?

S - Sleep: Are you able to sleep?

A- Anhedonia: Have you lost interest in previously enjoyed activities?

R - Repeated feeling: Any repeated feeling of guilt, hopelessness or

worthlessness?

 Grade his mood

 FAMISH
 R/O Suicidal ideation: Sometimes when people have such low

moods, they tend to want to take their own lives; has this been the case

with you?

 R/O Self-Harm: : Sometimes when people have such low mood, they

tend to want to harm themselves, has this been the case with you?

 Examine the patient

 Explain the diagnosis: From all you’ve told me, your CBT has failed

(only say this after the person has done 6 individualized sessions)

 Refer him to the Psychiatrist

 Tell him he’ll be placed on anti-depressants in addition to the CBT

 Are there side effects to this medication? Just like every other

medications, there are side effects like weight gain, worsens mood at

the beginning of treatment, erectile dysfunction… Also talk about the

treatment to side effects

 Inform Seniors

 Safety net

 Give leaflets

 Address further concerns

ANOREXIA NERVOSA
Patients can come with weight loss or low BMI

 GRIPS

 PARAPHRASE: I understand you’re here for….am I correct? I’m here

to talk to you and address your concerns

 Is the weight loss intentional?

 Can you give me a breakdown of your diet in a day?

 Can you also tell me about your exercise? How many hours do you

exercise in a day?

 Who is your role model?

 When you see yourself in the mirror, do you think you’re fat or slim?

 SCOFF History

S - Sick: Do you make yourself sick after eating?

C - Control: Do you think that you’ve lost control over what you eat?

O - One stone: Have you lost more than one stone in the last 3 months?

F- Food: Do you think food dominates your life?

F- Fat: Do you see yourself as being fat even when others think

otherwise?

 R/O Differentials: Depression (grade the mood), hyperthyroidism, etc

 R/O Complications: Severe anaemia (heart racing, tiredness, shortness

of breath), Menstrual irregularities, arrhythmia, etc

 Relevant PMAFTOSA

 ICE/JARSS

 Examine: Check observations, BP Lying and standing

 Do some blood tests, including TFT

 Explain the diagnosis: From our discussion so far and from my

examination findings, I suspect you have a condition called Anorexia

Nervosa. It’s an eating disorder and a serious mental health condition

 Admit if there are indications: BMI is low, if they have any

complication

 Refer to the Eating Disorder Clinic

 Refer to the Dietician to help plan their meals

 Refer to the Gym Instructor to guide her on appropriate exercise

routine

 Refer for Talking Therapy

 If you’re not admitting, give short appointment

 Safety net

 Give leaflets

 Inform Seniors

 Address other concerns

HYPOCHONDRIASIS
 GRIPS

 PARAPHRASE

 ODPARA the rash (patient thinks it’s cancer)

 Any pain?

 Any itching?

 Any discharge/bleeding?

 Relevant PMAFTOSA

 ICE

 JARSS

 Examine: no lump found on chest and hand

 Investigations: routine test

 Explain the diagnosis: From the history and examination, I don ’ t

think you have any underlying problems. There are times where we

feel we have some diseases, but in reality we don’t. Don’t worry, it’s

normal for some people to feel this way and that is what we call

Somatoform disorder

 What are you going to do for me?

 Refer for talking therapy /psychotherapy

 Medications can also be given to help cope with anxiety

 Keep a diary:

 note how often you check your body, ask people for

reassurance or look at health information

 try to gradually reduce how often you do these things over a

week

 Challenge your thoughts:

 draw a table with 2 columns

 write your health worries in the first column, then more

balanced thoughts in the second. For instance, in the first

column, you may write, “I’m worried about these headaches”

and in the second you may write, “headaches can often be a

sign of stress”

 Keep busy with other things:

 when you get the urge to check your body, distract yourself by

going for a walk, calling a friend or doing something entirely

different

 Get back to normal activities:

 try to gradually start doing things you’ve been doing things

you’ve been avoiding because of your health worries, such as

 sports, socializing, etc

 Try to relax:

 Simple breathing exercises

 Relaxation therapy like yoga, massage, listen to music, etc

 Inform Seniors

 Safety net

 Give leaflets

 Address further concerns

DELUSIONAL DISORDER
 GRIPS

 PARAPHRASE

 Establish rapport

 I can only imagine what you must have gone through all these while

with the police chasing you, it must have been a lot to deal with….

How have you been coping?

 Signpost to let patient know that the next set of questions may be

unusual

 R/O PSYCHOSIS

1. DELUSION:

Do you have any strong belief that people around you don’t agree with

you?

2. HALLUCINATION:

- Visual hallucination: Do you see (these policemen)things that people

around you don’t see?

- Auditory hallucination: Do you hear (these policemen) things that

people around you don’t hear?

3. THOUGHT DISORDERS:

- Thought Insertion: Do you feel that people are putting thoughts in

your head?

- Thought Withdrawal: Do you feel that people are removing thoughts

from your head?

- Thought Broadcast: Do you feel like your thoughts are out there even

before you say them?

 SUICIDE AND SELF-HARM:

- Suicide: Have you ever thought of taking your own life?

- Self-harm: Have you ever thought of harming yourself?

 FAMISH

 Examine

 Explain the diagnosis: I do not doubt the fact that the police are

chasing you, but sometimes there are certain beliefs we hold, which in

reality are not true and that ’ s what we call Delusional disorders or

psychotic disorders

 Admit patient: to ensure that the police does not come after you again,

we would like to keep you in the hospital.

 We would invite some of our colleagues called the psychiatrists.

They will come and see you, have a word with you and if possible give
 you some medications to help calm your mind. I can only imagine

what you ’ ve been going through. They will give you some

medications to help calm your mind and further protect you from the

police

 Inform seniors

 Safety net

 Give leaflets

 Address further concerns

COUNSELLING

PRE-OP / POST- OP ASSESSMENT

 GRIPS

 Paraphrase

 Ask how the patient is doing

 Ask about the complaints necessitating surgery

 Any signs of infections?

 Ask about Contraindications to the surgery

 Ask about Contraindications to anaesthesia

 Past medical history of conditions like HTN, DM; ask about

medications and use

 Allergies

 Emphasis on surgical history; complications of previous

surgery/anaesthesia

 Any loose teeth or dentures

 Assess living conditions

 Examination, GPE, chest, heart

 FBC, Liver and kidney function test

 Chest x-ray, ECG

 Address patient’s concerns

 Tell the patient what to expect before, during and after the surgery

 BEFORE SURGERY;

 Fast from solids about 6 hours prior to surgery

 Patient can take clear fluids up until 2 hours prior to surgery

 Withhold anti-diabetic medications on the morning of the surgery

(for diabetics)

 Complications: Bleeding, Infection, Reaction to anaesthesia… etc

 Always talk about the treatment of each complication

 AFTER THE SURGERY;

 Recovery room till full recovery from anaesthesia

 Move to general ward where he will be monitored closely

 Discharge from the ward

 He needs someone to take him home

 He needs someone to look after him for 24 to 48 hours after surgery

 Inform Seniors

 Safety net

 Give leaflets
PATIENTS WHO WANTS TO
SELF-DISCHARGE
 GRIPS

 PARAPHRASE

 I’m glad you feel better and will be more than willing to let you go

home, but can I ask a few questions

 Why did you come to the hospital in the first place?

 What were you told was wrong?

 What treatment were you given?

 Are you still having the same symptoms you came with?

 Any particular reason why you want to go home?

 Assess capacity;

 Are you aware of the treatment you’re receiving?

 Do you know the consequences of being discharged without being

certified medically fit to do so?

 Have you discussed this with your family/friends? What did they

say?

 Grade mood

 Relevant PMAFTOSA

 Examine the patient

 Explain the diagnosis: You ’ re being managed for a condition

called……..(state what’s given in the prompt)

 Dr, can’t I take these medications at home? I see you’re quite keen

on going home and we really wouldn’t want to keep you against your

wish, but these medications can only be taken IV just as prescribed by

the consultant, so you may not be able to take them at home

 But Dr I feel fine? I’m really glad to hear you’re fine, but sometimes

we can start to feel some relief, but that doesn’t actually mean that

treatment is complete. It’s important to complete your treatment, so as

to avoid complications

 Convince the patient to remain in the hospital

 Inform Seniors

 Safety net

 Give leaflets on the condition

 Address concerns
CYSTIC FIBROSIS - PRENATAL
COUNSELLING
 GRIPS

 Paraphrase: I understand you’ve got some concerns you would like to

talk to me about…… Dr, I’m getting married in a few weeks and I’m

worried about having a child with cystic fibrosis. Congratulate her and

ask why she’s worried about cystic fibrosis

 Dr, my brother has Cystic fibrosis: I can see why you’re worried and

anyone in your shoes will be worried, but do you mind if I ask a few

questions about your brother?

 How is your brother doing?

 It can be quite challenging having someone with CF, How is the

family coping generally?

 R/O Cystic fibrosis in patient: Ask the patient for history of cough,

breathlessness, diarrhoea, vomiting, bloating, etc

 Family history of CF in the patient: Apart from your brother, is there

anyone else with cystic fibrosis in your family

 History of CF in partner: Is there any of the above symptoms in your

partner?

 Family history of CF in her partner: Any of these symptoms in your

partners family?

 Relevant PMAFTOSA: smoking history

 Menstrual history

 Sexual history

 Contraceptive history

 Examine

 Explain the diagnosis l: You mentioned that you came to find out

about CF because you mentioned that you’re worried about having a

child with CF because your brother has CF…….. am I correct? So this

is what we call Pre-Conception Counselling

 Pick a pen and paper and draw the genetic diagram (optional)

 From what you told me so far, it is not likely you have cystic fibrosis

and your partner also doesn’t have any symptom of CF, however, there

is a chance you may be a carrier because of the history in your brother

 If you and your partner are carriers, the chances of having a baby with

cystic fibrosis is 1/4

 If you and your partner are carriers, the chances of having a baby

without cystic fibrosis is 1/4

 If you and your partner are carriers, the chances of having a baby who

will also be a carrier is 2/4

 If both of you are not carriers, the chances of having a baby with cystic

fibrosis is 0

 Do routine blood tests

 Moving forward, we will be referring both you and your partner to the
 Genetic Counselling and Testing Centre for genetic testing

 Can I find out before my baby is born? You can test for this during

pregnancy. Amniocentesis, chorionic villus sampling

 If I can’t do the test when pregnant and eventually deliver, can it

be done? Yes. Talk about Heel Prick Test and Sweat Test (where

necessary)

 Inform Seniors

 Offer leaflets

 Address any other concern

LEARNING DISABILITY
 Scenarios for LD;

1. DKA

2. Patient on warfarin (INR can be high or low)

3. Autism

 BASICS

- [ ] INR: International Normalized Ratio

- [ ] For patients: INR is a measure of how thick or thin your blood is

- [ ] Low INR: blood is thick and you’re likely to form clots (take history

of thromboembolic events.. DVT, P.E, MI, stroke)

- [ ] High INR: blood is thin and you ’ re likely to bleed (take history of

bleeding problems only)

 LOW INR

- [ ] DVT : pain in calf, swelling/redness

- [ ] P.E: shortness of breath

- [ ] MI: chest pain

- [ ] Stroke: weakness
 HIGH INR

- [ ] Are you bleeding from your nose?

- [ ] Any blood in your stool?

- [ ] Are you bleeding from any part of your body?

- [ ] Are you bleeding into your skin?

- [ ] Any recent history of rash (purpuric rash)?

OVERALL HISTORY FOR LD

 GRIPS

 PARAPHRASE … I can also see from your notes that you ’ ve got

some learning challenges . Am I correct?

 This learning challenge you ’ re having, is it with understanding or

remembering things?

 Moving forward, I’ll ensure that I’ll be very slow while explaining to

you and at any time you feel I’m too fast, call my attention and I’ll go

over it again

 At the end of this conversation, I’ll write everything we discussed in a

note for you to help you remember…Is that okay?

 Take history based on High or low INR

 Relevant PMAFTOSA (who does he live with…etc)

 Explain the result (low or high INR)

 Is it okay if I speak with the person you live with such that anytime

your medications is due, someone reminds you to take it?

 Ask him if he has a favorite tv program. Is it okay if we tie the

medication to your favorite tv show (for warfarin or once daily

medications)

 Ask if it ’ s okay to Get an alarm clock and set if for him. … take

medications whenever the alarm goes off

 Encourage patient to write it and paste in strategic positions in the

house

 Ensure chunking and checking is more frequent

 Inform Seniors

 Safety net

 Address concerns
FAMILIAL OBESITY
 GRIPS

 PARAPHRASE

 How much weight have you gained?

 Is it intentional?

 What were you weighing before and what do you weigh now?

 Diet: Can you tell me about your diet?

 Hypothyroidism: Do you feel cold when others are

comfortable/normal?

 Familial obesity: any family history of weight problems?

 Medications: are you on any medication like steroids

 Relevant PMAFTOSA

 Examine

 BMI

 From what you told me and from examination findings and from

BMI, you have a condition called obesity

 Dr am I fat? Just say you BMI falls within this category are

considered obese

 Smoking counseling: You mentioned that you smoke about ….. and

you’ve been smoking for the last.. am I correct? Have you ever given

it a thought to quit smoking?

 Tell them what smoking could do and how it could predispose them to

other conditions. Refer to smoking cessation clinic when patient

agrees to consider quitting

 Alcohol counseling: Also, you mentioned that you take … . alcohol.

Have you ever given it a thought to cut down?.

 Tell her how alcohol is a risk factor for other problems. Refer to

alcohol and substance misuse clinic immediately a patient agrees to

quit

 Diet: you mentioned that because you’re quite busy, you eat a lot of

junk. Am I correct?encourage her to make plenty of food during the

weekend when she’s not [Link] she agrees, immediately refer

to dietician who will help her to plan her meals.

 Exercise counseling: encourage her to create time for exercise. At

least 1hour of exercise every day for 5 days (for people who are trying

to lose weight). Encourage to do 3 sessions of 20mins each or 2

sessions of 30mins each

 Can you prescribe Orlistat for me: we don’t routinely give that until

we’ve tried the weight loss routine and other lifestyle practices and it

doesn’t work.

 Offer to speak to your senior and get back to patient if surgery is

indicated.

 Address concerns
MEASLES (TELEPHONE)
 TELEPHONE GRIPS

 PARAPHRASE

 ODPARA

 S4 C PID

 FLAWS

 Any preceding history of flu-like symptoms

 Any previous history of similar rash?

 Are you up to date with your jabs?

 Where do you live? Do you have a roommate?

 Relevant PMAFTOSA

 Examine the patient

 Explain the diagnosis

 Give pain killers

 Give anti-histamines

 Encourage to take plenty of fluids

 Can I come to the hospital myself? No, everything you need will be

delivered to you. It ’ s a notifiable disease and we need to notify the

public health department (Local Health Protection Team) for contact

tracing.

 Inform seniors

 Safety net/ Give leaflets

ALCOHOL WITHDRAWAL (TELEPHONE)
 TELEPHONE GRIPS

 PARAPHRASE

 Dr, I feel like I’m about to have a seizure

 Reassure him: Please take deep breaths and try to stay calm…etc

 The ambulance will be on its way to your house now.. Before the

ambulance arrives, can I ask you a few questions?

 Can you tell me exactly how you feel?

 Ask about last meal to R/O hypoglycemia

 Are you being managed for any medical conditions?

 Is this the first time this is happening? When it happened previously,

what were you told was wrong and what was done for you

 Have you tried to stop taking alcohol? How did you go about it? How

did it go?

 Relevant PMAFTOSA

 There is alcohol in my house, can I take some? Yes please go ahead

 From what you’re telling me, I suspect you’re having what we call

Alcohol withdrawal

 When you arrive, we’ll examine you

 We ’ ll also do FBC, LFT, RFT, check the level of alcohol in your

blood

 Give the appropriate medications/treatment when he arrives.

RELATIVE DIAGNOSED WITH BREAST
CANCER
 GRIPS

 PARAPHRASE

 It’s quite understandable that you’re concerned about cancer because

of the family history. Is it okay if I ask you a few questions

 Relevant PMAFTOSA (smoking, alcohol…etc)

 Examine

 Explain: From what you told me and from my examination findings,

you don’t have any symptom suggestive of breast cancer. But because

you mentioned a family history, we’ll do more investigations

 Blood tests, tumor markers (BRCA)

 We’ll discuss the way forward when results are out

 If I have cancer, what next? Explain all the options available

 Inform Seniors

 Safety net

 Address further concerns

SICKLE CELL DISEASE IN BROTHER
 GRIPS

 PARAPHRASE

 Dr, my brother has SCD and I’m very worried I may have it:

Acknowledge his concern and ask how his brother is doing

 You can also decide to briefly ask about the symptoms his brother has

 Any joint pains?

 Any fever/ flu-like symptoms?

 R/O anaemia: tiredness, heart racing

 Any yellowish discolouration of the eyes or skin?

 Chest symptoms: cough, chest pain

 Is he related to you by blood? OR Is he your biological brother?

 Apart from your brother, any other SCD patient in the house?

 Do you know your parents’ genotype?

 Relevant PMAFTOSA

 If patient is married, ask about spouse’s genotype; if unknown, ask

him to bring her for testing

 ICE

 Examine

 Investigations: routine, offer to repeat Genotype only if he hasn ’ t

done it in the NHS previously

 Reassure patient: From what you told me and from my examination

 findings, you don’t have SCD, but it’s possible you may have the trait.

It is so because your brother has SCD and there’s a possibility of you

being a carrier

 Explain the autosomal recessive nature of SCD:

 If both parents are carriers, the child has a 1/4 chance of having

SCD

 If both parents are carriers, the child has a 1/4 chance of not

having SCD

 If both parents are carriers, the child has a 2/4 chance of being a

carrier

 If both parents are not carriers (otherwise normal), the child has 0

chance of having SCD

 NOTE: If you find a pen and paper in that station, ensure to draw

the genetic diagram

 Can I have SCD in the future? It is not likely

 Refer to the Genetic Counselling and Testing Centre

 Inform Seniors

 Safety net

 Give leaflet

 Address further concerns

NSI - NURSE
 GRIPS

 PARAPHRASE

 Reassure her

 Did you observe universal precautions?

 What size of syringe did you use?

 What did you do afterwards? I washed my hands….

 Did you inform anyone when it happened?

 How is your patient doing?

 What is he being managed for?

 Relevant PMAFTOSA

 What ’ s your vaccination status like, HBV? When was the last time

you took your booster dose

 Commend her for first aid and informing her supervisor

 We can’t take samples from a patient without their consent

 We can go through the patient’s case note to see if there is any risk

 Samples should be collect from her for screening and saved for repeat

screening after 3 months

 Start her on PrEP if she’s concerned or if patient is high-risk

 Occupational health should be informed

 Tell her to fill an incident form

 Address other concerns

DRUG DEPENDENCY
 GRIPS

 PARAPHRASE

 Dr, I want to stop misusing drugs: Commend him: This is a big

decision you have made and I must commend you for trying to be

proactive about your health. I can assure you that this is a step in the

right direction and we’ll do our best to support you

 Offer confidentiality

 What drug are you misusing?

 How long have you been using this drugs?

 Where do you get it from?

 Who do you take it with?

 Why did you start in the first place?

 How do you take this drugs? Through my veins

 Do you share needles? Yes

 Have you heard about the Needle - Exchange Programme? They

offer fresh needles, use and return the used needles so as to get

fresh/new needles. This is done or avoid needle-sharing and by

extension, reduce the incidence of blood-borne infections

 Have you tried to stop in the past? acknowledge his concerns

 So what is the motivation now?

 Apart from heroine, do you use any other recreational drug?

 T - Tolerance: Do you sometimes need to increase the dose of this

medication just to have the same effects?

 D - Dependence: Do you need to take this drugs in order to be able

to function well?

 W - Withdrawal: In the event where you don ’ t take this drugs, so

you sometimes have symptoms like confusion, sweating, tremors, etc

 Relevant PMAFTOSA

 Examine the patient

 Explain the situation: From our discussion so far, I think what

you’ve been having is called Drug Dependency and I’m happy that

you’re here now to seek help. We’ll do our best to support you and

we’ll be with you every step of the way

 What are you going to do for me?

 Talking therapy: Talking therapies, such as CBT will help you to

see how your thoughts and feelings affect your behavior

 Medicines: If you’re dependent on heroin or any other opioid, you

may be offered a substitute, such as Methadone or Buprenorphine.

This means you can get on with your treatment without having to

worry about withdrawing or buying street drugs

 Detoxification program (Detox): This is for people who want to

stop taking opioids completely. It helps you to cope with

 withdrawal symptoms

 Support Groups/Self-help: Narcotics Anonymous

 Reducing Harm: You may be offered testing and treatment for

Blood borne infections: HBV, HCV, HIV

 Inform Seniors

 Safety net

 Address further concerns

WARFARIN - RAT POISON
 GRIPS

 PARAPHRASE

 Why did you come to the hospital in the first place?

 How are you feeling now?

 Have you been told about your condition? What were you told?

 How has the condition been managed?

 May I know why you don’t want to take the Warfarin? Acknowledge

concerns and give your condolences for the loss of patient’s father

 Any heart racing?

 Any shortness of breath?

 Any chest tightness?

 Any dizziness?

 Assess capacity to refuse treatment

 Relevant PMAFTOSA

 Examine the patient

 Explain the medication and it’s use: Warfarin is a type of medicine

known as anti-coagulant. It makes blood flow through your veins

freely and this means your blood will be less likely to make a

dangerous blood clot. It’s used both to treat blood clots and to prevent

future blood clots if you’ve had one previously, this is like it is in your

case
 Dr, I don’t want to take the medication because warfarin is a rat

poison and it also killed my father: Acknowledge and offer

condolences for the loss of his father. Indeed warfarin is used as a rat

poison, but the dose used in humans is very minute and it’s very safe.

Your safety is our priority and we’ll not give you anything that’ll harm

you.

 I just want you to be aware that we don’t want anything to happen to

you. You’ve had a clot in your leg and the medication is to ensure that

you don’t have another clot. If you don’t take this medication, you are

likely to suffer another clot. Also, this clot can move from your legs to

your heart to cause a heart attack. It can also move further to block

vessels in your lungs (pulmonary embolism) or move to your brain

and cause a stroke. We wouldn’t want any of this to happen to you

 If I start taking this warfarin, won’t I start bleeding and die like

my father? One of the side effects of warfarin is an increased risk of

bleeding, but we ’ ll be checking your warfarin levels regularly

(initially everyday till a stable dose is achieved, then at least every 12

weeks) and monitor you closely and adjust the dose accordingly.. This

will will prevent your blood from becoming too thin

 When you take this medications, we’ll need to look out for possible

causes of falls like wet floors, contact sports, use helmets while

cycling

 What if I fall? Please come to the emergency department if you’ve

had a fall, trauma to your head, you have an unusual headache or if

you were involved in any major trauma. We will do a CT scan of the

brain, in order to give you the best treatment. (This also covers for

safety netting)

 Anti-coagulant alert card (Warfarin card): It’s important that you

always carry this with you. Show it to your doctor or dentist before

you have any medical or dental procedures, including vaccinations and

routine appointments with the dental hygienist

 Inform Seniors

 Give leaflets

 Address further concerns

PULMONARY EMBOLISM - OESTROGEN
 GRIPS

 PARAPHRASE

 ODPARA shortness of breath

 Any other symptom? Chest pain

 SOCRATES chest pain

 R/O MI: chest pain, shortness of breath

 R/O Pulmonary embolism: shortness of breath

 R/O Pneumonia: any cough

 R/O DVT: any calf pain/swelling

 Relevant PMAFTOSA. Dr, I’m on oestrogen

 Medication history: Why are you taking the medication? Is this

oestrogen prescribed? How do you take them?

 TRANSGENDER HISTORY

 O - Orientation:

 Were you born a male or female?

 What gender do you identify as now

 S - Sexual History:

 Are you sexually active?

 Do you have a stable partner?

  What’s your preferred route of sexual intercourse?

 Do you practice safe sex?

 S - Support:

 Are your family and friends aware that you’re transitioning?

 Are they supportive?

 Have you heard about any support group like the LGBTQ

groups?

 Have you attended any of their meetings?

 D - Discrimination: Are you facing any form of discrimination

based on your new sexual identity?

 T - Treatment: Have you officially commenced treatment?

 ICE

 Examine the patient

 Investigation: routine, CXR, EXG, CTPA

 Explain the diagnosis: Pulmonary Embolism due to Oestrogen. PE

means there’s a clot in your legs

 Admit the patient, emphasize that’s it’s a life threatening emergency

 Discontinue the oestrogen

 Give anticoagulants

 Give painkillers

 I will speak to my seniors to see how we can speed up your treatment

 Quote to equality act of 2010 if patient is being discriminated. The

Equality act criminalizes all forms of discrimination against anyone,

on the basis of their sexual identity

 Support Groups: LGBTQ (if patient doesn’t already belong to one)

EPISTAXIS - TESTOSTERONE
 GRIPS

 PARAPHRASE

 ODPARA nose bleed

 Did you by any chance hurt your nose?

 Any nose picking?

 Any sneezing/nose-blowing?

 R/O complications: heart racing, dizzinesss

 Relevant PMAFTOSA : I’m taking testosterone and spirinolactone.

 Medication history: Why are you taking the medication? Were the

medications prescribed? How do you take them?

 TRANSGENDER HISTORY

 O - Orientation:

 Were you born a male or female?

 What gender do you identify as now

 S - Sexual History:

 Are you sexually active?

 Do you have a stable partner?

 What’s your preferred route of sexual intercourse?

 Do you practice safe sex?

  S - Support:

 Are your family and friends aware that you’re transitioning?

 Are they supportive?

 Have you heard about any support group like the LGBTQ

groups?

 Have you attended any of their meetings?

 D - Discrimination: Are you facing any form of discrimination

based on your new sexual identity?

 T - Treatment: Have you officially commenced treatment?

 ICE

 Examine the patient

 Investigations: routine, clotting profile

 Explain the diagnosis: You’re having epistaxis, which is most likely

from the Testosterone you’re taking. Testosterone imcreases BP, which

will in turn cause the nose bleed

 Admit, emphasize that’s it’s an emergency and it’s life threatening

 Discontinue the medication

 I will speak with my seniors to see how we can speed up your

transitioning treatment
 Give general advice on epistaxis

 Quote to equality act of 2010 if patient is being discriminated. The

Equality act criminalizes all forms of discrimination against anyone,

on the basis of their sexual identity

 Support Groups: LGBTQ (if patient doesn’t already belong to one)

DISCHARGE STATION
Discharge stations are counselling stations

THE APPROACH
 GRIPS: I’m Dr Mariam Ajugba, one of the doctors in………….

Ensure to smile and show that you’re happy your patient is being

discharged.

 PARAPHRASE: I understand that you were here…and you were

managed for….am I correct. I also understand that you’re being

discharged today... is that correct? How do you feel about that….

Would you mind if I ask a few questions just to be sure you’re good to

go home?

 C - Complaint: Why did you come to the hospital in the first place?

 C - Cause: What were you told was wrong?

 C - Care: What has been done for you? Have you been placed on any

medication? Has anyone explained how you should take the

medications?

 C - Compliance:Have you been taking the medications as

prescribed?

 C - Complications: Have you experienced any side-effects so far?

 Relevant PMAFTOSA: There may be some positives in the social

history (smoking, alcohol, diet, exercise)

 Examine the patient

 Explain the diagnosis

 Counsel on lifestyle modifications accordingly

 DIET:

 Scenario 1: You mentioned that you’re very busy and that’s the

reason you eat junk most of the time.. am I correct? Is it possible to

cook on weekends or when you’re off duty, refrigerate and then

microwave the food for the rest of the week? Refer to the Dietitian

if patient agrees to give it a thought.

 Scenario 2: You mentioned that you eat mostly junk because you

don’t know how to cook..Is that correct? There are food vendors

that offer healthy portions, they’re readily available and mostly

affordable.. Would you like to consider that option? Also refer to

the Dietician if patient agrees to give it a thought.

 EXERCISE: It is important to maintain a healthy weight and physical

activity/exercise plays a huge role in this

 To maintain a healthy weight: 30 mins of moderate exercises daily

for 5 days a week. You can have 2 sessions of 15 mins each.

 For patients who need to lose weight: 1 hour of moderate exercises

 daily for 5 days a week. You can do 2 sessions of 30 mins each or 3

sessions of 20 mins each

 Encourage to take the stairs instead of using the elevators…. For

instance, If going through several flight of stairs e.g 15 flights,

encourage the patient to walk from the 15th floor to the 10th floor

and use the elevator for the rest of the journey or take the elevator

from the 15th floor to the 5th floor and walk for the rest of the

journey

 Encourage to take walks home or walk some distance of home is

far.

 Refer to the Gym Instructor if patient agrees to give it a thought.

 SMOKING:

 You mentioned that you’ve been smoking… sticks daily for…..

years.. Is that correct? Smoking is harmful/detrimental to the

health; it cause damage to blood vessels, impairs wound healing,

etc so it is important that you should quite smoking. Would you

give it a thought?

 Refer to the Smoking Cessation Clinic if patient agrees to give

it a thought
 ALCOHOL:

 You mentioned that you’ve been drinking….for…..years.. Am I

correct? The recommended weekly consumption for alcohol is

about 14 units with 2 consecutive alcohol free days and anything

above that is considered harmful to the health.

 Have you ever given a thought to cutting down on alcohol?

 Refer to the Alcohol and Substance Misuse Clinic if patient

agrees…

 For chronic alcoholics, do CAGE DTW in the data gathering

 C - Cutdown: Have you ever thought about cutting down?

 A - Anger: Do you get angry when people talk about it?

 G - Guilt: Do you feel guilty when people talk about it?

 E - Eye opener: Do you drink first thing in the morning?

 D - Dependence: Do you feel like you can’t do without it?

 T - Tolerance: Do you now drink more to get the same effect?

 W - Withdrawal symptoms: Do you feel sick when you don’t

drink alcohol?

 Inform Seniors

 Safety net

 Give leaflets

 Address further concerns

EPILEPSY DISCHARGE - PAEDIATRICS
 GRIPS

 PARAPHRASE: I understand you were here and you were managed

for a condition. I also understand that you’re getting discharged today,

am I correct? How do you feel about that? Would you mind if I ask a

few questions just to be sure you’re good to go home?

 Why did you bring him to the hospital in the first place?

 How is he feeling now?

 What were you told was wrong?

 What treatment did he receive?

 Is he still having the same symptoms you came in with?

 Any new symptom?

 Elicit the risk factors … swimming, hiking, cycling, dancing,

hypoglycaemia, poor sleep, stress.. etc

 FMAM History

 Psychosocial history:

 Who takes care of him?

 Apart from you, who else takes care of him?

 Do you have support?

 Examine the patient

 Explain diagnosis: sudden burst of electrical activity in the brain

 Counselling

 Talk about “no bath tub”

 To reduce screen exposure time

 Bright light and loud noises stimulate epileptic fits

 Lifeguard must be fully aware of patient’s condition and patient

should swim in shallow areas and when the place is quiet; swim

when the place is quiet so that noise from other swimmers will not

distract the lifeguard when he’s having a fit while swimming

 Inform the dance instructor……

 To eat well

 To sleep well

 Etc (counsel based on other risk factors elicited)

 Discuss medications and emphasize on drug adherence even when

there is no fit.

 Encourage to identify seizure triggers and avoid them

 Do I need to be following my daughter everywhere he goes? I

can see that you’re quite concerned about your child any mum in your

shoes will be this concerned, but you don’t have to follow him

everywhere he goes….People around the child must know the

condition so as they can act where necessary. Also, please get an

Epilepsy Wrist-band for the child.

 What do I do if my child has a fit again?

 Do not try to stop the child from fitting

 Ensure the environment is safe

 Don’t put anything in his mouth, including medications

 Remove all tight clothing around his chest, neck etc

 Try to note the time the seizure starts and ends

 When the fit stops, put the child to lie on the left lateral side

 Call the ambulance: Ideally, if the fit lasts more than 5 mins,

sustained any injury or didn’t regain consciousness (please tell

them to call the ambulance regardless of the aforementioned)

 Is it possible for my child to ever be seizure free? Yes, but ensure

the child always takes medications as prescribed, adhere to the

management plan and come for your follow-up visits.

 Inform Seniors

 Safety net

 Give leaflets

 Address further concerns

EPILEPSY DISCHARGE - ADULT
 GRIPS

 PARAPHRASE: I understand you were here and you were managed

for a condition. I also understand that you’re getting discharged today,

am I correct? How do you feel about that?

 Why did you come to the hospital in the first place?

 How are you feeling now?

 What were you told was wrong?

 What treatment did you receive?

 Are you still having the same symptoms you came in with?

 Any new symptom?

 Elicit the risk factors … swimming, hiking, cycling, dancing,

hypoglycaemia, poor sleep, stress…etc

 Relevant PMAFTOSA (smoking, alcohol, hobbies, work, living

conditions…etc)

 Do you drive?

 Living Conditions

 Who do you live with?

 Is the person supportive?

 ICE
 Examine the patient

 Explain diagnosis: Duden burst of electrical activity in the brain

 Counselling

 Talk about “no bath tub”; shower instead of using a bathtub

 To reduce screen exposure time

 Bright light and loud noises stimulate epileptic fits

 Lifeguard must be fully aware of patient’s condition and patient

should swim in shallow areas and when the place is quiet; swim

when the place is quiet so that noise from other swimmers will not

distract the lifeguard when he’s having a fit while swimming

 Install smoke detectors to let you know if food is burning or you

forget what you’re doing or have seizures and lose consciousness.

 To cover edges of surfaces/furniture that are sharp or stick out

 To eat well

 To sleep well

 Counsel on alcohol/smoking if positive

 Etc (counsel based on other risk factors/social history elicited)

 Discuss medications and emphasize on drug adherence even in the

absence of fits.

 Are there side effects of this medication (Sodium Valproate): Just

 like every other medication, this medication has side effects, but they

may be mild and resolve over time, but if it doesn’t, there are

medications we can give you

 Side effects of Sodium Valproate

 Headache

 Abdominal discomfort

 Nausea

 Diarrhoea

 Weight gain

 Thinning of the hair… etc

 Encourage to identify seizure triggers and avoid them

 Encourage to get an Epilepsy Wrist-band so everyone know about

you condition and act swiftly in the case of an emergency.

 What do I do if I have a fit again?

Please inform family/friends around about what to do, they should;

 Not try to stop you from fitting

 Ensure the environment is safe

 Not put anything in your mouth, including medications

 Remove all tight clothing around your chest, neck etc

  Try to note the time the seizure starts and ends

 Put you in recovery position (left lateral position)

 Call the ambulance: Ideally, if the fit lasts more than 5 mins,

sustained any injury or didn’t regain consciousness (please tell

them to call the ambulance regardless of the aforementioned)

 Encourage to stop driving and Inform the DVLA; If you’re

seizure-free for a year, they may consider reviewing your license to

resume driving.

 Is it possible for me to ever be seizure free? Yes it is, but it is

important that you try to adhere strictly to the treatment plan and

attend your follow-up visits.

 Support Groups: Epilepsy Action, Epilepsy Society… etc

 Inform Seniors

 Safety net

 Give leaflets
MYOCARDIAL INFARCTION - DISCHARGE
 GRIPS

 PARAPHRASE

 Why did you come in the first place?

 What were you told was wrong?

 What has been done for you?

 Are you still having those symptoms?

 Any new symptom?

 Have you been placed on medications? Have they told you how to

take them? Do you understand? Do you have questions with regards

your medications?

 R/O complications

 Relevant PMAFTOSA

 ICE

 JARSS

 Examine the patient

 Explain the diagnosis: From our discussion so far, what you had

was a Myocardial Infarction. MI (heart attack) is a serious medical

emergency in which the supply of blood to the heart is suddenly

blocked, usually by a blood clot. Lack of blood to the heart may

seriously damage the heart muscle and can be life-threatening

 Counsel on Diet, Exercise, Smoking, Alcohol (as necessary based

 on scenario)

 Stop driving and inform the DVLA ( if the patient drives )

 When can I drive? 4 to 6 weeks

 When can I have sex? 4 to 6 weeks, but if you feel well earlier and

you can climb 2 flights of stairs without feeling breathless, you can go

ahead

 When can I get back to work? 4 to 6 weeks

 Talk about Bisoprolol and it’s side effect: Erectile dysfunction

 Talk about the side effects of the other medications and the antidote

 Address concerns

 Inform seniors

 Safety net

 Give leaflets
FOLLOW - UP STATION

THE APPROACH
 GRIPS: I’m Dr Mariam Ajugba, one of the doctors in……

 PARAPHRASE

 Why did you come to the hospital in the first place?

 How are you feeling now?

 C - Complaint: Why did you come to the hospital in the first place?

 C - Cause: What were you told was wrong?

 C - Care: What has been done for you? Have you been placed on any

medication? Has anyone explained how you should take the

medications?

 C - Compliance: Have you been taking the medications as

prescribed?

 C - Complications: Have you experienced any side-effects so far?

 Are you still having the same symptoms you came in with?

 Any new symptom?

 Relevant PMAFTOSA

 Examine the patient

 Explain the Diagnosis

 Give lifestyle/medication advice where necessary

 Inform Seniors
 Safety net

 Give leaflets

 Address all concerns

AUTISTIC SPECTRUM DISORDER
 GRIPS

 PARAPHRASE.. I understand you’re here for follow-up

 Why were you in the hospital in the first place?

 What were you told was wrong?

 What has been done?

 Does this child maintain eye contact?

 If you cuddle him, does he cuddle back?

 Does he play with other kids?

 Does he have any particular repetitive behavior?

 Does he have any particular preference to colours or toys

 PAMGUDU

 PBINDS

 FMAM

 From our assessment, a diagnosis of Autism Spectrum D has been

made.

 Do you know what it means? ASD is When a child has problems

interacting with people and their environment

 What are you going to do for us? I’m going to refer you to the The

Autism Clinic, which is a multi disciplinary clinic with different

specialists.

 In the event where he develops and speech or language challenges,

 We have the SPEECH AND LANGUAGE THERAPISTS

 Most autistic children are prone to having behavioral problems

(tantrums), don ’ t worry, the BEHAVIOURAL THERAPISTS will

be there to give the child all the support

 They could also have psychological issues; the PAEDIATRIC

PSYCHOLOGIST will be there to address these issues

 Will he be able to go to school with other children? Since he has

learning challenges, we’ll put him in special schools (if it’s not given

that the child is already in school, mention that you ’ ll put him in a

regular school first and if he doesn ’ t cope, he ’ ll be transferred to a

special school)

 We ’ ll involve the OCCUPATIONAL HEALTH PHYSICIANS

who will come to the house to see what changes need to be made to

make the child comfortable. Bright light, loud sounds can stimulate

autistic problems

 Could this be as a result of MMR vaccine that was given? MMR

vaccine is safe and it does not cause autism

 Refer parents for counselling sessions to help them cope with the

diagnosis
OPHTHALMIA NEONATORUM
(CHLAMYDIA)
 GRIPS

 PARAPHRASE: I understand you were 10 days ago and your son

was admitted. Am I correct?

 I also understand that a swab was taken from his eyes and you’re here

for the result. Am I correct?

 I’m here to share the result with you and address any concern you

may have, but would you mind If I ask a few questions just to be sure

we’re on the same page?

 Can you bring me up to speed as to why he was admitted in the first

place? I ’ m sorry about that.. I can only imagine what you went

through having a child who is barely a few days old come down with

this. But I’m glad you’re here and we’ll try to help you.. Is that okay?

 What treatment was given?

 How is your child now?

 Is he still having eye discharge?

 Any other new symptom?

 Any problem with his wee?

 Any problem with his poo?

 PBINDS

 PMAM
 Mum’s history:

 How are you?

 How are you coping with being a new mum?

 Do you have support?

 Have you been managed for any medical condition?

 Have you ever been managed for any STI in the past?

 Ask similar questions for spouse

 If your son was here, I’d have loved to examine him, but I would like

for you to bring him so we can examine and assess him, is this

something you’re willing to do?

 The result of the swab taken cultured a bug called chlamydia and

your child may have got it from you during delivery. But I’m glad your

child is currently on antibiotic and is fine

 I’ve never had any other partner…. Is it possible my husband is

cheating on me? That’s not what I’m saying, but just to mention that

this bug can be in someone ’ s system for a very long time. If your

husband had previous partners, this may have been in his system for a

long time and it doesn’t mean your husband is cheating.

 I must have brought this upon my child, I feel terrible…. Oh no,

you’re a wonderful mum. Bringing him means you mean well for your

child
 Is it okay if we refer you and your partner to the Sexual Health clinic

just to double-check that everything is fine?

 Address other concerns

 Inform Seniors

 Give Leaflet

 Safety net: If for any reasons he begins to have same discharge or any

other discharge, please bring him to the hospital.

POLYMYALGIA RHEUMATICA (PMR)
 GRIPS

 PARAPHRASE

 Why did you come in the first place?

 What were you told was wrong?

 What has been done for you?

 What medications are you on?

 Any side effects?

 R/O Risk factors

 R/O complications e.g giant cell arteritis

 Relevant PMAFTOSA

 ICE

 Examine the patient

 Explain the medications and their uses

 Investigations: routine including CRP, ESR)

 Explain the diagnosis: PMR is a condition where the body ’ s

immune system is attacking the body

 Encourage to continue steroids

 Offer to taper the dose instead of stopping it outrightly

 Counsel on the effect of stopping steroids abruptly

 Counsel on how to take steroids in a way that minimizes side effects:

e.g take medication with food to prevent heartburn

 Lifestyle modification

 Offer the Blue card if patient doesn’t already have one

 Address concerns

 Inform seniors

 Give leaflets

 Safety net: side effects of steroids

STATINS
 GRIPS

 PARAPHRASE: I understand you were here…

 Has any explained the results to you?

 Establish risk factors (smoking, alcohol, exercise)

 Relevant PMAFTOSA

 ICE

 Examine

 Explain the results (start with the good one)

 Explain what Q-risk is? Risk of you having cardiovascular events in

the next 10years

 Your q-risk is elevated and from what you told me, there are some

things I identified from your story that could be pointing towards the

direction

 Smoking: you mentioned that you ’ ve been smoking for … am I

correct? Have you thought about quitting? Explain why it’s important

to quit smoking. Refer to smoking cessation clinic the moment patient

considers quitting.

 Alcohol: You mentioned….. Refer to Alcohol and substance misuse

clinic

 Diet: you mentioned that you’ve been eating basically junk and you’

ve not had time to cook because of your busy schedule.. am I correct?

 Have you considered cooking home made meals during the weekend

and microwave to eat during the week… Once patient agrees to diet

plan, refer to Dietitian

 Exercise:1 hour every day for 5 days to lose weight. 30mins everyday

for 5 days to keep fit

 Inform Senior

 Safety net

 Give leaflets
TEACHING STATION

THE APPROACH
 GRIPS

 Introduce yourself by your first name: Hi, I’m Mariam one of the FY2s

in… (you can say FY2 because you’re speaking to a colleague and

they understand what FY2 means)

 Ensure you let the person know he can call you by your first name, not

to call you Dr l

 Be very cheerful and informal

 PARAPHRASE:

I understand that you want to……. (“I can see from my notes” is a bit

formal when speaking to colleagues)

 ESTABLISH RAPPORT:

 How are you doing?

 How’s your posting going?

 What rotation are you doing now? (For Medical Students)

 Hope you’re getting a hang of everything? Not to worry, it may

seem vague now, but with time it’ll become clearer

 Are you having any challenges with work? Please let me or any of
 our colleagues know if you’re encountering any challenges and

we’ll do our best to help you/figure it out, okay?

 INTEREST:

 So what spurred your interest to learn about… OR Why do you

want to learn about….? Commend knowledge seeking behaviour.

It’s important to ask this question because sometimes they may say

they missed the class where it was taught because they were sick or

their mum was sick; so it’s a good opportunity to throw IPS and

ask how they’re feeling now or how their mum is doing.

 What exactly would you like to learn about….

 KNOWLEDGE:

 So what do you know about? OR

 Do you have an idea what….. is all about? OR

 Could you please tell me what you know about…….?

 Etc…..

 RESPONSE:

 What you’ve said is correct, but let me explain a bit further and

build on what you already know, is that okay?

 It’s okay if you don’t know anything about it for now and that’s
 why I’m here and hopefully after this session, you’ll have an idea

of what…. is all about. How does that sound?

 TEACHING PROPER: So I’m going to teach you…. using this

outline;

DIMPIA

 Definition

 Indication

 Materials (USED FOR PROCEDURES)

 Procedure (USED FOR PROCEDURES)

 Interpretation (USED IN PROCEDURES)

 Adverse Effects

 SAFETY NET (do it before the teaching proper or when you get the

“2 minutes remaining timer”)

 In the event where we’re unable to complete this, would you mind

if I send you reading materials/links to NHS websites?

 Also, is it okay If call you when next I see a case of….

 Anytime you see me, we can pick up where we left of, is that okay

with you?

 Ensure to chunk and check

EPIPEN
 There are two pens and one anti-histamine

 To always carry the kit around

 Find out the patient’s weight

 Epipen >25kg (yellow)

 Epipen junior < 25kg (green)

 Encourage mother to stay calm

 Lay patient flat and raise his legs above his chest

 If unconscious, turn patient to the side

 HOW TO USE THE EPIPEN

 Take Epipen out of the case and hold with dominant hand

 Wrap your fingers around the Epipen like you’re making a fist

 Don’t cover the end of the pen

 The pen has a blue end (to the sky) and an orange end (to the

thigh)

 Jab the upper outer part of the thigh with the orange part in one

firm and swinging motion

 You will hear a click when you jab the thigh

 After jabbing, count to 3 elephants (1 elephant, 2 elephants, 3

elephants)
 Call 999 and inform them. Say the word “ anaphylaxis ” or “ severe

allergic reaction”

 Ask mother to repeat what you said

 Encourage mother to stay with the patient during the anaphylaxis

 If after 5 mins, patient is not better and ambulance is not there, use the

second Epipen

 If he’s feeling well enough, give the antihistamine

 Take patient to hospital whether there’s full recovery or not

 Epipen is single use only so exchange it when you get to the

emergency room

 HOW TO CARE FOR THE EPIPEN

 Make sure the clear window is always clear; if it looks cloudy or

brown , change it

 On the first day of every month, look at the expiry date. If it has

expired, take it to be exchanged

 Tell everyone around about the patient ’ s allergies, they should know

how to use the Epipen and avoid things patient is allergic

 Give leaflets

 Address concerns
INFORMED CONSENT
 GRIPS

 PARAPHRASE

 ESTABLISH RAPPORT

 INTEREST

 KNOWLEDGE

 RESPONSE

TEACHING PROPER

 What is an Informed Consent

Informed consent means that before you do anything for a patient, you

must inform them and get their consent

 Types of consent

 Written Consent: Patient agrees and puts it in writing

 Verbal consent: Patient agrees verbally, but doesn ’ t put it in

writing

 Implied consent: Patient makes gestures or body language

without to show/imply that they give consent. For instance, rolling

up his sleeves when you say you want to collect sample,

undressing when you say you want to examine, etc

 When to take consent

 Consent is taking when you need to do anything for a patient.

 For instance;

 For examinations

 For minor procedures like IV line, sample collection, etc

 For major procedures, etc

 The right person to seek consent

Ideally, the person actually treating the patient should seek the patient ’ s

consent. However, you may seek consent on behalf of colleagues if you

are capable of performing the procedure or if you have been specially

trained to seek consent for that procedure. If you do not feel you know

enough about the procedure to take consent, you MUST ask a senior

colleague to take consent

 Assess Capacity

To assess capacity, check that patient

 U - Understand: understands all you’ve said

 R - Retain: is able to retain the information

 W - Weigh: can weigh the benefits/risks

 C - Communicate: can communicate all you’ve said when asked

 Validity of Consent

 C - Capacity: Patient must have capacity

 I - Informed: You must give a clear explanation of what you want

to do, the risks involved, other procedures which may be required,

after care, length of hospital, expected length of leave from work

(used where necessary), etc

 V - Voluntary: Patient must not be coerced into agreeing

 Special Circumstances

 Next of kin (NOK) can consent to procedures if patient doesn ’ t

have LPoA. However, if NOK ’ s decision is not in patient ’ s best

interest, the managing team makes the decision

 Patient doesn’t have next of kin or LPoA: the managing team will

determine what’s best for the patient

 Unconscious patient: no consent required. Save their lives first,

but explain everything when patient becomes conscious

 You don ’ t need a chaperone to take consent, but you need a

chaperone when you’re about to carry out the procedure

 Consent for Children

 Children who are 16 and above are technically adults, so they can

give consent to their own treatment

  If a patient is less than 16, consent is taken from parents or

guardian, however, if a 14 year old has capacity/Gillicks

competence , consent can be taken from him.

 A patient’s biological mother can always give consent

 Father can give consent if parents are married and he’s the

biological father OR if father is named on the birth certificate,

irrespective of marital status

 In life-threatening conditions, treatment can be given to a child

irrespective of parents views or beliefs

 Types of Consent Forms

 Form 1: For adults who have capacity and will be having

anaesthesia like GA

 Form 2: For an adult giving consent for a child

 Form 3: For adults or children going for procedures that don’t

require sedation

 Form 4: For adults who lack capacity and the form should be

completed by the professional doing the procedure. Where this is a

member of staff who does not know the patient, then it should be

completed by the referring doctor making the decision in the

patient’s best interest. An example of where it’s used it’s in

patients with moderate/severe cognitive impairment

URINE DIPSTICK
 GRIPS

 PARAPHRASE

 ESTABLISH RAPPORT

 INTEREST

 KNOWLEDGE

 RESPONSE

DIMPIA
DEFINITION

Macroscopic way of assessing and interpreting the urine

INDICATION

For conditions like UTI, DKA, Pregnancy, etc

MATERIALS

 Urine sample

 Dipstick

 PPE like gloves, gown/apron, etc

 Paper

 Stop watch

 Clinical waste, etc

 PROCEDURE

 Wash your hands and wear PPE

 Examine the Urine

Ensure that the patient’s details are correct

Colour:

 Straw/amber: Normal

 Deep amber: Concentrated from dehydration, etc

 Cloudy: UTI, etc

 Blood: Renal stone, UTI, Nephropathy, etc

 Brown: Suggestive of bile pigments (jaundice), myoglobin

(rhabdomyolysis), medications like choloquine, etc

 Frothy: Proteinuria

Smell: Rarely done in practice

 Offensive: UTI

 Sweet: Glycosuria

 Dipstick

 Ensure the pack of strips is tightly closed to prevent oxidization

 Ensure to check the expiry date

  Dip one strip into the urine sample and ensure all the reagent

squares are fully immersed and bring it out immediately

 Remove the strip immediately and gently shake off excess urine

 Place strip horizontally/flat on the paper towel to avoid

cross-contamination of the reagent squares

 Start the timer and record each reading based on their timing,

usually between 30 to 60 seconds

 Discard the strip and PPE into the clinical waste after interpreting

 Wash your hands

INTERPRETATION

The strip is colour coded to allow for easy interpretation and only

interprete what you see

The parameters to be interpreted are as follows;

 Glucose: Diabetes, etc

 Bilirubin: Jaundice

 Ketones: DKA

 Specific gravity:

 Normal range: 1.002 - 1.035 mOsm/kg

 Low SG: Diabetes Insipidus, Acute Tubular Necrosis, etc

 High SG: DM, Nephrotic syndrome, etc

 PH:

 Normal range: 4.5 to 8.0

 Low ph: starvation, DKA, etc

 High ph: UIT, medications like diuretics, etc

 Blood: UTI, Renal stone, Myoglobinuria,, Nephritic syndrome, etc

 Protein: Nephrotic syndrome, DKA

 Nitrites: UTI

 Urobilinogen:

 Normal range: 0.2 - 1.0mg/dl

 Low urobilinogen: Biliary obstruction

 High urobilinogen: Haemolysis from haemolytic anaemia, malaria,

etc

 Leucocyte esterase: UTI, any condition that could cause haematuria

TO COMPLETE THE EXAMINATION

 Summarise your findings

 Document the urinalysis results.

 Suggest further investigations/care based on urinalysis results.

ELECTROCARDIOGRAPHY (ECG)
 GRIPS

 PARAPHRASE

 ESTABLISH RAPPORT

 INTEREST

 KNOWLEDGE

 RESPONSE

TEACHING PROPER

 I’m going to start teaching you about the ECG now, but In the event

that time doesn’t permit us today, I’ll be sending you a link or giving

you reading materials. Anytime I see an interesting ECG, I’ll call you..

Is that okay?

 Give an outline

 Pick up your pen and paper and draw the ECG tracing OR Ask if they

have an ECG strip with them

 Usual ECG strips:

 Normal ECG

 ST Elevation

 Tall tented T waves

 Complete heart block

 So the ECG is plotted, voltage against time in an iso-electric line

 Do you know what an iso-electric line Is? It’s the point where the

charges are neither positive nor negative

ANATOMY

 The heart has four chambers, two atria and two ventricles

WAVES

 Waves: There are basically 3 waves; P-wave, QRS complex, T-wave

 P - wave: atrial contraction which is also atrial depolarization

 QRS Complex: Ventricular contraction which is ventricular

depolarization

 T wave: ventricular relaxation which is ventricular repolarization

 Did you notice I didn’t mention atrial repolarization? It’s because

it ’ s buried within the QRS complex. The atrium relaxes when the

ventricles are contracting, so the atrial relaxation goes unnoticed

RHYTHM

 There are 2 rhythms

 Sinus rhythm: every p- wave must be followed by a QRS complex

 Non-sinus rhythm: absent p-wave

 RATE

 Rate: regular and irregular

 Regular heart rate is between 60 to 100bpm

 Regular rate:

 300/ number of big boxes between R-R interval OR

 1500/number of small boxes between R-R interval

 Irregular rate:

Number of R-R intervals in 30 big boxes X 10

 Describe the pathology on the ECG strip available

 Address concerns/questions

 Recap/summarize (if you still have time)

PATIENT CONFIDENTIALITY
 GRIPS

 PARAPHRASE

 ESTABLISH RAPPORT

 INTEREST

 KNOWLEDGE

 RESPONSE

 Define patient confidentiality

 Patient confidentiality refers to the right of patients to keep their

records private and represents physicians’ and medical

professionals’ moral and legal obligations in handling patients’

sensitive medical and personal information

 It also means that medical professionals cannot legally share

patient’s information without their consent

 Explain the importance of confidentiality

 It helps to build trust between patients and medical professionals

 To protect patient’s information against improper disclosure

 It help to support the needs of both the patient and the physician

 Confidentiality is one of the main elements of the good medical

practice, etc
 Obligations for all Staff

All Staff must;

 always ensure to maintain patient confidentiality

 not discuss confidential information with colleagues without

patient consent (unless it’s part of the care)

 not discuss confidential information in a location or manner that

allows it to be overheard

 handle patient information received from another prover

sensitively and confidentially

 not allow confidential information to be visible in public places

 store and dispose of confidential information in accordance with

the Data Protection Act of 1998 and the Department of Health’s

Records Management Code of Practice (Part 2)

 not access confidential information about a patient unless it is

necessary as part of their work

 not to remove confidential information from the premises, unless

it’s necessary to do so to provide treatment to a patient, the

appropriate technical safeguards are in place and there is

agreement from the information governance lead

 Scenarios where confidentiality may be breached

You have the right to tell the medical professional if you don’t want your

personal health information to be shared in a particular way or to specific

people. This right is an important legal and ethical duty, but it is not an

absolute right

In some circumstances, NHS can use your information without your

permission if;

 You lack capacity to give your permission

 Court order

 Cases of public interest: to prevent the outbreak of a disease or

crime, etc

 Violence committed against a child or other vulnerable person

 Address concerns
PROCEDURES

THE APPROACH
 GRIPS

 PARAPHRASE

 ESTABLISH RAPPORT

 INTEREST

 KNOWLEDGE RESPONSE

 DIMPIA

 ADDRESS CONCERNS
PARACETAMOL OVERDOSE -
VENEPUNCTURE
 GRIPS

 PARAPHRASE

 I ’ m here to have a chat with you and take blood samples for some

tests, but before I do do I ’ d like to ask a few questions; is that okay

with you?

 What medication did you take?

 How many tablets did you take?

 When did you take it?

 What did you take it with?

 Symptoms of overdose: abdominal pain, jaundice, nausea, vomiting,

etc

 Relevant PMAFTOSA: medications, allergies, liver problems

 Examine

 Thank you for answering my questions. I’d like to proceed to take the

sample

 Describe procedure: it ’ ll involve me pricking your hand and taking

some blood samples for testing. Do I have your consent to proceed?

 Any arm preference?

 Any needle phobia? Offer to use a smaller needle or numbing agents

like lidocaine cream if patient has a phobia for needles

 Any arm soreness?

 Any bleeding disorder?

 Are you on any medications like blood thinners?

 Equipment: I’d like to get my equipments/materials

 Alcohol swab

 Tourniquet

 Syringe and needles

 Plaster

 Sample bottles

 PPE, etc…

 Inform patient of the incoming sharp scratch

 Take 3 samples

 Blue bottle: clotting profile

 Yellow/golden bottle: Chemistry; PCM level and LFT

 Purple: FBC and differentials

 Remove tourniquet

 Clean patient

 Discard your needle in the sharp box/others in the clinical waste

 Verbalize that the sample will be labelled and taken to the lab

 See paracetamol chart…So we’ll be plotting your paracetamol level

on the Paracetamol Nomogram…

 Your paracetamol level is above the treatment line so we will need to

treat you with a medication called N-Acetyl Cysteine (NAC)

 This is an emergency and it will require you to be admitted….

 This medication will be given to you through your vein at 3 different

doses over a 21-hour period

 1st dose: 150mg/kg given over 1hour

 2nd dose: 50mg/kg given over 4 hours

 3rd dose: 100mg/kg given over 16 hours

 When you’re much better (after Medical management), we’ll involve

a talking therapist (Clinical Psychologist)

 Refer to the Psychiatrist after a medical management

 NOTE: Pink bottle: grouping and cross matching for simmans

AFTER CARE

 How do you feel?

 Any pain/discomfort?
ABG SAMPLING
NO NEED TO TAKE HISTORY

 GRIPS

 I ’ m here to take your blood samples from you for an ABG test to

enable us determine the level of oxygen and other gases in your

blood. Do I have your consent to proceed?

 Any arm preference?

 Any arm soreness?

 Any needle phobia? Offer to use a smaller needle or numbing agents

like lidocaine cream if patient has a phobia for needles

 Any bleeding disorder?

 Are you on any medications like blood thinners?

 Have you got an A-V fistula?

 Can you please roll-up your sleeves?

 Alen’s test: The test assesses for the integrity of blood supply in your

[Link] patient to open their palms, clench their fist, use your both

hands to occlude both the ulnar and the radial artery, tell patient to

open their hand and you see that the palm becomes very pale. Release

the ulnar pressure but still put pressure on the radial side. Look out for

ulnar reflush. Verbalize that ulnar reflush is within 15secs

 DON’T TIE TOURNIQUET

 Palpate the radial artery

 Clean with alcohol wipes

 Inform the patient of the incoming sharp scratch

 Collect sample using ABG needle at the radial pulse at an angle of 45

degrees

 YOU ’ RE EXPECTED TO PRICK THE PATIENT ONLY

ONCE, after which you involve your seniors

 Don’t empty the blood from the syringe

 Discard your needle in the sharp box and other materials in the

clinical waste

 I’ll be running this test now and the rest should be back in 5mins, in

the event where the machine is faulty, I’ll label the sample and take it

to the lab myself

 We’ll discuss the results with you when it’s ready

 Address concerns (if any)

AFTER CARE

 How do you feel?

 Any pain/discomfort?
GENERAL TIPS
1. Explain every component and confirm patient understands before

moving on to the next segment

2. You don’t need to make diagnosis to pass your exam

3. You must follow principles/patterns

4. Don’t rush to R/O differentials when you’re not certain

5. Stop all offending medications in A& E, solve the problem and then

send to their GPS to modify the medications.

6. If you ’ re unsure whether or not to prescribe a medication say “ is it

okay if I speak with my seniors with regards this medication and get

back to you?”

7. You can say anything that’ll be of benefit to patient’s care, but ensure

to complete the original task.

8. Don’t let the exam overtake you, you’re still a doctor

9. Confidentiality is not yours, give it copiously

10. Anytime you’re explaining results to patients, Always tell them the

good/normal ones first

11. The things contraindicated in patients conditions is what they love to

do

12. On that day, to avoid distractions close your ears with your right and

left index fingers

13. Ensure to acknowledge patient’s emotions

END OF PROFORMA