COMMON GMC QUESTIONS AT A GLANCE

Pain management in terminally ill1. Find out what are the concerns

2. Reassure that you will not be in pain

3. Explain different type of medications-Simple pain killers like paracetamol, NSAIDs-slight stronger medication like codeine, tramadol-very strong medication called opiates like fentanyl, diamorphine, morphines. 4. Explain medications available in different i.e tablets, injection and through the pump.

5. We will start giving you these medications in a tablet for and we will increase the dose until we control the pain and if we fell to control your pain with tablets, we will give what we call a morphine pump.

6. Morphine pump is a pump in which we put pain killers like morphine and other medications which will help you to be comfortable. Reassure that he/she will not be in pain

Lower abdominal pain in a young patient history taking

1. SOCRATES of abdominal pain2. Rlue out differentials3. P3MAFTOSA4. Give diagnosis or differential diagnosis depending on the question.

Post operative pain managementpatient was in severe pain during last operation, now he has is concerned

1. Introduce yourself.2. Find out what are the concerns3. Apologise for his experience during last admission.

4. Reassure that we will make sure not in pain this time.5.Find out what analgesia he had during last admission5. Will give strong painkillers through your veins with a help of morphine pump ( syringe drive)6. Will then change the it to oral morphine, then will step down to simple analgesia once your pain has improved. And eventually will not need analgesia.

Insulin dose calculation – 2 units in 500 ml bag

1. Ask for sterile areaSay Ideally I will do all the preparation with a witness, can I ask you to be my witness2. Do the calculations on a piece paper3. Check the name of medication, strength, expiry date. Expiry date of syringes and normal

saline. Check its normal saline and the amount of normal saline e.g. 500ml bag4. Draw the insulin and show the examiner by putting it on the sterile area5. Insert the medication into the bag if the question says so.6. Dispose the needle into the sharp bin.7. If you inserted the medication into the bag then label the name, hospital number, date of

birth and concentration of medication.

NB: 1. In the exam the question may state do not insert /insulin medication into the bag.

Anorexia nervosa1. Introduce yourself know the name of the patient2. Confidentiality3. Take history, do not ask why are you in hospital today. Say I understand……………..4. Questions about amenorrhoea, weight loss, diet, social life, role model, Insight.5. Rule out other differential diagnosis( Hyperthyroidism, malignancy, bulemia nervosa)6. Give diagnosis7. Discuss management -dietician to help you mentain your weight and eat properly as well-Do blood test to make sure that you are not dehydrated and if on blood test ok will refer you to a specialist in this area- psychiatrist.If there will be anything wrong with the blood test we will admit you.

Dysphagia – history taking1. ODPARA of dysphagia2. Differential diagnosis3. Finish P3MAFTOSA3. diagnosis or differentials according to the question.

Menorrhagia1. ODPARA of menorrhagia.2. Rule out differential diagnosis3. Finish P3MAFTOSA

Febrile convulsion.1. Take only relevant history-fever-fit-duration of fits-Any previous episodes of fits-Any family history of febrile convulsion-Age of the child

2.Rule out diferential diagnosis( Epilepsy, Hypoglycaemia, meningitis, Otitis media, UTI)3. Rule out head injury during the fit 4. Give diagnosis( febrile convulsion) 5. Definition of febrile convulsion – a fit which is usually caused by fever6. Find out the concerns of the patient7. Counselling: -sometimes runs in the family -May happen again -Its not epilepsy -does not cause epilepsy -during seizure child can sustain head injury

-during seizure remove all dangerous object -after seizure bring the child to hospital immediatly -If seizure does not stop within 5 minutes please call an ambulance8. 8. You can prevent seizure by dressing you child lightly, giving him paracetamol and giving him a sponge bath when ever his temperature is high. Peanut allergy.1. Take history of presenting complaint2. Take focused history ( wheeze, sob, tongue swelling, facial & neck swelling, collapse), previous episode, family history, Past medical history3. Disclose diagnosis-peanut allergy4.Explain what it is5. Reassure. We are here to help you -condition can be avoided, -avoid eating foof containing peanut-Refer to dietician6. Find out concerns7. medication-anti-histamine for the nesxt 2 days, keep some home in case has another allergy8. If happens again youcan again use anti-histamine9. if any sign of anaphylaxis ( wheeze, any noise breathing, facial swelling, neck swelling, swelling of the tongue, difficulty in breathing) Say we will give you medication called adrenaline in a device called EpipenYou inject through the thigh-I will ask one of the nurses to demonstrate how to use it.10. Do not use the epipen if there are no signs of anaphylaxis.

Lung cancer – Breaking bad news.1. check who you are speaking to2. check how much patient knows3. Break the news in layers4. show sympathy and empathy5. Explain the cancer is at the stage where we can not cure.6. explain that we will give palliative therapy i.e pain relief and radiotherapy to relieve the symptoms 7. check if the question contain how long patient has remaining for him to live and make sure you tell him that.( last time it was 6 months)8. Multidisciplinary team-pain team, physiotherapist, oncologist.Other help-Mcmillan nurses, social services.

9. Offer leaflets and websites and support groups. Hip examination1. Gait2. Inspection3. Trendelenburg test4. Look- DRSSS , muscle wasting 5. feel – temperature + tenderness6. move – flexion & extension , internal & external rotation , abduction & adduction7. special test-Thomas test and Tronchateric thump tests.8. Diagnosis - osteoarthritis9. Management: only if required – pain killer , physiotherapy , rest , follow up in clinic steroid injection, surgery. Heart failure – Management lifestyle modification

1. If he is being discharged show a smile it’s a good news.2. Talk about lifestyle modification. -stop smoking,- Diet-reduce saly intake and fat food, and refer to dietician.

- reduce alcohol -exercise, refer to gym instructor.3. Check for concerns all the time

Rectal bleeding in a child – history taking.1. ODPARA of rectal bleed.2. Rule out differential diagnosis3. Finish P3MAFTOSA4. Rule dehydration5.Give diagnosis and/or differential diagnosis

NB: do not forget to rule out gastroenteritis and intussusceptions..

Assess child for anaesthesia. 1. Check they are aware they are having an operation.2. Rule out systemic symptoms GIT: diarrhoea, vomiting, abdominal pain Renal: dysuria, frequency, CVS: chest pain, palpitationRS: fever, cough, running nose, difficulty in breathingCNS: headache, dizziness3. PMH: Diabetes, Asthma, Epilepsy, (Child diabetic type 1 and on insulin)4. Management- Nil by mouth a day before operation from midnight-No insulin in the morning-Will check the Blood glucose in the morning of the operation-If needed will give insulin through the drip.-check concerns from time to time-will take to theatre, put to sleep and details of a operation will be discussed by the anaesthetist-after the operation will come to the ward, depending how he is doing will may keep him in or send you home at the end of the day.-Keep checking the concerns Blood transfusion – Counselling.1. Explain that we found her/him to be anemic2. Needs blood transfusion2. Blood from donors, who are healthy people 3. Blood is checked for infections like HIV, Hepatitis, and other bags4. This blood will be given through the vein.5. Check how many units prescribed.6. Each units takes 4 hours, therefore if 2 units it will take 8 hours. Check the number of units and explain how long it will take.7. We will hang blood on the stand and you will be lying down on the bed.8. Explain the risk: -infections but we do screen the blood, --reaction to blood but will keep a close eye, -wrong blood but we have taken due care by checking your blood first and it does

much very well with the blood we are giving you-You may develop temperature, or feel unwell genenerally in such case we will stop the blood transfusion and try to restart it later-During transfusion you can eat or drink.9 Explain will repeat blood test once your blood transfusion has finished to check if you blood levels have picked up.

Unconscious patient primary & secondary survey done1. GCS2. Neurological exam-reflexes-tone-pupils-PlantarsNB: GCS CHART IS THERE IN EXAM

Pain management – back pain1. Clarify what the analgesia have been prescribed for him2. Reassure that we have different type of analgesia3. Go through all analgesia-simple ones like paracetal & NSAIDs like ibuprofen-Slight stronger ones like codeine, tramadol4. Very strong ones like morphine, Oxycodone, Fentanyl patches.Explain also the patient control analgesia5. Reassure that she/he will not be in pain

Shoulder examination1. Look - inspection2. Feel ( temp & tenderness)3. Movements( flexion, extension, adduction, abduction, internal rotation & external rotation)4. Special test:-painful arc test = +ve-Impigement test = +ve-apprehension test = -ve-drop arm test = -ve-speed test=-ve

6. Check the pulse and ask to wriggle the fingers7. Diagnosis – supraspinatus tendonitis

Asthma discharge prescription.1. Check you have 2 inhalers Brown and blue inhalerBlue inhaler-reliever , take it when you develop wheeze, shortness of breath or cough-Brown inhalers –preventer. ( e.g Take 2 puffs twice a day)2. Check on the inhaler for the dose and frequency of inhaler or ask the patient.3. Explain side effect after each inhalers4. Invite questions from the patient.

Nephrectomy – Counselling1. Check how much a patient knows about the condition2. Break bad news in layers if he was not aware of the diagnosis3. Talk about operation: pre-operative, the operation itself and post-operative.4. Complications: infection, risk to life, DVT, PE, bleeding, damage to surrounding structures,4. Consent for blood transfusion4. Do not commit yourself when he/she can go home-depends how he/she is doing

Fever + cough + green sputum – COPD1. ODPARA of the presenting complaint.2. Differential diagnosis3.Finish the P3MAFTOSA4. Give diagnosis-COPD with chest infection. Take proper smoking history-how many years of smoking, How many ciggarettes a day.

Coeliac disease couselling.1. As you know we have done some test……. I am here to explain the results of the test.2. Tell diagnosis: Coeliac disease3. Give the definition4. Glutein free diet for life is the treatment.5. Also take some vitamins, calcium and iron supplements.6. Complication: anaemia, osteoporosis, lymphoma

Post MI counseling1. Congratulations him/her if she is going home.2. I am here to discuss few things which you need to do in order for you to cope with this new condition which you have.3. exercise-waling 10-15 minutes a week is good4. diet –avoid putting too much salt in your food, try to eat balanced diet5. refer to dietician.6. Smoking ( ask if she/he smokes)7. Alcohol ( ask if he/she drinks alcohol )8. Ask her concerns.9. Ask if she drive? What does she do for her living?Avoid driving for atleast 2 months, but it depend how you feel. Telephone conversation - Meningitis1. Take name, age, sex of the child2. Take Telephone number & adress4. Ask for concerns5. Ask about rash, fever, lethargic, vomiting, eating and drinking, passing wee, playing active, fit.7. If child is unwell send an ambulance otherwise ask to bring child to hospital.NB: always ask child to come to hospital.

Catheterization1. drape2. Put gauze on the shaft of the penis3. clean 3 times only the glans4. insert gel5. inset catheter6. insert distilled water7. connect urobag8. stick to the thigh9. measure urineTear the drape & thank patient

Testicular pain history taking and management.1. Take relevant history only-SOCRATES

-vomiting, swelling, local redness-Differential diagnosis( UTI, Torsion, testicular tumour, Cyst , Epidydimo-orchitis)2. Give diagnosis – if fever then epididymo – orchitis, if no fever its torsion.3. Management: check urine if epidydimo-orchitis and exploratory surgery if torsion -analgesiaDiscuss with senior immediately always.NB: for differential diagnosis always include torsion.

Infantile colic-history management.1. ODPARA of crying2. Differential diagnosis (infantile colic, intussusceptions, testicular torsion)3.P3MAFTOSA4. Give diagnosis.

Warfarin counselling – Mentally retarded patient.1. I am here to explain to you the medication called warfarin.2. Can I ask do you take any other medication.3. Is there anyone who helps you with the medication4. Has anyone accompanied or you are alone?5. Check who she lives with? Ask if there is anyone who can help you with taking the medication.6. Explain the medication: -warfarin -blood thiner -to prevent you from developing clots -Explain both in milligrams and number of tablets -Make sure you pose each time to check he understand.7. Ask if there is anyone at home who you can call and ask to help him take the medication.8. Tell him the complication-bleeding. If he develops bleedinh from anywhere to come back to hospital immediately.8. Explain that he need to be going for blood test called INR. And the dose he will be taking will depend on this blood test. There he needs to attend all the blood test appointment.

Palpitations history taking1. ODPARA2. Differential diagnosis3. P3MAFTOSA4. Diagnosis or D/D’S

Diplopia exam1. Inspection2. 3 reflexes ( light, red and accommodation reflex.)3. Visual aquity-finger counting4. Ideally snellen for visual acquity & ischihara chart f clour vision.5. Make an H for 3,4 & 6. Patient will see double on one side. Finish the H first and then go back to where patient saw double. Analize the diplopia by asking the following questions:A. Do you see double here?B.. Do you see these images as inner and out?C. Can you cover one eyeD. Do you still see double?E. Which image do you see?F. Can you cover the other eye Repeat question D & E for the other eye.6. Cover cover test and cover and uncover test

UTI – Talk about management1. ODPARA of presenting complaint.2. Rule Differential diagnosis BPH, prostate cancer, bladder cancer( ask about dysuria, frequency, nocturia, dribbling, weight loss, back pain , fever)3. P3MAFTOSA4. Diagnosis-5. Management: take urine sample and check for infection results take few minutes, if positive will start on antibiotics

NB: if history of BPH then refer to a specialist urologist.

Vomiting in a child1. ODPARA-vomiting2. Paediatric questions( pregnancy, delivery, problems during pregnancy-like veDntilations or infection)3. Rule out D/Ds4. Rule out dehydration( wet nappies. Lethalgic, actively playing, crying without tears)5.P3MAFTOSA

Chronic kidney disease – Blood results with patient.1. I am here to explain the results.2. They are showing that you kidneys are not fucntioing properly.3. This is a chronic condition-meaning that your kidney function is progressively becoming worse.4. Usually our kidneys clean toxic substances from our body. And one of the toxic substances is called creatinine . And when we look at your blood test this substances has progressively going up in the blood which is showing that your kidneys are slowly failing more and more. 4. You see here ( show blood tests) your creatinine level was ……it is now ….5.Explain she will need dialysis in future and transplant depending on the situation.

Abnormal LFTs .1. I am here to talk to you about your blood test we did few days back.2. They are showing that you liver is not functioning properly.3. We were wondering why this is so, can I ask you few question.Rule out D/Ds ( ask about IV drugs, tattoos, Blood transfusion, history of travel, alcohol, sexual history. Chronic liver disease, previous jaundice, scratching, abdominal pain)4. Finish P3MAFTOSA

MI risk factors & Counselling.1. smoking2. DM3. HTN4. Family history of IHD, stroke, HTN and age of onset.5. Hx of IHD6. Kidney disease7. stroke, peripheral vascular disease

8 . management: aspirin if not already on ; lifestyle-what ever you find positive in the history (diet, smoking, alcohol, exercise)

Miscarriage (Ultrasound scan done and shows missed abortion.)1. Breaking bad news station-memorise phrases to use2. Explain the results of the scan-break the news in layers3. Encourage: don’t blame your self there is nothing that could have been done to stop this, 4. Management: Will give you some medication to help you develiver the baby or you consider an operation ( if it is missed miscarage).

Crying baby history taking- was seen by the consultant & all investigations done were normal1) ODPARA of the presenting complaint 2) D/Ds – intussusceptions , torsion, infantile colic3) management: if infantile colic, then reassure that all investigations normal meaning that nothing serious going on. It is common condition in children and normally I settles in withn 3 -4 months.

-adverse to get help from family member in looking after the child.-if intussusceptions=admit, inform senior, and management is passing gas through his back passage which will help resolve the telescoping of the gut.

A lady with DVT wants contraception.

1. Show a smile ad be positive, reassure you will help her.2. warn that no contraceptionis 100 percent2. Rule out contraindications: DVT, PE, IHD,Migraine with aura, liver disease, smoking, age, breast cancer.3. Explain the options- Combined contraception, progesterone only pill, IUCD, Depo provera, Implant)

-give 1-2 advantages and disadvantages for each one.4. Do not rush, do not aim to finish.5. Say that I would not recommend you a combined pill because it will increase the risk of clot formation in the lungs and legs.6. Provide leaflets and ask to take time and if makes up her mind you will provide the contraception.

Chronic Fatigue Syndrome.1. Take history-ODPARA and differential diagnosis.2. D/Ds hypothyroidism, myasthenia, malignancy, depression, systemic diseases e.t.c3. The explain that the good news is all investigations normal.4. Give diagnosis-you are having a condition called chronic fatique syndrome5. reassure-some people improve with time, refer to psychiatrist, advice to rest and do light exercise, follow up in clinic. Treatment is aymptomatic

Pre – eclampsia – history taking.1. ODPARA of the presenting complaints. 2. D/Ds ( DM & HTN before pregnancy, DM & HTN during pregnancy, swelling of legs, abdominal pian, headaches, visual symptoms, family hx of pre-eclampsia or eclampsia, any previous pregnancies, any problems during previous pregnancy).- did she attend all antenatal clinic, was she told any problems with her pregnancy- Is she expecting twins.

Black stools – history taking1. ODPARA of black stool.1. Rule out D/Ds3. P3MAFTOSA4. Diagnosis

Drug abuse

1. Know the name2. Offer confidentiality4. Speak with confidence5. Take history-what drug, any other drugs, is he injecting, any other roots, any sharing of needles, does he drink alcohol, any past medial history, 6. Hallucinations, delusions, insight, suicide, previous suicide.7. Ask if he tried to stop in the past, ToleranceT. Would he consider stopping drugs if yes refer to substance abuse team , of no then offer needle exchange program and offer to stop and tell we have special services which helps people to stop using drug.-if scared of police reassure no police

Laparoscopic sterilization.1. Offer confidentiality2. I understand you would like to know more about female sterilization. Ask if she has finished familyExplain the operation-it’s a key hole surgery-2 small holes on your tummy, For camera and 1 for instruments.3. Explain the normal process of getting pregnant i.e connection between the womb and egg producing glands and explain that you will be blocking the tubes either by cutting them or applying clips.4. Its regarded as permanent procedure5. advice not to make decision during crisis6. Explain about male sterilization=easier and simplier is also available and ask if she knows about it.7. This operation we can try to reverse it but success rate very very low with a lot of complications8. Explain that female sterilization can fell as well., its not hundred percent.9. Offer leaflets

Diabetic retinopathy.1. Find out what stages of diabetic retinopathy has been diagnosed2. Do not commit yourself to the prognosis3. can loose vision and can be blind but difficulty question to answer4. advise about life style modification ( smoking, alcohol, diet, exercise, blood glucose control)6. talk about Blood glucose control, ask if hypertensive IHD.

NB: Do not talk about bad habbit which patient does not have.

Delayed walking – history talkingFind out the age of the patient.1. D/Ds (Duchene muscular dystrophy, cerebral palsy, irritable hip, constitutional, septic arthritis, trauma, DDH, e.t.c)3. Duchene-does he climb on himself when he tries to stand up? After develivery did your child need any help with breath? Was he ventilated=cerebral palsy.

PID – Talk about consequences.1. How much she knows about her condition.1. Explain the outlined problem in the question-has been diagnosed with a condition called Pelvic inflammatory disease which infection of the wound and tubes.2. I am here to explains some problems which this condition can cause.

Consequencies:1. Painful periods2. infertility3. Ectopic pregnancy4. repeated infection and abscesses

Elderly abuse – History and counseling.1. Do not be judgemental & offer confidentiality2. Take history-ODPARA of the presenting complaint.3. Take social hx: where does she live, who lives with her, her mobility, how they are coping at home, any medical condition of the patient. Any carers at home4. Management: -admit-investigations-analgesia-treat whatever you find in the history-need assessment by occupational and physiotherapist.

Alcoholic foot – Examination.1. Approach like diabetic foot2.check wether its neurological or relevant examination3. Neurological ( touch, vibration, position, pain, reflexes)4. If relevant start with gait and inspection

Smoking cessation – counseling.1. Find out how long has been smoking.2. Offer stopping and reassure that there is a lot of help available.3. Inform the disadvantages of smoking4. we have medication which would make stop eassily, ask of he had tried to stop in the pastNB: patient has been posted for angioplasty and this is the main reason why he needs to stop smoking. Tell him that even if we do angioplasty if he does not stop smoking the chance that he may have heart attack will remain very high

Post Traumatic Stress Disorder1. ODPARA of presenting complaint2. Typical PTSD questions3 hallucination, delusion, suicide, insight4. management: psychiatrist,5. Invite questions and address those questions.

Telephone conversation – Diarrhoea . 1. Take name, age, adress and telephone number2. take presenting compliant and history3. Rule out dehydration.4. If blood in the stool, dehydrated ask to bring child to hiospital.5. if no need of admission ask to go to GP , do not give advice over the phone to saty at home without doctor review and if GP not around then should come to hospital.

Heniorrhaphy counseling – under local anaesthesia.1. Explain the procedure is to remove the sack and strengthen the muscles so the contents of the tummy stops coming out2 . Patient will not be put to sleep3. He will feel they are doing something but will feel no pain.4. They will use local numbing agent to numb the area.They will inject the numbing agent around the area of an operation.5. complications: bleeding, infections, damage to surrounding areas6. address concerns and invites questions more frequently.

Shortness of breath – history taking1. ODPARAof shortness of breath2. Rule out D/Ds3.P3MAFTOSA4. Diagnois or differential

Unconscious child – found collapsed in school, speak to mum.1. Take history from the mum2. was the mother around, if not still take history from her . Ask if she was told anything.3. Rule out D/Ds ( DM, Head inury, Epilpesy, Meningitis temperature, PMHs.4. Other questions-was child well before going to school, any fever, cough, running nose, any previous collapse in the past.5. Management= blood test, urine, tracing of the heart-ECG, if we do not find anything we do not find anything. (CT head if still no cause found and patient still unconscious)If the diagnosis is typical of vasovagal then management is explain what is vasovagal and reassure that it not a life threatening condition and and as children grow up , usually they stop having vasovagalsyncope. Discharge them home but say you will first speak to your seniors first for a second opinion.

Foreign body ingestion in a child – Talk to mum.1. What happened?2. Questions: was the mother there ? what did the mother see? how did she know child swallowed a coin? Cough, shortness of breath, did child turn blue?3. Management: CXR-if coin below the diaphragm, can do home and continue checking for the coin in the pool.4. To come back if: vomiting, abdominal pain or not passed the coin in 2 days.

Morphine teacher counseling.1. You are taking morphine for good reasons.2. Can get addicted but the chance is low if you are taking at low dose 3. This is medication for treatment , its different from the one people misuse on the street.4. Reassure that its her right to receive treatment and to be pain free.And she is not using it for any other reason other than for pain.

Needle stick injury in a child.1. Find what happened and what time.2. Other questions-what type of a needle? what did they do after it happened? is child upto date with immunizations? 3. What are they worried of.4. If HIV-reassure, and say that the chance is small but we will take blood to be tested for HIV in about 3 months.5. Invite questions from a patient.

NB: if patient not sure what they are worried of then tell them that the 2 things they should be worried are HIV and Hepatitis. And what we will do is to take blood, save it so it can be tested in 3 months time.For now we can give you the medication what we call post exposure prophylaxis to prevent child from getting HIV and these mwdication are usually taken for 28 days , but these medication have serious side effect, they can cause damage to the liver or kidneys.We will also give hepatitis immunoglobin to try and prevent from hepatitis B.

Uncontrolled epilepsy-patient on carbamazepine ( patient not taking the dose properly)1. May I know what brings you to hospital2. Take history=is she on any medication, is she taking them properly, has the dose changed recently, has she gained weight recently, has they changed the medication recently, has she been started on new medication recently, does she drink alcohol, Has she been to disco. Has the seizures been happening more frequently recently.3. Does she have a specialist who looks after her-if yes say we will inform him the address this concern.4. Also advise any negatives you have found in the history

Testicular lump – history taking.1. ODARA of lump2. D/Ds-hernia, cyst, tumour, hydrocele, hernia, varcocele.3. Not clear at the moment=to be on safe side its better that we do biopsy and unfortunately the only way is to remove the testis.3. P3MAFTOSA if its history taking only. If questions says discuss management as well then take only relevant history3 Management= remove the testis and send to the lab to be tested. Speak with sympathy if the question says discuss management.

Cranial nerves 2 – 7 exam1) Inspection – DRSSS , proptosis2) reflexes ( light , red & accommodation reflex ) 3) visual acuity by finger counting ( ideally snellen ‘s chart for visual acuity & ischihara’s chart for colour vision )4) peripheral visual field 5) make an H for 3rd , 4th & 6th cranial nerves 6) 5th nerve – sensation with cotton wool & muscle of chewing- ideally will check for corneal reflex and jaw jerk reflex 7) 7th nerve – frown , say EE , close your eyes tight

Upper abdomen examination1) general inspection – start from hands , flapping tremors , pulse , cyanosis , increased sweating , peripheral oedema , mouth + eyes 2) inspection of abdomen – from foot end , cough for hernia 3) palpation - superficial( rigidity, guading or soft) & deep 4) Murphy sign5) check for rebound & percussion tenderness on the RUQ

6) palpation of liver & spleen 7) palpate for loin tenderness + kidney 8) flank dullness9) diagnosis – acute cholecystitis

Multiple Sclerosis counseling1) As you know , you came with such symptoms , we have done some test 2) Diagnosis – Multiple sclerosis3) definition – this is a condition , in which the nerves in the body are affected , mainly the ones in your brain & spinal cord . Nerves in the body contains sheath. The immune system which normally defends us from infection is attacking your nerves for some unknown reason and as a result the nerves loses their sheath 4) symptoms usually comes & goes 5) Mx – medication : A- interferon + B Lifestyle modifications ( avoid heat , over exercise 6) Can be will chair bound, lose vision but difficulty to answer, hopefully not7) her children get getting but difficulty to tell, hopefully not

Hyperemesis gravidarum1) take history – about vomiting - how long , family Hx , is this the 1st pregnancy , weeks of pregnancy 2) rule out dehydration – dizziness , tired 3) Mx – bloods , anti – emetics , USS( molar / multiple pregnancy) , IV fluids , NBM – followed by light diet

Talking mannequin with limb ischaemia + ECG – Exam1) introduce yourself to the mannequin2)say your are here to examine his legs 3)examination – 1) inspection , 2) temperature , 3) tenderness , 4) capillary refill, dorsalis pedis4) do burgers test if the capillary refill is delayed. 4) acute limb ischaemia - refer to vascular surgeon 5) ECG is usually AF. The cause is likely to be an emboli. Mangement is embolectomy.

Fluoxetine counselling1) Explain that the medication is to help elevate mood 2) SE: increase thoughts of harming yourself , but this is only for short period, then it will help you feel better. So even if it makes you have thought of harming yourself, please do stop taking them but do come to hospital immediately.4) medication take 6-8 weeks to start to work but must be given atleast 3 months before we can say its not working 5) give General advices like keep out of reach of children , no changing dose e.t.c

Anaemia – Lab report + history taking.1) As you know …… have done some test…..2) we have found that your blood levels are low , by this I mean you are anaemic3)Mx – investigation if Hb <8 – transfusion , if Hb >/= 8 – investigate. 3) rule out dizziness , weakness – if positive = blood transfusion Management: Investigations( blood tests and possibly GI endoscope) Take history to find out the possible cause ( aspirin, NSAIDs, PMH, history of bleeding. Liver problems)

Diabetes Mellitus in a child1) as you know …… done some tests…..2) diagnosis – DM- type 13)definition – blood sugar levels are constantly high 4) not enough insulin , pancreas an organ which is not producing enough , reason not clear 5) Mx – replace insulin Given by injection Small needle 6) lifestyle modification – carry sweat drink , check glucose regularly , no missing meals, wear a bracelets7) explain hypoglycaemic attack.8) the nurse will show you how to inject the insulin9We will provide you with our telephone number, if any problems please ring us back.

Headache examination1)universal precautions2) reassure : dim off lights + pain killers , tell him that you are there to help him I know you are in pain I have dimmed of the lights

Help him to remove the hand from the face ( don’t force ) Help him lie on the back3) Do GCS 3) meningeal signs ( neck stiffness, bruzinski’s & kernig sign

Visual examination1)peripheral vision ( use white pin) : can you see this white head pin , I will be moving it fro outside into inside, please let me know when you can see it as white2) blind spot-from centre to peripheral, cover same side eye as a patient and check one eye at the time and move the pin slowly3)Central scotomas-use red pin

Ovarian cystectomy1)fasting 6- 8 hours before operation 2) key – hole surgery , small 3 nicks below the belly button3) insert harmless gas to distend your tummy 4) gas will be removed after the surgery 5) warn possibility of open surgery if problems during key hole surgery , & removal of the whole ovary if the cyst is very big 6) complication – bleeding , infection , damage to the surrounding tissues7)consent for blood transfusion 8) no stitches

MRSA counselling1) apologise that the wound has become infected 2) its one rare complication after operation which my collegue must have told you before the operation3)Mx : admit , clean , bloods , isolate , temperature , pulse , -will take advice from the microbiologist about which antibiotics use and how best to treat you.4) warn it is difficult infection to treat & but there are antibiotics which can clear this infection 5) do not commit yourself on period or that you will clear the infection

Emergency endoscopy1) usually patient presented with bleeding 2) life threatening condition 3) Endoscope is a test where we use a flexible telescope to look into your gut & stomach & to

find the bleeding & to stop it as well 4) Procedure: you will lie on the side on the couch, plastic guide will be placed in your mouth, numbing agent spread into your throat, and they will give mild sedation, the operator will ask you to swallow the tip of the endoscope, gentle he will push the endoscope further., will look into the stomach and gut.4) The procedure will take between 15-20 minutes depending wether treatment is required. 5) complication: mild sore throat, damage from gut, vomiting, fever, difficulty breathing.

Bruises in a child – history taking1) ODPARA of the presenting complaints ( ITP)2)DD’s (ITP , NAI , meningitis , HSP , HUS , leukemia)3) diagnosis

NB: in ITP there recent history of URTI and patient has got nose bleed.

Talking mannequin – Shortness of breath1)Take relevant short history. ODPARA of SOB DD’s – asthma ,COPD 2) Examination – Listen to the chest anteriorly : wheeze = Diagnosis : asthma3) Mx : O2 , nebulized salbutamol + Ipratropium bromide prednisolone 40mg. If fever give antibiotics4)Mx – ABG , CXR

Child with URTI, mother worried of meningitis1) may I know what brings you to the hospital 2)rule out : URTI , AOM , GE , meningitis , UTI 3) reassure that the child has got viral infection.

Chest pain – history taking1) SOCRATES 2)DD’s 3)finish the P3 MAFTOSA4)give diagnosis / differential diagnosis

Osteoporosis ( DEXA scan done )1) Tell the results of DEXA scan , shows osteoporosis, meaning the your bones are weak.2)Take history : family Hx , use of steroid, ask about the fracture mechanism-did she fall heavily or it was just a simple fall.Tell that this condition is common after menopause3) Managemnt :tablets – which contains calcium & vitamin D3 called calcichew Biphospanate= Alendronic acid ( rule out peptic ulcer & advice to sit up right for 30 min after taking it )4) Also advised to do moderate exercise and to stop smoking if she smokes.

Head injury in a child – Management with mum1) take history – any witness , how did he fall , what was the mother told , any vomiting /LOC/seizures /drowsiness2)Mx : We need to examine him – if no indication for CT then discharge with head injury advice ( observe carefully and any signs of serious head injury to come back)Indications for Ct head=serious head injury

NB: indication for head injury: vomiting x3, fits, drowsiness, loss of consciousness, memory loss if order child, persistent headache

Lymphoreticular exam1)Sitting – cervical +neck lymph nodes2)Standing – axillary lymph nodes 3)lying – head to toe : head – alopecia ; mouth – gum hypertrophy , dental abscess ; ears – no signs of infection , chest – CT for thymus + mediastinal LN4)abdomen – palpate liver & spleen , Ct scan for paraoartic lymph nodes

5)Inguinal LN – (vertical & horizontal )6)popliteal , pre – trochlear lymhnodes.

Eclampsia – talk to husband1) his wife is in serious condition2) but not fitting now been looked after by a good specialist 3)if the fit repeats its s risk to life for both wife & baby 4) only way to save both is by doing a caessarian section 5)complication : MI , PE , stroke , bleeding , pneumonia , infection , risk to life , aspiration 6)consent read & sign

Knee pain – history taking1)ODPARA 2)DD’s ( RA , reactive arthritis , trauma , gout , osteoarthritis , haemarthrosis , septic arthritis , SLE 3) finish P3 MAFTOSA

NB: recent GMC diagnosis reactive arthritis

Knee examination1) gait 2) look – inspection =DRSSS, muscle wasting, bone deformity3) feel - temperature , tenderness4) special test – patella tap test , patella grind test , anterior & posterior draw test , collateral stretch test , Mc murray test

Hypertension management – talk to patient1) look at BP ( if </= 160 /100) = no medication only life style modification 2) if >160 / 100 then medication + life style modification 3)lifestyle – decreased alcohol intake , decrease weight , exercise , decrease coffee , stop smoking , control BP.NB: ask if patient smokes or drink before talking about them

Depression history and counselling1)ODPARA of presenting complaints 2) DD’s / PTSD / anxiety e.t.c3) Mx : refer to specialist – the psychiatrist , who will assess + decide either to give medication called anti – depressant or to use talking therapy

Irritable Bowel Syndrome1) As you know you came to us with ….. and we have done some investigatsions, we found that the cause of your symptoms is….2) diagnosis – IBS 3) Take history to rule out DD’S ( bowel cancer , IBD )4)Management: symptomatic( pain- mebeverine , constipation – laxatives ; diarrhea – loperamide) Prognosis – difficult to say, but some people become symptom free after sometime and still some people mptoms persists 5 ) refer to psychiatrist if patient depressed.

Respiratory examination + PEFR

I. Start by explaining the PEFR ( ask patient to do it once)

II. Then move to respiratory examination.

1. General inspection( pallor.clubbing, cyanosis, pulse, eyes, flapping tremor, central cyanosis, JVP, peripheral oedema)

2. Inspection of chest.( scars, use of accessory muscles, respiratory rate, flaring of alae nasae, intercostals recession)3. Palpation( chest expansion, tenderness and vocal resonance)4. Percussion5. Auscultation front and back , then say Ideally I will inspect, palpate and percuss on the back as well.

Drug abuse psychosis-calmer person.1. Be confident.2. Take history: drugs, route, how long, alcohol, social history, financial, 3. rule out psychosis: hallucinations, delusions, thought disorders,4. Insight5. suicide6. Offer to stop drugs-if agrees refer to substance abuse team.7. If not willingly to stop then offer needle exchange program and explain what it is.

Assess anaesthesia for a child with DM for pin removal. 1. Check that they know about the operation.2. Ask the systemic questions: -Respiratory: cough, fever, running nose, SOB.-Cardiovascular: chest pain, palpitation-GIT: diarrhea and vomiting-Urinary tract: Burning sensation on passing water, fever3. Past medical history: asthma, Epilepsy, heart problems, previous general anesthesia-any problems, drug history, allergies,4.Instruction: NBM from midnight a day before operation, admitted a day before, No insulin on the day of an operation. 5. On day of an operation will check blood sugar level and will start him on a drip of normal saline and insulin. And will try to put join first on the list.

Diabetic foot – examination( can be relevant or neurological examination)1. Gait2. Inspection3. Palpation( temperature & tenderness)4. dorsalis pedis

5. Capillary refill6. Neurological -touch sensation use a cotton wool-Vibration-Position-pin prick-reflexesNB: check all sensation from distal to proximal

Ulcer over the back – history taking1. History about the ulcer( duration, colour, increasing in size, pigementation, bleeding, shape, painful)2. rule out D/Ds ( pressure sore, trauma, melanoma, diabetic ulcer)3. Management: Take biopsy and send to the lab. And treatment will depend what the results will show.

Wound infection – counselling 1. Take history about the wound: discharge, smelling, colour of discharge, bleeding, pain, cough, vomiting, shortness of breath.2. Apologise and tell him its one of rare complication of surgery which my collegue must have told you before the operation.3. Management: admit, isolate swab the wound and send to lab, blood tests, temperature, blood pressure, tell him you will inform his consultant.Consult the microbiologist about the treatment

CVS Examination – Signs of heart failure 1. Genral inspection ( pallor, pulse, collapsing pulse BP, JVP, Roths spot, Jenewal lesion, osler nodes, splint haemorrhages, peripheral oedema, Hepatojugular reflux)

2. Inspection of the chest: precardial bulge, parasternal heave3. Palpation: apex beat, palpable thrills, parasternal heave.4. Auscultation: Bell and diaphragm in all the 4 areas and then listen to specific murmur

Headache – History and DD1. SOCRATES2. D/Ds=SAH, Migraine, cluster hedache, brain tumour, GCA, tension headache, Trauma, benign raised intracranial pressure, sinusitis, trigeminal neuralgia3. Give diagnosis or differential diagnosis

Severe dyskariosis – Counsel for colposcopy-Tell the results of cervical smear-we found there areabnormal cells-the condition is called severe dyscariosis-2. Mx: colposcopy. It is like a big telescope which the doctor uses to look inot the neck of your womb. He will apply stains and take biopsy from the cells which get stained.3. If treatment is required , the doctor may treat you at the same time by doing a procedure what we call cone biopsy.4. Offer general advice-cary a sanitary towel, expect a little bit of spotting after after procedure for a day or two.ou

Haemoptysis – History and DD1. ODPARA of haemoptysis2. Differentials: lung cancer, PE, pulmonary oedema, pneumonia, goodpasture’s syndrome, e.t.c)3. Give diagnosis or differential as per questions

Elbow examinationLook-DRSSS, muscle wasting, bone deformity.Feel-temperature and tendernessMove-flexion, extension, supination and pronationSpecial test: Cozens and Mills manoeuvreNeurovascular-pulse and wriggle toesDiagnosis: lateral or medial epicondylitis

Pain management in labour Medical-entonox, pethidine, Epidural anaesthesia

Non medical –water/birthing pool, TENs, breathing exercise.

Anxiety history1. ODPARA of presenting complaints2. D/Ds: phobias, generalized anxiety, panic attack, depression3. Give diagnosis

Red eye – history taking1. ODPARA of red eye2. D/Ds : foreign , body. Conjunctivitis,anterior uveitis, trauma, acute closed angle glaucoma, scleritis, episcleritis, ankylosing spondylitis, 3. Give diagnosis or differential diagnosis

Menigococcal septicaemia1. As you know your child came in with a rash2. Tell the diagnosis3. Defination: The infection of the coverings of the brain have now spread into the blood system4. Tell them that the child is on critical condition5. Management: admitted to ITU, oxygen, IV fluids, antiobiotics, isolation( basically tell them what is written in the question)6.Ask if she has got other children and offer prophylaxis to all household.

Ante-partum haemorrhage – history and management. 1. ODPARA of per vaginal bleed2. Tell the results of ultrasound scan. Tell her that the 2 things were were worried of is what we call placenta meaning the the pace where the baby is sitting may have come out or theta the baby sit is not located in the right place but the scan has shown that there non of the two.

There simple bleeding which is usually common in pregnancy.3. Tell her we need to do CTG to check if the baby is fine, do not say the baby is fine.4. Reassure that nothing serious is going on and if the baby is doing fine we simply admit you for a period of observation .5. Do blood test to see how much blood loss has occurred and ask question of severe blood loss( dizziness, palpitation, light headedness)

Telephone conversation 6 hrs post op collapse1) Find out who you are speaking to:

Hello! Can I speak to Mr Thompson the surgeon consultant on call?I am Samson, one of the junior doctors in surgery department

2) Apologise for disturbing:

I am really sorry to disturb you at this time, I’ve got a patient I need to discuss with you, is it alright?

3) Situation: Age, Sex, What is wrong

4) I have got a 35 year old patient, Mr Jone who is hypotensive and tachycardiac with a BP of 90/60 and Pulse 120

5) Background:This patient had hemicolectomy 3 hours ago, for “whatever” reason (e.g. Bowel cancer)

6) Assessment: Examination , Observations & investigationsI was called to see him 10 minutes ago. On examination: “say whats in the task”(Assess as ABCD) On assessment Airway is patent, Chest is clear, CVS examination is

unremarkable

7) Impression:I feel this is a case of intra abdominal bleeding

8) Management given so far:I have taken care of ABC of the patientA: His airway is patentB: Oxygen and mention what is given on examination of the chestC:connected to the monitor , 2 wide bore IV line, send blood for FBC, U & E, LFTs, Blood

glucose, clotting screening, group and save.I have informed my registrar, also the operation theatre & anaesthetist for possible operation

9) Recommendations:The patient may need to go back to theatre for intra abdominal bleedingIs there anything else you want me to do? Would you please come and help us with the management

9) Thank you very much for your help.

Whiplash injury1. Hx (mechanism, vomiting, fits, head injury, neck pain)2. Inspection and palpation of the neck3. Say I will apply a collar and do cervical spine x-ray ( examiner will say x-rays normal)4.Neurological examination(sensory according to demartomes, ulna, radial, median and power of upper limb)5. Neck movement.

MMSE1.Explain thst iam here to ask you few questions and some of the questions may seem very obvious, so please bare wit me.2. Take 2 papers: one for your marking and another for testing the patient.3. Do not rash the patient4. Keep encouranging patient from time to time.5.you need to show that you are able to work with elderly patient .

Gout counselling1. Begin with as you know you came to us with …and we have done sone test.2. Tell him Diagnosis3.Management: medication ( anti-inflamatory medication called indomethacin)4. Life style modification: avoid dehydration, reduce alcohol intake, red meat, tomatoes, sea food.

Telephone conversation – NAITelephone conversation Non-accidental injury-telephone conversation with the examiner.Find who you are speaking to: Hello, can I speak to Dr Williams the consultant paediatrician on call.Consultant: Yes speaking.Apologize for disturbing: Hi, Dr Williams, I am really sorry to disturb at this time my name is Samson. I am one of the junior doctors in paediatrics.Can I discuss the patient with you please?Situation: I have a 2 year old child who has been brought by her mother with multiple bruises of different ages and child has got left humeral fracture on the x-ray.Background: So this is a 2 year old child who lives with her mum and step father, the mother gives history fall from a sofa 2 days ago.Assessment Upon examination –the child has got bruises of different ages, the left humerus is deformed and swollen. Otherwise the child is ok.X-ray of the left humerus has shown a transverse fracture of the left humerus, it’s a closed fracture, displaced , angulated, neurovascular intact.Diagnosis: I feel this is a case of non accidental injury.

Management:1. I have admitted the child

2. I have given the child analgesia.

3. I have done good clinical skeletal survey on him

4. Do blood test FBC, U&E, LFT, group and save, give analgesia and I have informed the registar.

5. I have checked the child name on protection registrar and I think we will need to contact the

social services.

6. I have informed the orthopaedics.

7. Is there anything else you would like me to do?

Would you please come and help in the further management of the patient.

Stroke risk factors1. Risk factors: AF=irregular heart beat, high cholesterol, IHD, vulvular heart disease, circulation problems, renal failure, family history of stroke, diet, exercise

Telephone conversation – intestinal obstruction

Telephone conversations:

1. Find out who you are speaking to: surgical consultant on call

2. Apologise for disturbing: tell him /her you have you a patient to discuss, can I go ahead.

3. Situation: Age, sex, whats wrong. ( I have a 50 year old man with abdominal pain, vomiting and constipation

4. Background: He has past medical history or past medical history of ......4. Assessement; examination, observation and investigations-you will have abdominal x-ray in

the exam.5 Impressions/Diagnosis= I feel this is the case of intestinal obstruction.6. Management given so far: Taken care of his ABC, bloods, group and save, LFT, clotting screen, U&E, glucose, amylase. Inform

the registar, theatre and anaesthetist about the possible operation.7. Recommendations: Is the anything else you would like me to do?

8. Thank you very much , please if you can come and help us in the management of the patient. NB: Prepare your information and plan what you will say before you pick up the phone.

Fracture femur and rupture spleen in a child1. tell him that his child is in critical condition2. Child has suffered 2 injuries-spleen rapture and femur fracture. Main concern is spleen rapture 3. explain procedure including the complication include risk to life.Consent for theatre and explain about vaccinations and long term antibiotics as well as measures to be take when if going abroad.

Weight loss history taking1. ODPARA of weight loss2. Differentials( hypothyroidism, malignancy, depression, IBD, systemic diseases like SLE)3. Give diagnosis or differentials.

Herniorrhaphy cancellation – anaemia 1. As you know that we are planning to do an operation to remove your hernia-And you know that we have done some blood test recently.-the results are back and I am to discuss the results with you.2. unfortunalely Mrs Williams the blood test have shown that you blood levels are low , in other ways you are anaemic.3. Tell him we need to counsel the operation for now until we you have sorted out the her anaemia.Management: blood test, possible GI endoscope and iron tablets. -ask questions for the possible cause of anaemia ( weight loss, use NSAIDs, peptic ulcer use aspirin.4. Apologise that you had to counsel the operation. And its for her wellbeing due to associated risk like poor wound healing, risk to life, bleeding.5. Tell her that you want her t undergo successfully that is why you are counseling it now but as

soon as we sort out the anemia we will reschedule it once your anaemia is resolved.

Hoarseness of voice history taking1. ODPARA of horsenes of voice2. differentials (laryngitis, hypothyroidism, laryngeal cancer e.t.c3.Give diagnosis or differentials depending on the question.

Giant cell arteritis – counselling 1. As you know …….symptoms and investigations2. Tell that you are suspecting GCA3. Management: intravenous steroid in for 3 days and then will switch to oral. Will be given high dose for 2=3 years4. Biopsy within the next 3 days.5. Tell the side effects of steroids

Calf pain history taking1. SOCRATES of calf pain2. Differentials: DVT, PVD, bakers cyst , trauma, spinal claudication, e.t.c3.Give diagnosis

Child with ear ache – counsel mother

1. Take history of ear ache2. Rule out differentials: 3. Managemement: Antibiotics usually amoxicillin oly if the diagnosis of acute otitis media

Headache – wants MRI1. find out what brings her to hospital, why she thinks she need an MRI or CT and if she thinks she has got brain tumour ask why she thinks so? If she gives family history of brain tumour sympathize with her.

2.Take history to rule out brain tumour( weight loss, progressive worsening headache, change in character of headache, anaemia, weakness or sensory loss in the legs or arms, headache, vomiting)3. Explain how brain tumour present and and say she has non of these signs.4. If she still persist to demand for scan then say we usually do not do scan in this situation but w may do it since you are worried but I will need to speak to my seniors.

Gastroscopy counselling 1. Camera testA telescope like instrument passed through your mouth into your stomach and gut2. numbing agent on your throat will be spread, the doctor will ask you to swallow the tip of an endoscope and he will push the the whole endoscope in, we will also give you mild sedation,3. procedure lasts about 1o-15 minutes4. it is usually performed as a day case unless there are some complication of the procedure.5. complications: damage to the oesophagus or stomach, vomiting difficulty in breathing

Ectopic pregnancy – counselling 1. As you know………..symptoms and blood test2. Suspecting a condition called ectopic pregnancy3.We will need you to stay in hospital so that we can do an ultrasound scan so that we can know where the pregnancy is.4 No place will accommodate your pregnancy other than your womb.5.It is like a ticking bomb , at any time it can burst.6. If you go away from the hospital , it may burst and we may not be able to help. An even if we are able to help you will need a big operation that will leave you with a big car with complications like difficulty to get pregnant and even if you get pregnant its more likely to be outside the womb again.7. I am sure you would not like such things to happen to you.

Post partum depression1. history of the presenting complaint2. ask how she feels about thye baby3.Check for psychosis, suicide, insight4. Management: refer to the specialist , who may decide to treat you either with talking therapy or anti-depressant.

Venepuncture1. prepare trolly ( needle, vacutaine holder, blood form, vacutainer)2. Palpate and apply tourniquet3. load the needle4. palpate and clean5. Take blood6. Fill the vacutainer and blood form 7. Put in the blood form and send to the lab.

Adult CPR1. safety +c.spine2. time3. Response4. Airway with head tilt and chin lift5.Breathing for 10 sec.6. 999 or 22227. 30:2 until help arrives or patient shows signs of life

Suturing1. Ask for sterile area2. open suture3. Flush 4.Clean5. check anaesthesia and suture with same forceps ( put 2 stiches)6. Put needle in the sharps bin.7. dress the wound, antibiotics, go to GP for stitch removal in 7 days.

Paediatric CPR 1. 1. safety +c.spine2. time3. Response4. Airway with head tilt and chin lift5.Breathing for 10 sec6. 5 breaths7. carotid pulse for 10 secs8.15:2 compression with one hand9. 999 or 222210.Airway11. Breathing for 5 sec.12. 2 breaths13. carotid pulse 5 sec. If pulse 60 and above give 1 breath every 3 secs but if examiner does not give you pulse do not stop and ask just give 15:2 compression until help arrives.

Otoscopy –you will have both a real patient and a manikin1. Do inspection, temperature , tenderness and tragus on a real patient.2. Rinnes and webers on a real patient.3. otoscopy on the manikin4. Describe the slide and give diagnosis to the examiner.NB: do not talk during the examination

Fundoscopy-you will have both a real patient and manikin1. Explain the procedure and check red reflex on the real patient.2. Do fundoscopy on the manikin3. Explain the slides and tell the examiner the diagnosis.NB: do not talk during the prodecure and explain the slide do not just give diagnosis.

PV Exam-wear gloves, you will be required to do so in GMC exam.1. Inpection: DRSSS, palpate for the batholin cyst2. Insert fingers (slowly and gently and apply gel)3. Feel for the cervix( os closed, downward and backwards,4.Feel for the fornices, the uterus is in the anterior fornix5. Give diagnosis6.

Breast exam1. Sitting=inspection ( 6 positions=hands on thighs, lean forward, hands on the waist, lift breats, squeeze the nipples)2. Lying= anti-clockwise palpation of the breast ( superficial and deep palpation). There is always a mass in GMC.3.Standing: Axillary lyph nodes.

PR Exam=1. Inpection of the buttocks and anus2. Place the finger on anal sphincter and wait for few seconds for the sphinter to relax.3. Insert: inside no faecal impaction, mass, ask to strain for prolpse.4.Feel for the walls5. Palpate the prostate through the anterior wall6. Give diagnosis( normal, unilateral BPH, Bilateral BPH, unilateral ca, bilateral ca)

Spacer1. This a volumetric device called spacer. It is used to administer medication to young children. It has 2 parts: This end here is called the mouth piece , this is where your child will have to make a tight seal of his mouth. This very side has got a valve which will be making a clicking sound each time he will breath in and out. It makes 1 click sound when you breath in and 1 clicking sound when you breath out.This other end is where you place the inhaler. Before you place the inhaler you need to prime it in air, just to make sure that it is working.2. Let your child sit up and make a tight seal of his mouth on the mouth piece.3.Give a 1 puff and let your child take 10 breaths. This will be equal to 20 clicking sounds.

4.Give break between inhalers5. Explain according to prescription e.g 2 puffs6. Explain how to use the mask-should cover both the nose and mouth

Food poisoning history and counselling

1. ODPARA of presenting complaint.2. Differential diagnosis3. Mangement: fluid replacement, advise about hygine, , rule out dehydration, isolate, Admit for observation.

PEFR and charts.1. Explain how to see the PEFR2. Ask him to take one reading, 3. Tell him needs to do it twice/trice a day and each time he has to blow it 3 days but to record only the highest. 4. Explain the 3 charts-Diary chart-Age, sex, height chart-Also you have a previous diary chartNB: makes sure you choose the correct chart male of female and check that patient understands.

Talking manikin shortness of breath/chest pain-do examination

1. Great , introduce yourself to the talking manikin2. Look at the monitor for observations: BP, Pulse, Pulse oxymetry, RR.

3. General inspection: hands, pulse, JVP, eyes , mouth, Peripheral oedema.4. Inspection of the chest just like normal CVS examination for apex beat, parastenal; heaving, palpable thrills, 5. Auscultation: listen with bell and diaphragm throughout all the 4 auscultations.6. Auscultate for basal crepitations just by placing the stethoscope under the manikin on the sides.(it wont sit up)

NB: there is a pansystolic murmur head through out the chest but loudest at the apex.Diagnosis is mitral stenosis.Managemeent: refer to the medical team.