SAMSON CLINICAL COURSES

PLAB 2 COURSE
E S
LONDON
R S
O U
C
O N
M S
S A By Dr. Samson
Edited 20TH MAY 2020
 CONTENTS:

Day 1: Introduction, History Taking Approach, Communication Tools,

SOFTEN, PEARL Protocols.
Day 2: History taking (Part 1)
Day 3: History taking (Part 2) and Psychiatry Scenarios
Day 4: History taking (Part 3) and Suspected Cancer

S
Day 5: Paediatrics

E
Day 6: Surgery Counselling, Explaining Investigations, Motivation Sta-
tions, Pregnancy, Sexual Health and Contraception

R S
Day 7: Medicine Counselling, Living Healthy, Transient Ischaemic At-
tack, Dis- charge Discussion and Follow up

O U
Day 8: Breaking Bad News, Palliative Therapy, Abuse, Medical Errors,

C
Angry Patients and Unhappy with Hospital Management

N
Day 9: Ethics, End of Life Discussions, Patients Refusing Treatment and

O
Culturally Competent Communications

S
Day 10: Medicine Clinical Examinations

M
Day 11: Manikins part 1

A
Day 12: Manikins part 2

S
Day 13: Orthopaedic and Surgical Examinations
Day 14: Diabetic Patients, Inter-personal skills, Pre-op Assessment,
Miscellaneous, Telephone Conversation
Day 15: Examinations, Talking manikins, Assessment of Acutely Ill Pa-
tients and Advanced Trauma Life Support (ATLS)
 DAY 1

Introduction to the course and the PLAB 2 exam:

• Introduction to PLAB 2
• About PLAB 2 (Watch GMC video)
• PLAB 2 marking system (Quantitative feedback)

S
• Top tips for PLAB 2 exam

E
• Common PLAB 2 mistakes

S
• Understanding your scores -Qualitative feedback from GMC website.

R
• Medical consultation ( Initial approach, first and second parts of con-

U
sultation)

O
• Listening skills

C
• PLAB 2 pass rates
• Why Samson Courses

N
• Dressing code (watch other doctors from GMC video)

O
S
• Body language
• SOFTEN approach

A M
S
1. Introduction to data gathering

• The P3MAFTOSA
• Presenting complaint
• Past medical history
• Family history
• Travel history
• Occupational social history
• Social history
• Anything else
 2. Urology history

3. Rheumatology history

4. Paediatric history

S
5. Surgical history

6. Communication tools

S E
• The Initial approach

U R
• Systemic review

C
• Effects of symptoms on patient’s life O
N
• ICE

O
• Sign posting

S
• Summarising

M
• Finish a consultation

S A
6. Responding to patient’s emotions
• EVE protocol
• PEARLS protocol
• Patient centered consultation (biopsychosocial module presentation)
• Building rapport with the patient (approach or presentation)

7. Practice
• Subconjunctival haemorrhage (184)
• Acute closed angle glaucoma (69)
 • Dizziness:
• Vestibular neuritis (102)

• Haematemesis (116)

• Chest pain:

S
• Acute coronary syndrome (33)

E
• Myocardial infarction and angiography explanation(33)

S
• Angina (215)

R
• Pericarditis (156)

U
• Shingles (234)

O
• Musculoskeletal chest pain (178)

• Sore throat:
C
N
•Tonsillitis in a woman (289)

O
S
• Musculoskeletal pains:

M
A
•Polymyalgia Rheumatica (143)

S• Sneezing in a 40 year old man (339)

 DAY 1:

Introduction to the course and the PLAB 2 exam:

● Introduction to PLAB 2
● About PLAB 2 (Watch GMC video)
● PLAB 2 marking system (Quantitative feedback)
● Top tips for PLAB 2 exam

E S
S
● Common PLAB 2 mistakes

R
● Understanding your scores -Qualitative feedback from GMC website.

U
● Medical consultation ( Initial approach, first and second parts of consulta-

O
tion)
● Listening skills

C
N
● PLAB 2 pass rates

O
● Why Samson Courses

M S
● Dressing code (watch other doctors from GMC video)
● Body language

S A ● SOFTEN approach

Top tips from PLAB examiner

1. Be yourself – just be a doctor, try not to think of this as an exam, but a

busy clinic day.
You have 18 consultations on your clinic list, you have time to have a look over
the patient’s notes before each one, and there may be some test results to check
too.
 You could be seeing a patient or perhaps a relative – this could be the first time

they have come in. You may be asked to provide advice for an ongoing condi-
tion or you could be asked to speak to a relative about a patient’s care.

Whatever you are faced with, you have eight minutes to complete the task and
you will be marked on three areas:

● Domain 1 – Data gathering, technical and assessment skills: covers

E
history taking, physical examination, practical procedures, investigations
S
S
leading to a diagnosis.

R
● Domain 2 – Clinical management skills: covers diagnosis, explaining

O U
something to the patient, formulating a management plan.
● Domain 3 – Interpersonal skills: covers how the candidate approaches

C
the station – whether they establish a rapport with the patient, how they

N
use open and closed questions, involving the patient in their care and how

S
ciples O
they demonstrate their professionalism and understanding of ethical prin-

A M
S
2. Communication is key
In my experience, one of the biggest factors to a candidate’s ability to perform
well in the test is their communication skills. This typically comes down to ver-
bal English language skills. There is a requirement to demonstrate English lan-
guage skills before applying to take the PLAB test. However, some candidates
struggle to communicate clearly in the test environment.
 3. Take the time to read the task
It’s really important to take the time to read the task and understand what is ex-
pected of you.
Make sure you think of how to approach the scenario in terms of the three do-
mains you will be marked on and make sure you cover all three elements for
each station.
Read the scenario carefully, including who you are and where you are working,
along with the patient, relative or colleague’s details.

E S
4. Keep up to date with any changes to the PLAB test

R S
U
In September 2016, there were a number of changes to PLAB 2. For example,

O
we extended the number of scenarios (from 14 to 18) and the time for each sce-

C
nario (from five to eight minutes). The scenarios are more reflective of a patient

N
consultation, rather than just asking a doctor to carry out a procedure. We also

O
now have a stronger focus on the professional values and behaviours expected

S
of doctors working in the UK, across both parts of the PLAB test

A M
What do you like about being a PLAB examiner?

SI find it very interesting. I get to meet a diverse range of doctors from all over
the world and with that, I get to see varying standards of medical practice. Some
are of an exceptionally high quality and others can be poor, with the majority in
between. I feel that I am doing a duty to my profession, by assessing the stan-
dards of doctors coming to practice in the UK.
 The feedback statements
The ten feedback statements are listed below.

Descriptions of the feedback statements you’ll receive for each station and what they
mean

F e e d b a c k
Description
statement

Disorganised / unstructured consultation. Includes illogical and

S
disordered approach to questioning. You did not demonstrate

E
sufficiently the ability to follow a logical structure in your consultation.

S
For example, your history taking may have appeared disjointed, with

R
Consultation
your line of questioning erratic and not following reasoned thinking.

U
You may have undertaken practical tasks or examination in an illogical

O
order that suggested you did not have a full grasp of the reason for

C
completing them or a plan for the consultation.

N
Does not recognise the issues or priorities in the consultation (for
example, the patient’s key problem or the immediate management of an

O
Issues acutely ill patient). You did not recognise the key element of

S
importance in the station. For example, giving health and lifestyle

M
advice to an acutely ill patient.

S A
Shows poor time management. You showed poor time management,
Time probably taking too long over some elements of the encounter at the
expense of other, perhaps more important areas.

Does not identify abnormal findings or results or fails to recognise their

Findings implications. You did not identify or recognise significant findings in
the history, examination or data interpretation.
Does not undertake physical examination competently, or use
Examination
instruments proficiently.

Does not make the correct working diagnosis or identify an appropriate

Diagnosis
range of differential possibilities.
 Does not develop a management plan reflecting current best practice,
Management
including follow up and safety netting.

Does not appear to develop rapport or show sensitivity to the patient’s

feelings and concerns, including use of stock phrases. You did not
demonstrate sufficiently the ability to conduct a patient centred
Rapport consultation. Perhaps you did not show appropriate empathy or
sympathy, or understanding of the patient’s concerns. You may have

S
used stock phrases that show that you were not sensitive to the patient

E
as an individual, or failed to seek agreement to your management plan.

S
Does not make adequate use of verbal & non-verbal cues. Poor active

R
listening skills. You did not demonstrate sufficiently that you were

U
Listening paying full attention to the patient’s agenda, beliefs and preferences.

O
For example, you may have asked a series of questions but not listened

C
to the answers and acted on them.

N
Does not use language or explanations that are relevant and

O
understandable to the patient, including not checking understanding.
Language

S
The examiner may have felt, for example, that you used medical
jargon, or spoken too quickly for the patient to take

A M
S
 Introduction to data gathering:

1. The P3MAFTOSA

● Presenting complaint
● Past medical history
● Family history
● Travel history
● Occupational social history

E S
S
● Social history

R
● Anything else

2. Urology history

O U
C
3. Rheumatology history

N
4. Paediatric history

O
5. Surgical history

M S
6. Communication tools

S A ● The Initial approach

● Systemic review
● Effects of symptoms on patient’s life
● ICE
● Sign posting
● Summarising
● Finish a consultation
 7. Responding to the patient’s emotions

● EVE protocol
● PEARLS protocol
● Patient cantered consultation (bio-psycho-socio-module presentation)
● Building rapport with the patient (approach or presentation)

HISTORY TAKING PROFORMA:

P3MAFTOSA

E S
P – Presenting complaint (SOCRATES/ODPARA)
P – Past Medical History
R S
P – Personal History
M – Medication History

O U
A – Allergy History

C
N
F – Family History

O
T – Travel History

S
O – Occupational History

M
S – Social History

A
A – Anything else you would like to tell me?

S1.PRESENTING COMPLAINT:

• SOCRATES (only for pain) or ODPARA (for other symptoms)

• Differential diagnoses

S – Site: Where is the pain, can you show me with one finger?
O – Onset: How did it start? Suddenly or gradually?
C – Character: What type of pain is it? Dull ache/compressing/sharp?
R – Radiation: Does the pain go/move anywhere?
 A – Associated: Differential diagnoses
T – Timing: Is there any specific time you experience the pain or when is it
worse? Is it always there or does it come and go?
E – Exacerbating and relieving factors: Is there anything that makes the pain
worse? Is there anything that makes the pain better?
S – Severity/Score: On a scale of 0 – 10, 0 being no pain and 10 being the
worst, how would you score your pain?

S
O – Onset: How did it start? Suddenly or gradually?

E
D – Duration: When did it start? or How long have you had these symptoms

S
for?

R
P – Progression: Is it becoming worse, improving or is it the same?

U
A – Aggravating factors: Anything which makes it worse or anything which

O
brings it on (if intermittent symptoms)?

C
R – Relieving factors: Anything which makes it better?
A – Associated symptoms: Differential diagnoses

O N
M S
2. PAST MEDICAL HISTORY:
• Do you have any medical conditions?

A
• Have you ever been admitted to hospital for any reason?

S
• Have you ever had any operations performed on you?
• Do you have any medical conditions like asthma, high blood sugar / high
blood pressure / heart problems /epilepsy/stroke?

3. PERSONAL HISTORY:

Sexual history: ( You should be non judgemental and comfortable with

sexual history)
 I need to ask you a few personal questions, if you find it a little bit a little too
much, please let me know and I will stop.
Sexual practices:
• Are you sexually active?
• Is your partner male or female?
• Do you practice safe sex? By this, I mean do you use condoms?
• What kind of sexual intercourse do you usually practice? Oral, vaginal, anal ?
• When was your last sexual intercourse?
• Have you ever had sexual intercourse for casual purposes?

E S
S
• How many sexual partners have you had in the 6 months?

R
• Have you travelled abroad? Did you have sexual intercourse with anyone

U
when you while you were abroad?

O
Relationship

C
• Are you in a stable relationship?
• Are you married?

N
Previous infections and testing:

O
• Have you ever had a sexually transmitted infection before?

M
Symptoms:
S
• Have you ever been tested for STI such HIV, chlamydia or gonorrhoea?

A
• Are you experiencing any discharge from your penis or vagina?

S
• Any burning sensation when passing urine?
• Any ulcers or lumps around your genital areas?
• Are running any temperature?
 Partners
• Is there any chance you could have any other partner ?
• How many partners did you have in the past 6 months?
Symptoms in partner:
• Is your partner experiencing symptoms such as discharge from the private
parts, pain or lumps anywhere?

S
Tracing contact: ( This is where there has been exposure)

E
• Did you have sexual intercourse with your partner or your wife after that?

S
• What kind of sexual intercourse did you have with your partner? oral , anal

R
or vaginal?

U
• Did you have sexual intercourse with anyone else after that ?

Menstrual History:
• When was your last menstrual period?
C O
O N
• Are your periods normally regular?
• How many days do you bleed?

M S
• How many days is your menstrual cycle?
• Do you pass any clots?

A
• Are your periods painful?

S• Are your periods heavy?

• When was your last cervical smear?
• What were the results of your last cervical smear? (Ask only if patient had a
previous cervical smear.)
• Do you use any type of contraception? (If yes, you need to ask further.
Which contraception are you using?)
 Drug Abuse History

• Use of recreational drugs:

• Is there any chance you use recreational drugs?

• Type of drugs - What kind of drugs do you use?

S
• Route - How do you take these drugs?

E
• Duration - For how long have you been taking them?

S
• Other drugs - Do you use any other drugs?

R
• With whom? Who do you do drugs with?

U
• Withdrawal - If you stop taking these drugs, do you develop any withdrawal

O
symptoms? What kind of symptoms do you usually develop?

C
• Previous attempts:
• Have you ever attempted to stop using recreational drugs?
• Needle:
• Do you use needles?

O N
S
• Do you share needles with other people?

M
S A
Needle Exchange Program
• Do you know about needle exchange program?
• Do you use the needle exchange program?
• Is there any particular reason you do not use the needle exchange program?

Safe guarding issues

• Who else is at home?
• Do you use drugs at home?
• Are there any children at home?
• Do you ever take drugs in front of your children?
 Social services
• Have safe guarding issues ever been raised about your children?
• Have the child protection services ever been involved?

Social history:
• Where do you get drugs from?
• What do you do for your living?

S
• How to you get money to buy drugs?

E
• Have you ever been in problems with the law?

S
• Do you have any siblings ?

R
• Are you parent around?

U
• Do they know you use recreational drugs?

O
• How do your family feel about you using drugs?

C
• Would your family or partner be supportive of you while trying to stop us-
ing recreational drugs?

N
• Does your partner use recreational drugs?

S O
M
4. MEDICATION HISTORY:

A
• Are you taking any regular medication?

S
• Are you taking any over the counter (OTC) medication?
• Are you on any type of contraception (for females of reproductive age only)?

5. ALLERGY HISTORY:
• Are you allergic to anything?
• Are you allergic to any medication?
• If yes: What happens when you take it?
 6. FAMILY HISTORY:
• Anyone in the family with similar conditions or problems?
• Anyone in the family with heart problems, high blood pressure, high blood
sugar levels or asthma?

7. TRAVEL HISTORY:
• Have you travelled abroad recently?

S
• If yes, where did you travel?

8. OCCUPATION HISTORY:

S E
• What do you do for a living?

U
• Are you retired? What did you use to do for a living? R
9. SOCIAL HISTORY:

C O
N
• Who do you live with?

O
• Do you live in a house or a bungalow?

S
• Do you walk independently? (For elderly patients or patients with disabilities)

M
• Is there anything that is causing you stress in your life?

A
• Are you married? Do you have any children?

S
• Do you smoke? If the patient says no, ask if he/she has ever smoked.
• Do you drink alcohol?
• Has this affected you at home or at work?

10. ANYTHING ELSE:

Is there anything else you would like to tell me about your condition?
NB: Ask these questions after taking a full history of the presenting complaint
 1. RED EYE - 168

ODPARA of Red eye

O – Onset: How did it start? Suddenly or gradually?
D – Duration: When did it start? Or How long have you had these symptoms

for?

S
P – Progression: Is it becoming worse, improving or is it the same?

E
A – Aggravating factors: Anything which makes it worse or anything which

S
brings it on (if intermittent symptoms)?
R – Relieving factors: Anything which makes it better?

A – Associated symptoms: Differential diagnoses

U R
Differential Diagnosis:
C O
N
● Bacterial conjunctivitis (purulent discharge, red eyes, stickiness of the

O
S
eyelids, especially in the morning, vision is usually not affected)
● Viral conjunctivitis (watery discharge, red eyes, foreign body sensation

AM in the eyes)

S
● Cluster headache (severe unilateral headache in a middle-aged man,
headache occurs in clusters, associated with lacrimation of red eye)
● Acute closed-angle glaucoma (acute pain in the eye, reduced vision, red
eye, nausea and vomiting)
● Sub-conjunctival haemorrhage (spontaneous blood shot eye, no pain,
vision not affected, usually occurs after patient has been rubbing the eye
or in elderly patients with hypertension)
● Trauma
 ● Rheumatoid arthritis (iritis): (symmetrical polyarthritis, especially of
the small joints, red eye is due to anterior uveitis)
● Iritis/Anterior uveitis (ankylosing spondylitis, usually a young man with
back pain, plus or minus family history of similar complaints or a family
history of back pain in young males)

● SLE (iritis, polyarthritis, young female, butterfly rash on the face)

S
● Inflammatory bowel disease (iritis, can be unilateral or bilateral, chronic
diarrhoea, abdominal pains)

S E
R
● Reiter’s syndrome (conjunctivitis, arthritis and urethritis, positive sexual

U
history)

O
● Foreign body (foreign body sensation in the eye, patients usually re-

C
member an episode when they felt something entered their eye)

N
Questions for differential diagnosis

O
S
● Bacterial conjunctivitis
! Any discharge from your eyes?

AM ! Is it a clear discharge or thick pus-like discharge?

S
! Any matting of your eyes in the morning?
● Viral conjunctivitis
! Is the discharge watery?
● Cluster headache
! Is it associated with headaches? If yes, is this the first time? Does
the headache come at a particular time of the day?
● Acute closed-angle glaucoma
! Any pain in your eye?
! Is your vision affected?
 ● Sub-conjunctival haemorrhage
! Are you taking any medication like aspirin or warfarin?
● Trauma
! Did you sustain an injury to your eye?
● Rheumatoid arthritis

S
! Is there any joint pains?

E
● Iritis/Anterior uveitis (ankylosing spondylitis)

S
! Any back pains?

R
! Anyone else in the family with similar complaints?

U
● SLE

O
! Any fever, joint pain, swollen joints?
! Butterfly rash?

C
N
● Inflammatory bowel disease

O
! Are you experiencing any diarrhoea? Have you noticed any blood

S
in your stool?

M
● Reiter’s syndrome

A
! Any discharge from your penis/vagina?

S ● Foreign body
! Any gritty sensation in your eye?
 Scenario 184

You are FY 2 in GP surgery. A 50-year-old male has made an urgent appointment to see
you. Take a focused history and discuss management.
Patient Information:
You are a 50-year-old man who woke up this morning with a red eye. It is very red but no
pain. You do not have any other symptoms; no vomiting or headache. You are normally fit

S
and well and not on any medication. You are worried that you could lose your vision.

E
Questions:

S
What do you think is happening doctor?

R
Will I lose my vision?

U
Is it something serious?

O
Is there any treatment?

C
Emotions:
You look worried and are sitting on chair.

N
Examiners Prompt:

O
Fundoscopy is normal and provide a photograph

M S
S A
Approach to scenario 184

● Initial Approach or GRIPS

● ODPARA
● Differential Diagnosis
● Red Flags
● MAFTOSA
● ICE
● Summarise
 ● Examination
○ Observations
○ Examination of the eye, including the back chamber ( fundoscopy)
○ Check pressure in the eye
● Explain the findings
● Diagnosis

S
● Sub-conjunctival haemorrhage. It is caused by bursting of small blood

E
vessels in the eye.

S
● Management:

vessels to burst.

U R
○ Check BP as sometimes if the BP goes up it can cause small blood

C
○ Advise not to use aspirin or NSAIDs. O
○ Artificial tears to reduce irritation if it causes discomfort in the eye.

N
○ Reassure that it is a self-limiting condition.

O
S
○ Resolves within 12-14 days.
○ Leaflets

AM
S
● Safety Netting:
Advise patient to come back if any of the following happen:
○ Visual loss
○ Severe pain
○ Photophobia
○ Coloured haloes around the light
○ Pain in the eye
 Practical Scenario

E S
R S
"

O U
C
N
69

S O
AM
S
 2. DIZZINESS

Description of Dizziness
Can you tell me what you mean with dizziness?
Do you have an experience of buildings rotating around you?

S
FODPARA of Dizziness:

E
F – Frequency: How often do you experience dizziness?

S
O – Onset: How did the dizziness start? Suddenly or gradually?

R
D – Duration:

U
● When did it start?

O
● How long have you had the dizziness for?

C
● How long does the dizziness last? A few seconds, minutes, hours or days?

N
● Have you ever experienced dizziness before?

O
P – Progression: Is it becoming worse, improving or is it the same?

M S
A – Aggravating factors:
● Is there anything that triggers the dizziness?

S A ● Does head or neck movement trigger your dizziness?

● Does coughing, sneezing and straining trigger your dizziness?
● Did you recently have any viral illness – cough, runny nose, sneezing?
● Does standing from sitting or lying down provoke your dizziness?
● Does standing for a long time make you dizzy? If you don’t eat on time,
do you experience dizziness?

R – Relieving factors:
● Is there anything that makes the dizziness better?
● Does your dizziness improve when you sit down?
 ● Does it become better if you don’t move your head?
● Does vomiting makes it better?
● Does closing the eyes makes it better?
● Does lying down makes it better?
A – Associated symptoms: Differential diagnoses

S
Differential Diagnosis:

E
● Panic attack (SOB, feeling of impending doom, peri-oral paresthesia,
butterflies in the stomach)

R S
U
● Trauma (there will be history of trauma).

O
● Acute otitis media (earache, ear discharge, fever, history of recent upper

C
respiratory tract infection)
● Labyrinthitis (recent history of flu-like illness, dizziness)

O N
● Benign positional vertigo (symptoms worse in the morning when wak-

S
ing up, especially when changing posture e.g. turning in bed or rising

M
from a supine to a sitting position in bed)

A
● Stroke (usually in an elderly patient, weakness of the legs, speech or

S
swallowing difficulty, any weakness on the face)
● Anaemia (light-headedness, weakness, fatigue, tiredness, history of use
of NSAIDs or aspirin)
● Acoustic neuroma (hearing loss, dizziness, progressive headaches, fami-
ly history of similar complaints)
● Meniere’s disease (intermittent deafness, dizziness, tinnitus)
● Brain tumours (weight loss, headache, vomiting, weakness in the limbs,
any other focal neurological symptoms)
 ● Postural hypotension (side effects of drugs especially thiazides, typical
presentation is a hypertensive patient on anti-hypertensive medication)
● Hypoglycaemia (usually in a diabetic patient)
● Medications - ototoxicity (e.g. gentamicin)

Questions for differential diagnosis

S
● Panic attack

E
! Do you ever experience shortness of breath or chest pain together

● Trauma
with the dizziness?

R S
U
! Is there any chance you could have hurt your ear?

O
C
! Did you sustain a head injury?
● Acute otitis media

N
! Are you running a temperature?

O
● Labyrinthitis

M S ! Any nausea?
! Any problems with the balance?

S A ! Have you recently had any flu like illnesses?

● Benign positional vertigo
! Is the dizziness worse in any particular position?
● Stroke
! Any weakness in the legs or arms?
! Any speech problems?
● Acoustic neuroma
! Have you lost weight recently? If so, quantify.
! Do you feel tired all the time?
! Any hearing problems? Was it gradual?
 ● Meniere’s disease
! Any ringing in the ears?
! Any hearing problems?
! Do you also feel sick with the onset of dizziness?
! Any feeling of fullness in the ear?
● Postural hypotension

S
! Does the dizziness start on sitting up from lying position or stand-

E
ing up from sitting position or standing for long period of time?

S
● Hypoglycaemia

R
! Have you been told your blood sugar levels are low?
● Medications

O U
! Are you on any medication for your symptoms?

C
O N
M S
S A
 Scenario 102

You are FY 2 in in A&E. A 25 years old lady presented with dizziness. Please take a
focused history, assess and discuss management with the patient.
Patient Information:
You are having dizziness. You feel like the building is spinning around. You went to the
marker shipping and you suddenly felt dizzy when you turned your head to look at your
friend. Your symptoms started 3 hours ago. You could not stand. You felt sick but did not

S
vomit. You felt this until the ambulance came. 2 weeks ago you had a flue (cough, fever,

E
running nose and sore throat). Your ears feels blocked. The flue symptoms are completely

S
gone now.

R
Questions:

U
Q. What is wrong with me doctor?
Q. What are you going to do for me?

O
Q. Is it something serious?

C
Q. Can it be stroke?

N
Q. Do you think it can be stroke?
You are sitting on a chair with a bucket in your hands as if you are about to vomit.

S O
AM
Approach to scenario 102

S ● Initial Approach or GRIPS

● ODPARA
● Differential Diagnosis
● Red Flags
● MAFTOSA
● ICE
● Effects of Symptoms
● Summarise
 ● Examination
a. Observations
b. Eye examination
c. Neurological examination
d. Cranial nerve examination
e. Gait, rombus test.
● Explain the findings

E S
S
● Diagnosis

R
Summarise the findings and give diagnosis.

U
So you have told me that you developed sudden onset of dizziness today while

O
you were shopping when you turned your heard

C
You mentioned that about 2 weeks ago (10 days ago) you had flu like symptoms

N
like flu, sneezing, cough, runny nose

O
Is there anything else i have missed. Now from this information, I feel that you

S
have a condition called Vestibular Neuritis, it is an inflammation of the nerves

M
responsible for balance.

S A
MB: If a task says perform relevant examination, such as assess the patient, then
you must examine the patient unless stopped by examiner.

Management
● Bloods ( FBC, GS, inflammatory markers )
● Opinion from seniors
 ● Reassure that it normally resolves on its own within a few days.
But we will make sure that there is nothing else causing your
symptoms other than infection of the nerve.

● Admit under medical team

● If there is repeated vomiting give iv fluids
● Leaflets

E S
R S
O U
C
O N
M S
S A
 3. HAEMATEMESIS

Nature of Haematemesis
● What is the colour of your vomit?
● How many times did you throw up?
● Did you see blood in it?

ODPARA of haematemesis

E S
S
O – Onset: How did you vomiting start? Suddenly or gradually?

R
D – Duration: When did it start? Or How long have you had these symptoms
for?

O U
P – Progression: Is it becoming worse, improving or is it the same?

C
A – Aggravating factors: Anything which makes it worse or anything which

brings it on ()?

O N
S
R – Relieving factors: Anything that makes it better?
A – Associated symptoms: Differential diagnoses

AM
S
Differential Diagnosis:
● Peptic ulcer (upper abdominal pain worse with meals)
● Gastric erosions (aspirin, NSAIDS, clopidogrel, warfarin)
● Oesophagitis (GERD - reflux symptoms e.g. heartburn, sour taste in the
mouth, ± recurrent chest infections)
● Mallory–Weiss tear (usually follows binge drinking, patient vomits
small amount of blood, retching before vomiting starts)
● Gastric carcinoma (weight loss, epigastric pain, anaemia, weakness, el-
derly patient, early satiety)
 ● Oesophageal carcinoma (progressive dysphagia for solids, initially for
solids only and then liquids as well, weight loss, elderly patient)
● Bleeding diathesis (check for a family history of bleeding disorders)
● Oesophageal varices (history of alcohol abuse or any chronic liver dis-
ease)

● Instrumentation (recent endoscopy or any other instrumentation)

E S
Questions for differential diagnosis
● Peptic ulcer disease

R S
! Any abdominal pain?

O U
C
! Does the pain changes with food intake?
● Gastric erosions

N
! Are you taking any regular medications?

O
! Any over the counter medications, like aspirin, naproxen, ibupro-

M S fen?
● Oesophagitis

S A ! Any heartburn or sour taste in mouth?

! Any recurrent chest infections?
● Mallory-Weiss tear
! Were you retching before you started vomiting blood?
! Do you drink alcohol? If yes, were you drinking just before you
started vomiting?
● Gastric carcinoma
! Have you lost weight recently? If yes, quantify.
! Do you feel tired all the time?
! Do you feel satisfied after eating small meals?
 ● Oesophageal carcinoma
! Have you lost weight recently, If yes, quantify.
! Do you feel tired all the time?
! Do you ever experience difficulty in swallowing?
● Bleeding diathesis
! Anyone in the family with bleeding problems?

S
● Oesophageal varices

E
! Do you drink alcohol? If yes, how much?

S
! Any liver issues?

R
● Instrumentation

U
! Any recent endoscopy or any other instrumentation?

Red Flags

C O
N
● Tachycardia

O
● Melena

M S
● Dysphagia
● Epigastria mass

S A● Jaundice
● Weight loss
 Scenario 116

You are FY 2 in A&E. A 32 years old female presented with vomiting blood.
BP 100/80 HR 110 RR 18 O2 sat 96%
Take a focused history, discuss differential diagnosis with the patient and inform him of
your next management plan
Patient Information:
You have been vomiting dark blood (coffee ground) since 3 hours ago. You have vomited

S
twice; once before coming to the hospital and once in the hospital. The amount was about

E
three small cups full. No abdominal pain/abdominal pain. Abdominal pain started after

S
vomiting. It started suddenly. You drink one bottle of wine everyday and smoke 15

R
cigarette per day for past 10 years/does not smoke. You have been taking ibuprofen (at

U
least 5 times a week), diclofenac (400mg three times a day) and aspirin for past 6 months.
You are feeling weak and dizzy, no blood in stools. You take ibuprofen for hangover due

O
to alcohol. You have No colour changes in stool.

C
Questions:

N
Q. What is wrong with me?

O
Q. What are you going to do for me?

S
Q. Will I go home today?
Q. What has caused this?

M
Q. When the doctor tells you about endoscopy you ask: “will it be painful?”

A
Examiner’s prompt:

S
PR: normal
Abdominal pain-tenderness in epigastrium/no findings
Observations (verbally) BP 100/70 HR 110 and everything else is normal

Approach to scenario 116

● Initial Approach or GRIPS

● ODPARA
● Differential Diagnosis
 ● Red Flags
● MAFTOSA
● ICE
● Effects of Symptoms
● Summarise
● Examination

S
a. Observations

E
b. Abdominal exam
c. Per rectal exam

R S
U
! Explain the findings

O
● Diagnosis

C
Explain possible causes (medication Ibuprofen, diclofenac, aspirin)
1. It could be due to the medication you have been taking. Because di-

O N
clofenac/Aspirin/Ibuprofen can all cause damage to the lining of the

S
stomach. This could be the most likely cause

M
2. Bleeding due to Alcoholic Liver Disease.

A
Management

S
● Admit
● Monitors
● IV fluids.
● Bloods – FBC, U&E, LFT, clotting, glucose, group & save
● Emergency Endoscopy (to go and see where the he is bleeding from)
● Advice to stop smoking.
● If he needs blood transfusion, does he have any restrictions to blood
transfusions.
● Give leaflets about blood loss.
 4. CHEST PAIN

SOCRATES for chest pain

S – Site: Where is the pain , can you show me with one finger?
O – Onset: How did it start? Suddenly or gradually?

C – Character: What type of pain is it? Dull ache/compressing/sharp?

S
R – Radiation: Does the pain move/go anywhere?

E
A – Associated: Differential diagnoses

S
T – Timing: Is there any specific time you experience the pain or when is it

R
U
worse? Is it always there or does it come and go?

O
E – Exacerbating and relieving factors: Is there anything that makes the pain

C
worse? Is there anything that makes the pain better?

N
S – Severity/Score: On a scale of 0 – 10, 0 being no pain and 10 being the

O
worst, what would be the score of your pain?

M S
Differential Diagnosis:

A
● Myocardial infarction (central crushing chest pain radiating to the left

S
arm or throat, lasting >20 minutes, nausea, sweating in palms, middle-
aged or elderly patient)
● Angina (chest pain lasts < 20 minute, may be difficult to differentiate
from MI)
● Thoracic aneurysm (chest pain radiating to the back)
● Pulmonary embolism (haemoptysis, chest pain, SOB, positive risk fac-
tors e.g. long flight, postoperative, immobility)
● Pericarditis (pleurisy chest pain, relieved by leaning forward, mild grade
fever)
 ● Pneumonia (fever, cough with sputum, SOB, chest pain)
● Tension pneumothorax (sudden onset SOB, chest pain, usually in a tall,
thin young man)

● Trauma
● Musculoskeletal pain (usually after strenuous exercise e.g. after gym,
there is usually tenderness on palpation of the chest)

S
● GERD (heart burn, sour taste in the mouth ± recurring chest infections)
● Costochondritis (pain along the ribs)

S E
R
● Shingles (rash, usually starts from the back to the front along the inter-

U
costal spaces, usually in immunocompromised patients e.g. elderly pa-

O
tients, patients on steroid, patients with cancer)

C
● Fractured rib (history of trauma, localised tenderness)

N
● Oesophageal spasm (retrosternal chest pains)

O
● Pleurisy (pain on inspiration, usually after URTI)

M S
Questions for differential diagnosis

A
● Myocardial infarction

S
! Do you have central chest pain? Does it radiate?
! How long have you had this pain?
! Do you have nausea or sweating?
● Angina
! Is the pain less than 20 minutes?
! Have you ever been diagnosed with angina?
! Have you had these pains before?
● Thoracic aneurysm
! Does the pain radiate to the back?
 ● Pulmonary embolism
! Do you have blood in your sputum?
! Is there any shortness or breath?
! Have you been on long flight or had operation recently or been
immobile recently?
● Pericarditis

S
! Have you been feeling feverish?

E
! Does the pain improve on leaning forward?

S
● Pneumonia

R
! Do you have any fever?

U
! Do you have cough? Any discharge in sputum?

O
C
! Any shortness of breath?
● Tension pneumothorax

N
! Do you have any shortness of breath? Did it start suddenly?

O
● Trauma

M S ! Did you injure yourself recently?

● Musculoskeletal pain

S A ! Have you recently done a lot exercise?

! Does it hurt to touch?
● GERD
! Do you have sour taste in mouth or burning in throat?
! Do you have recurring chest infection?
● Costochondritis
! Do you have pain along your ribs?
● Shingles
! Did you notice any rash, particularly in the back coming to the
front?
 ! Are you on any medicines like steroids?
● Fractured rib
! Have you recently fractured your rib?
! Does it hurt to touch?
● Oesophageal spasm
! Is your pain on and off?

S
● Pleurisy

E
! Do you have any pain during breathing in?

S
! Have you recently had cough, runny nose or sore throat?

Red Flags

U R
O
Pain not relieved with nitrates, pain on exercise or nausea, vomiting or sweat-
ing.

C
O N
M S
S A
 Scenario 33

You are FY 2 in A&E. A 57 years old man presented with chest pain. An
electrocardiogram has been done. Take a focused history, perform relevant examination
and discuss management with the patient.
Patient Information:
You have presented with central crushing chest pain that radiates to the neck and left arm.
The severity of pain is 7/10. Nothing makes it better or worse. You smoke 20 cigarettes

S
per day for the last 20 years. You drink 2-3 units of alcohol per week and take a well

E
balanced diet. Your brother who is 47 years of age had a heart attack 2 years ago. You are

S
worried you could have a heart attack. You developed severe chest pain 3 hours ago while

R
you were making breakfast, the pain radiates to left arm and to the jaw.

U
Questions:
Q. Will I go home today?

O
Q. What is wrong with me?

C
Q. How long will I stay in the hospital? (only if candidate says you need admission)

N
Q. Which blood thinning tablets will you give me?

O
Q. What if it is a heart attack, what will you do?

S
Q. What is an electrocardiogram?
Q. What are there zig zag lines on this paper?

AM
SApproach to scenario 33
● Initial Approach or GRIPS
● SOCRATES
● Differential Diagnosis
● Risk factors for MI: DM, hypertension, family history, smoking, previous
IHD and high cholesterol)
● Red Flags
● MAFTOSA
● ICE
 ● Effects of Symptoms
● Summarise
● Examination
a. Observations
b. CVS exam
c. RES exam

S
● Explain the findings

Diagnosis

S E
hours ago.

U R
You have told me that You had a sudden onset of chest pain which started 4

C O
You mentioned that the pain is crushing in nature and it radiates to the throat .
The pain made you sick but you did not vomit. You also mentioned that your

N
brother and father had a heart attack. Is there anything i missed?

O
S
Explain the diagnosis:

M
A
Explain that from what you have told me unfortunately, I feel that your chest

S
pain is coming from the heart. And unfortunately, it could be a heart attack. But
it could also be a simple Angina attack. So we need to perform some investiga-
tions and blood tests to make sure that you have not suffered a heart attack.

Management
● GTN
● We need to connect you to the monitors just to check that your oxygen
levels in your blood are normal
● Give blood thinner tablets: Aspirin, clopidogrel,
 ● Take bloods (FBC, U&E, cardiac enzymes, cholesterol, clotting profile)
and give morphine and metochlopramide (anti sickness medication)
● Explain that you need to perform an ECG. Once the examiner has given
you the ECG then explain whether it is normal or has a heart attack .This
is bad news.

● Give you also a blood thinner injection ( LMWH subcutaneously)

S
● Take a second opinion from my senior colleague
● Refer to Cardiologist

S E
R
● Admit you to the Coronary Care Unit ( CCU)- this is the ward where we

U
admit anyone suspected of a heart attack.

O
● When you go to the coronary care unit the cardiologist might need to per-

C
form what we call an angioplasty.

N
● Angioplasty is a procedure where a catheter is inserted through the groin

O
all the way to the heart. A dye is injected which maps out the blood ves-

S
sels.

M
● Blocked blood vessels become visible and a stent is inserted.

A
● If there are too many blocked blood vessels, you might need a different

S operation which we call bypass operation.

● It is a big operation so it is usually done on a separate day.

Complications
● Anaphylaxis: if it happens we will give you a medication to treat it
● Pain on the site: can take analgesia.
● Bleeding at the site: we will be keeping a close eye on it.
● Can affect the kidneys but we will give you fluids to prevent that from
happening.
 Scenario 178

You are an FY2 in A&E. A 25 years old man has presented with chest pain. Take a
focused history, assess the patient and discuss management.
You fell 3 days ago and now have chest pain on the left side. The pain is on lower ribs.
You thought the pain would go away but it didn't go away.
Q. What is wrong with me?
Q. What are you going to do for me?
Q. Is it a heart attack?
Q. I heard that other people have their heart on the right? Do I?

E S
Approach to scenario 178
● Initial Approach or GRIPS

R S
● ODPARA

O U
C
● Differential Diagnosis
● Red Flags
● MAFTOSA

O N
S
● ICE
● Effects of Symptoms

AM
● Summarise

S
● Examination
a. Observations
b. Chest exam
c. Palpation of chest for tenderness
● Explain the findings

● Diagnosis
Explain that it is most likely to be musculoskeletal pain
 ● Management
a. Analgesia-ibuprofen
b. Chest X ray
c. Blood tests
d. ECG
e. Leaflets

S
f. Warning signs: chest pain radiating to neck, back or throat, palpita-

E
tions and shortness of breath

R S
O U
C
O N
M S
S A
 Scenario 156

You are an FY2 in A&E. A 25 years old man presents with chest pain. Take a focused
history, assess the patient and discuss management.
Patient information
You have chest pains for last 2 days. 10 days ago you had viral illness. You have a dull
central chest pain, relieved by leaning forward and worse on inspiration.
Questions:

S
Q. What is wrong with me?

E
Q. What are you going to do for me?

S
Q. What does ECG show?

R
Examiners Prompt:

U
Observations chart and ECG in the cubicle

Approach to scenario 156

● Initial Approach or GRIPS
C O
● ODPARA

O N
S
● Differential Diagnosis

M
● Red Flags

A
● MAFTOSA

S
● ICE
● Effects of Symptoms
● Summarise
● Examination
a. Observations
b. Chest exam
● Explain the findings
 ● Diagnosis
From what you have told me and from the examination that I have performed, it
looks like you unfortunately have pericarditis. It is inflammation of the layer
surrounding the heart.
● Management
a. Routine bloods

S
b. Chest X ray

E
c. ECG
d. Admit

R S
U
e. Analgesia ( NSAIDS)

Practical scenarios

215, 234
C O
O N
M S
S A
 5. SORE THROAT

FODPARA of sore throat

F – Frequency: How frequently do you get the sore throat?
O – Onset: How did it start? Suddenly or gradually?

D – Duration: When did it start? Or How long have you had these symptoms

S
for?

E
P – Progression: Is it becoming worse, improving or is it the same?

S
A – Aggravating factors: Anything which makes it worse or anything which

brings it on (if intermittent symptoms)?

U
R – Relieving factors: Anything which makes it better? R
C
A – Associated symptoms: Differential diagnoses
O
Differential Diagnosis:

O N
S
● Tonsillitis (fever, difficulty in swallowing, sore throat, cough, sneezing)
● Upper respiratory tract infection (cough, sneezing, runny nose, fever)

AM● Instrumentation (recent history of procedure carried out in the throat)

S
● Laryngeal carcinoma (weight loss, progressive symptoms, hoarseness of
voice, smoker, elderly patient)

● Laryngitis (cough, sneezing, ±fever)

● Foreign body (history of foreign body ingestion)
● Trauma
● Voice abuse (over-shouting e.g. football supporters)
● Glandular fever or infectious mononucleosis (coryza, symptoms like
cough, runny nose, sneezing, low-grade fever, sore throat, rash, cervical
lymphadenopathy).
 ● HIV (Prodrome period of HIV can present with glandular fever-like ill-
ness i.e. fever, myalgia, pharyngitis, headaches, diarrhoea, lym-
phadenopathy, neuralgia, maculo-papular rash).

Questions for differential diagnosis

● Tonsillitis

S
! Do you have any fevers?

E
! Did you experience any difficulty in swallowing?
! Do you have any cough?
● Upper respiratory tract infection

R S
● Instrumentation

O U
! Do you have any cough, fever, runny nose or sneezing?

C
! Have you recently had a procedure carried out in the throat?

N
● Laryngeal carcinoma

O
! Have you recently lost weight? If yes, quantify.

M S ! Are the symptoms getting worse with time?

! Have you noticed your voice becoming hoarse?

S A ! Do you smoke? If yes, how much and for how long?

● Laryngitis
! Do you have a cough?
! Have you been sneezing?
! Do you have a fever?
● Foreign body
! Is there a history of foreign body ingestion?
! Possibility of unintentional foreign body ingestion?
● Trauma
! Have you recently sustained any trauma?
 ● Voice abuse
! Are you a teacher or singer?
! Have you excessively used your voice recently?
● Glandular fever or infection
! Do you have runny nose, sneezing and low-grade fever recently?
! Have you noticed a rash on your body?

S
! Do you feel your neck glands are increasing in size?

E
● HIV

S
! Do you have fever, myalgia, headaches, diarrhoea or rash on your

body?

U
! Did you notice any lumps and bumps on your body? R
C O
! Do you use recreational drugs, have unprotected sex or have multi-

ple blood transfusions in the past?

Typical approach:

O N
M S
● Initial Approach or GRIPS
● ODPARA

S A● Differential Diagnosis
● Red Flags
● MAFTOSA
● ICE
● Effects of Symptoms
● Summarise
● Examination
● Explain the findings
● Diagnosis
● Management
 Practical scenarios

289

E S
R S
O U
C
O N
M S
S A
 6. MUSCULOSKELETAL PAINS

The Nature of the pains

● Where are the pains?
● Is it one joint or more?
● Are they most painful first thing in the morning or later in the day?

SOCRATES

E S
S
S – Site: Where is the pain? Can you show me with one finger?

R
O – Onset: How did it start? Suddenly or gradually?

R – Radiation: Does the pain move/go anywhere?

O U
C – Character: What type of pain is it? Dull ache/compressing/sharp?

A – Associated: Differential diagnoses

C
N
T – Timing: Is there any specific time you experience the pain or when is it

O
S
worse? Is it always there or does it come and go?
E – Exacerbating and relieving factors: Is there anything that makes the pain

AM
worse? Is there anything that makes the pain better?

S
S – Severity/Score: On a scale of 0 – 10, 0 being no pain and 10 being the
worst, what would be the score of your pain?

Swelling:
● Do your joints swell?
Stiffness:
● Are your joints stiff when you wake up in the morning?
● Do you experience stiffness in your joints when you wake up in the
morning?
 ● How long does it take you to get the joints going?

Differential Diagnosis:
● Fibromyalgia (memory loss, muscle pains, fatigue, extreme exhaustion
lasting more than 24 hours after physical exercise)
● Malignancy (weight loss, loss of appetite, anorexia, weakness, fatigue)

S
● Polymyalgia rheumatica (muscle pains and stiffness often occur in the

E
shoulders, neck, arms and hips, usually associated with GCA)
● Drug side effects e.g. statins
● Chronic fatigue syndrome
R S
O U
● Dermatomyositis (body rash, muscle weakness, especially of the hips,

C
thighs, upper arms, shoulders etc.)
● Polymyositis

O N
● SLE (butterfly rash on the face, joint pains)

S
● Rheumatoid arthritis (multiple symmetrical joint pains, red eye may

M
suggest iritis, episcleritis or scleritis)

A
● Rhabdomyolysis

S
● Myofascial pain syndrome
● Porphyria

Questions for differential diagnosis

● Fibromyalgia
! Have you noticed any problems with memory?
! Do you have muscle pains and fatigue?
! Do you have exhaustion lasting more than 24 hours after exertion?
 ● Malignancy
! Any history of weight loss? If yes, quantify?
! Do you have weakness, fatigue and are generally unwell?
● Polymyalgia rheumatic
! Do you have stiffness in muscles especially shoulders, neck, arms
and hips.

S
! Have you every been diagnosed with giant cell arteritis?

E
● Drug side effect

S
! Are you taking any regular medication?

R
! Are you on statins?
● Chronic fatigue syndrome
● Dermatomyositis

O U
C
! Have you noticed any body rash?

N
! Do you experience muscle weakness, especially in hips, thighs,

O
upper arms and shoulders?

M S
● Polymyositis
● SLE

A
! Any fever, joint pain, swollen joints?

S ! Butterfly rash?
! Rheumatoid arthritis – maybe caused by gastroenteritis or urethritis.

Gastroenteritis usually caused by campylobacter, salmonella, clostridium

etc. and urethritis usually by chlamydia trachomatis.
! Do you have pain in multiple joints?
! At what time of day is the pain worst?
! Does the pain improve on movement?
 ● Rhabdomyolysis
! Have you recently worked out excessively?
! What is the colour of your urine?
! Any local tenderness?
● Myofascial pain syndrome
! Does the pain feel to be deep in the muscle?

S
! How has your sleep been recently?

E
● Porphyria

S
! Do you have chest/abdominal/leg or back pain?

R
! What is the colour of your urine?

U
! Do you feel more confused or find it difficult to concentrate?

O
C
! Do you have any nausea or vomiting?

O N
M S
S A
 Scenario 191

You are an FY2 in GP surgery. A 40 years old lady presented with pain in her hands. She
is a smoker. Take history, assess the patient and discuss management with the patient.
Patient Information:
You have pains in hands on both sides. You have gradual onset of pain for past 3-4 weeks.
Work as a secretary in a hospital and find that pain is worse when typing. You also have
morning stiffness in both hands. You live with your husband and smoke 10 cigarettes per

S
day for past 20 years. You have tried to use paracetamol but it did not help.

E
Questions:

S
Q. What could be the cause of the pain?

R
Q. Can I use ibuprofen?

O U
C
Approach to scenario 191

N
● Initial Approach or GRIPS

O
S
● ODPARA

M
● Differential Diagnosis

A
● Systemic Review

S
● Red Flags
● MAFTOSA
● ICE
● Effects of Symptoms
● Summarise
● Examination
a. Observations
b. Exam of hands
c. Functional assessment
 ● Explain the findings

● Diagnosis
Explain that it is most likely rheumatoid arthritis but we would need to investi-
gate to confirm it.

S
● Management

E
• Routine bloods tests
• Rheumatoid factor

R S
U
• Inflammatory markers

O
• Ibuprofen and PPI

C
• Refer to rheumatologist: they may assess again and may start you
on some medication called disease modifying agents: DMARDs

O N
• Refer to occupational therapist and physiotherapist for advice on

S
how to manage work and to advice about exercises to help pain and

M
mobility respectively.

A
• Warning signs: Return to hospital in case of fever and redness of

S
joint

Practical scenarios

143