This page will have exam materials for all the specialities as well as PLAB, and other exams. Always questions first and you can try the questions and then contact us we will send you the answers.

This MCQ is about paediatric A&E, written by Dr Nagi Barakat

1-The following features are true for children presented with status asthmaticus

a- Able to talk

b- Respiratory rate of more than 40 breaths per minute

c- Capillary refill time is usually less than 2 seconds

d- Using accessory muscles

e- No wheezes on auscultation

2-In respiratory acidosis associated with acute respiratory failure, the following are correct

a- PH is less than 7.35 Kpa

b- PCO₂ is low

c- PO₂ is normal

d- PH is more than 7.36 kpa

e- HCO₃ is low or normal

3-The alpha-adrenergic affect of adrenaline is

a- Elevates the systolic blood pressure

b- Increases renal blood flow

c- Increases myocardial contractility

d- Relaxes bronchial muscles

e- Enhances delivery of oxygen to the heart

4-True or false about history of excessive bleeding in children

a- Bleeding into skin or muscle may be an indication of intrinsic factor problem

b- Spontaneous bleeding mucus membrane could be due to extrinsic factor problem

c- Spontaneous bleeding into skin is often due to platelets defect

d- Isolated bleeding from gastrointestinal tract is usually an indication of bleeding disorders

e- Brisk bleeding from mucocutaneous membrane is criteria of DIC

5-Children presented to A&E with purpuric rashes may suffer from

a- ITP

b- Septicaemia

c- SLE

d- Viral infection

e- NAI

6-In anaphylactic reaction

a- It only affects organ systems when mast cells concentration are abundant

b- Upper and lower respiratory tract are affected

c- Intravenous epinephrine of 1:1000 should be given with dramatic improvement

d- Intravenous aminophylline is contraindicated

e- Shock is due to intravascular fluid loss

7-Electro-physiological changes occurring in pyloric stenosis include

a- Urea increased

b- Metabolic acidosis

c- Hypocalcaemia

d- Hypercholraemia

e- Hypokalaemia

8-These are true about acute appendicitis in children

a- Abdominal pain & tenderness are almost always present

b- Presence of leucocytes in mid-stream urine is an indication of perforation

c- Rectal examination should be performed in all children

d- Blood glucose test is not required in children presented with suspected appendicitis

e- Inflamed appendicitis lies posterior to caecum and peritoneum may not show rebound tenderness

9-True or false about burns in children

a- Children with 10% burns of body surface area should not be admitted to hospital

b- Involvement of both arms and posterior trunk will be calculated as 36% burns

c- Intravenous colloids can be given as % of burns x body weight over 8 hours

d- Silver nitrate dressing is contraindicated for burns affecting the face

e- Dextrose/saline intravenous fluid is not recommended as a resuscitating fluid

10- These are good indicators for lead poisoning

a- Basophilic stippling of RBCs

b- Detection of urinary coproprophyrin

c- Raised transaminase

d- Raised serum aminolevulinic acid level

e- Target cells on blood film

11-In children with sequestration crisis of sickle cell disease, which of the following occur:

a- Increased RBCs destruction

b- Sudden enlargement of spleen

c- Raised transaminase

d- Abdominal pain

e- Profound decline in circulating RBCs

12- Which of the following statements are true about acute mesenteric lymphadenitis

a- Associated with gram negative organism infection

b- Rebound and tenderness is often present

c- Leucocytosis is uncommon

d- Pain and tenderness is more diffuse than with appendicitis

e- Usually associated with large inflamed tonsils

13-Migrain in children is often associated with the following

a- Bilateral headache

b- Headache is often described as a band round the head

c- Diplopia

d- Abdominal pain

e- Hallucination

14-The common causes of hypernatraemic dehydration in children are

a- Nephrogenic diabetes insipidus

b- Diabetic ketoacidosis

c- Profuse sweating

d- Salicylate poisoning

e- Congenital adrenal hyperplasia

15-The commonest organisms causing meningitis in children at all ages are

a- H. Influenza

b- N. Meningitides

c- E. Coli

d- Streptococcal pneumonia

e- Mycobacterium

16-In Salicylate poisoning, metabolic acidosis develops as result of which of the following

a- Salicylic acid

b- Increase in organic ketoacids

c- Hypoglycaemia

d- Loss of fixed base

e- Renal tubular leakage

17-Low CSF sugar in bacterial meningitis is due to which of following

a- Increased glucose utilisation by the brain

b- Defective glucose transport from blood to CSF

c- Increased glucose utilisation by bacteria in the CSF

d- Increased insulin production

e- Increased glucose utilisation by RBCs

18-The following organisms are causing purulent otitis media in children

a- Staph aureus

b- H. Influenza

c- Beta haemolytic streptococcus

d- Streptococcal pneumonia

e- Adenovirus

19-Renal calculi in children is often presented with

a- Iliac fossa or abdominal pain

b- Haemturia

c- Proteinuria

d- Urinary tract infection

e- Vomiting

20-These are true about hypoglycaemia in children

a- Increase in plasma glucagons

b- Increase in plasma cortisol level

c- Increase in C-peptides

d- Decrease in growth hormone level

e- Increase in insulin level

21-These are the most common causes of haemturia in children

a- Urinary tract infection

b- Postural hypotension

c- Sickle cell anaemia

d- Acute golmerulonephritis

e- Rota virus infection

22-The following drugs can be used in management of acute supraventricular tachycardia in infants

a- Digitalis

b- Flecanide

c- Morphine

d- Adenosine

e- Verapamil

23-The most common causes of stridor of 2 weeks old newborn are

a- Laryngeal web

b- Vascular ring

c- Tracheal Haemangioma

d- Hypocalcaemia

e- Thyroglossal duct remnant

24-Rectal bleeding in 3 years old child may be due to

a- Anal fissure

b- Child sexual abuse

c- Haemorrhoids

d- Milk allergy

e- Meckel’s diverticulum

25- The following statements are true about Diabetic Ketoacidosis (DKA) in children

a- Can be presented with nausea and vomiting

b- Abdominal pain is always one of the associated features

c- Insulin sliding scale is the current management

d- Addition of potassium chloride is not required in first two hours of DKA management.

e- Deficit and maintenance fluid should be given in first 24 hours.

26-Which of the following are good clinical markers of Child Sexual Abuse (CSA)

a- Ano-genital warts

b- Anal fissure

c- UTI in girls

d- Herpes simplex vagnitis

e- Laceration of penis

27- The following statements are true about status epilepticus in children

a- It can be defined if seizure lasts more than 30 minutes

b- The commonest cause is bacterial meningitis

c- Intravenous Lorazepam is superior to IV diazepam

d- Intravenous phenytoin may cause skin burns in young children only

e- EEG is often normal following febrile status epilepticus

PLAB two questions by seven sisters.

100 questions.

History, Physical Examination & Counselling:
Q.1: IDDM: Annual Check up.
1. Measure Body Weight.
2. Examine the eyes:
a. Xanthelasma and arcus.
b. Visual acuity (maculopathy).
c. Test eye movements (Mononeuritis multiplex, III, IV, VI CN).
d. Ophthalmoscopy (cataract, rubeosis iridis, retinopathy, vitrous haemorrhage).
3. Mouth: candidiasis.
4. Neck: listen for carotid bruit (atherosclerosis).
5. Upper limb:
a. Blood pressure (sitting and standing for postural hypotension, and hypertension).
b. Radial pulse (for resting tachycardia).
c. Inspect hand for wasting of thenar (carpal tunnel syndrome), hypothenar and interossei muscles (ulnar nerve palsy). Index for infection of prick site, ask the patient to do prayer sign (joint contracture).
6. Chest: auscultate for signs of TB, pneumonia, or CCF.
7. Examine lower limb:
a. Inspection:
i. Foot for ulcer, gangrene, callus, infection at prick site. In between toes and look for small muscle wasting, pes cavus, claw toes.
ii. Ankle: for deformity (charcot joint, OHCS, 5th ed. p668)
iii. Leg: for muscle wasting.
iv. Knee: for deformity (charcot joint).
v. Thigh: for injection sites (infection, lipo-atrophy, lipo-hypertrophy), muscle wasting (especially quadriceps for diabetic amyotrophy).
b. Foot pulses:
i. Dorsalis pedis: on dorum of foot just lateral to extensor hallucis tendon
ii. Posterior tibial: 1-2cm below and behind medial malleolus
c. Tendon reflexes:
i. Ankle jerk (S1): lower limb flexed at knee and extended at ankle by hand of examiner and ankle put at dorsum of opposite foot (can be abscent in elderly)
ii. Knee jerk (L3, L4): lower limb flexed at knee to 60° and carried by hand.
iii. Plantar reflex (S1, S2): rake with blunt object along lateral border of foot from heel to little toe (can be extended in Diabetic amyotrophy).
d. Sensory exam:
i. Joint position: ask the patient to close eyes. Show him up and down positions first. Then start form interphalangeal (IP) joint of hallux holding proximal and moving distal phalanx. If sensation is impaired, move to metatarso-phalangeal (MP) joint, ankle and knee.
ii. Vibration: ask the patient to close eyes, apply tuning fork to sternum, to establish baseline sensation. Test base of big toe, medial malleolus, tibial shaft and tuberus of anterior iliac crest.
iii. Touch: ask the patient to close eyes, use cotton piece. Ask the patient to respond verbally. Examine segments in turn and compare.
iv. Pain: Ask the patient to close eyes and to respond verbally. Use disposable pin, establish baseline sensation at the sternum. Test segments in turn and compare. Ask patient to report if quality of sensations changes (hypo or hyper-aesthesia).
v. Temperature: ask the patient to close eyes. Use two containers of warm and cool water; or use a cold subject (e.g. tuning fork). And ask the patient about quality of sensation (test segments in turn and compare).
vi. Deep pain: ask the patient to close eyes. Apply firm pressure to nail or squeeze the calf belly. And ask the patient to report pain.
e. Power (motor system): Test from proximal to distal.
i. Flex, extend, abduct, and adduct hip joint.
ii. Flex, and extend knee joint.
iii. Dorsiflex (L5), plantarflex (S1), invert, and evert foot.
iv. Flex, and extend toes.
f. Sensory loss in DM:
i. Early: vibration, deep pain, and temperature.
ii. Later: joint position sensation.
g. Investigations:
i. Glycosylated Hb (HbA1c): relates to blood glucose level over 6-8 weeks (normal: 2.3-6.5%).
ii. Glycosylated plasma proteins (fructosamine): relates to blood glucose level over 1-3 weeks.
iii. Urine for glucose, Ketones, and Albumin (macro and micro-albuminuria).
iv. Blood for plasma creatinine, and lipids.
h. Questions to ask:
i. Review of self-monitoring results and injection techniques.
ii. Review of eating habit.
iii. Ask about symptoms of hypoglycemia.
iv. Talk about general and specific problems.
v. Education.

Q.2: Examine the lower limbs of a diabetic patient.
Introduction, and then you may say: “As far as I know you have high glucose level, I would like to examine your legs. Can you please slip off cloths from your bottom half to your underwear?”
1. Observe patient's gait.
2. Inspection:
a. Foot: for ulcer, gangrene, infection, callus at prick sites (heel and heads of metatarsals). And look for small muscle wasting, pes cavus, claw toes, loss of hair, and trophic (waxy) changes.
b. Ankle: for deformity (charcot joint).
c. Leg: for muscle wasting.
d. Knee: deformity (charcot joint).
e. Thigh: for injection sites (lipo-atrophy, lipo-hypertrophy, infection). Quadriceps (diabetic amyotrophy).
3. Palpation:
a. Pulses: (always compare bilaterally)
i. Dorsalis pedis: on dorsum of foot, just lateral to extensor hallucis tendon.
ii. Posterior tibial: 1-2cm below and behind medial malleolus.
iii. Popliteal: flex knee to 30°, press firmly with thumbs in front, and four fingers of both hands posteriorly over popliteal artery below knee.
iv. Femoral: midway between anterior superior iliac spine and pubic tubercle (lateral extension of pubic hair).
b. Palpate for temperature changes, with dorsum of hand.
c. Palpate hind foot, mid foot, and fore foot (MP, IP joints). Compress fore foot for tenderness.
d. Reflexes:
i. Ankle jerk (S1): lower limb is slightly flexed at knee, and extended at ankle, which is placed on the dorsum of opposite foot.
ii. Knee jerk (L3, L4): lower limb is flexed at knee to 60آ؛, and held by hand of examiner.
iii. Plantar reflexes (S1, S2): rake, with blunt object, lateral border of foot. (extension is noted in amyotrophy).
e. Sensory:
i. Joint position: show the patient up and down and then ask him/her to close eyes. Start from IP of big toe. Hold the proximal part and move the distal one, if impaired then move downwards to MP, ankle, knee.
ii. Vibration: ask the patient to close eyes, and apply TF to sternum for baseline sensation. Test base of big toe, medial malleolus, tibial shaft, tibial tuberosity, and anterior iliac crest.
iii. Touch: ask the patient to close eyes. Use cotton piece. Examine segments in turn.
iv. Pain: ask the patient to close eyes. Use disposable pins and start from sternum for baseline sensation. Test segments in turn and ask the patient to report if quality of sensation changes (hypo-, or hyper-aesthesia).
v. Temperature: ask the patient to close eyes. Use two containers of warm and cool water. Or you may use cold object (e.g. TF). And ask the patient about quality of sensation he/she felt. Test segments in turn.
vi. Deep pain: ask the patient to close eyes. Apply firm pressure to toe nail and squeeze calf belly. Ask the patient to report pain.
f. Motor System:
i. Power:
• Flex, extend, abduct, and adduct hip joint.
• Flex, and extend knee joint.
• Dorsiflex (L5), plantar flexion (S1), invert and evert foot.
• Flex, and extend toes.
ii. Tone:
• Rotate the foot (ask the patient to relax).
• Rotate the leg, internally and externally, with knee extended.
• Flex and extend knee.
For segment distribution, dermatomes check OHCM, 4th Ed, p 410.

Q.3: Diabetic coma (M. X.). Explain to examiner.
1. Hypoglycemia:
a. Blood Glucose <2.5 mmol/L.
b. Clinical Findings: autonomic symptoms (sweating, tremor, pallor). Neurological symptoms (irritablity, abnormal behaviour, drowsiness, convulsion, focal neurological sings, and coma). None specific symptoms like nausea, tiredness, and headache.
c. Management: if in doubt, take blood sample for test and give glucose bolus injection before results are out. (50 ml 50% Dextrose IV, followed by Normal Saline flushing. Or give Glucagone 1mg IM).
2. Diabetic Ketoacidosis(DKA):
a. Clinical findings: nausea, vomiting, abdominal pain. Signs of dehydration. Hyperventilation (Kussmall Breathing). Ketotic (acetone) breath smells. Neurological symptoms (confusion, stupor, coma).
b. Management:
i. Insulin: 10 u IV stat, then by pump according to Insulin sliding scale. If no pump available 10 u IM stat, then 6 u IM/hr.
ii. Fluid: 1L N/S over ½ hr, 1L /1hr, 1L /2hrs, 1L /4hrs, 1L /6hrs, till when blood glucose < 15 mmol/L then change to 4% Dextrose, 0. 18% N/S.
iii. Add KCL 20 mmol to all fluid except the first liter (Contraindicated in Renal Failure, and if K+ >6)
iv. Before starting treatment take blood for glucose, U & E, Osmolality, Blood Gases, FBC, Blood C/S, urine for Ketones and C/S. Then measure Blood Glucose and U & E hourly.
v. Insert N/G tube. Chart vital signs, B. Glucose, coma level, Input/Output.
vi. Consider cathetrisation if no urine for 4 hours.
vii. Treat infections with antibiotics.
viii. Shift to SC Insulin and allow by mouth intake when Ketones level <1+.

Differences between Hypoglycemia and DKA coma:

Hypoglycemia DKA
Moist skin and tongueFull pulseNormal, or high blood pressureNormal breathingHyper-reflexia Dry skin and mouthWeak pulseLow blood pressureHyper-ventilationHypo-reflexia

3. Hyperosmolar Non-Ketotic Coma:
a. Clinical findings: typically affects elderly NIDDM, severe dehydration, no acidosis, focal neurological signs may be found, increased risk of DVT.
b. Management:
i. Fluid: N/S half rate of fluid given in DKA.
ii. Insulin: wait after fluid correction, since insulin may not be needed then. But, if needed give 1 u/hr.
iii. Heparin: prophylactic for DVT risk.

Q.4 A 24 year-old female patient presents with vaginal bleeding and 8 weeks of secondary amenorrhea. Take history, make a diagnosis, and discuss management plan.
Introduce yourself. And you may, then, start by saying: ” As far as I know, you didn’t have your periods for the last 8 weeks, and now you have bleeding from your down below. I would like to ask you some questions, and then I will explain to you what we will do”. (You may ask her if it is ok, then proceed with your questions).
When did the bleeding happen? (Or you may ask) when did you first notice the bleeding? Can you describe the bleeding for me? Is it bright red? (Abortion). Or dark red or brown? (Ectopic pregnancy). Is it heavy bleeding with clots? Or just slight blood loss? Have you felt any pain in your tummy? (Site, and character). Have you always had regular periods? Do you think you might be pregnant?
Do you feel sick? Is there any pain in your breasts? Did you notice if your breasts enlarged lately?
Do you use any contraceptive method? What kind you use? IUCD, pills? (IUCD, Progesteron Only Pill risk ectopic pregnancy).
Have you ever had ectopic pregnancy? Have you ever had previous miscarriages? Have you ever had vaginal discharge? Any recurrent pain in the lower part of your tummy? (PID).
Have you ever had any previous operation in your tummy? (appendectomy,C/S).
How have you been feeling in yourself recently? Any stress in job or at home?
Have you experienced any pain between shoulder blades?
Do you have any pain when passing water? Any burning sensation?
How is your bowel motion?
Do you have any medical problem? Do take any medication?
Do you have any bleeding from other sites?
Have you suffered any dizziness? Have you fainted?
After finishing the History taking, you may proceed by saying: “Now I would like to examine you, and after exam we need to run some tests especially pregnancy test to make sure if you are pregnant or not. And we need to do ultrasound examination (ask the patient if she knows what U/S is about, and shortly explain if necessary) to be sure that the possible pregnancy is in the right place, which is in your womb”.
Don’t worry, you will be all right, we will look after you.

Q.5 A young lady presenting with vaginal bleeding and left iliac fossa pain. Take history, and establish differential diagnosis.
Introduce yourself, and you may continue by saying: “As far as I know, you have bleeding from your down below, and you feel pain in the left lower part of your tummy. I would like to ask you a few questions about your condition”.
Can you describe the bleeding for me? Is it bright red? (Miscarriage). Or dark red or brown? (Ectopic pregnancy). Is it heavy bleeding with clots? How many tampons (or pad) you use? Is it heavy bleeding (miscarriage), or slight blood loss? (Ectopic pregnancy).
Can you tell exactly where the pain is? Can you tell what it feels like? Did the pain started before bleeding? (Ectopic pregnancy). Or you saw bleeding before feeling pain? (Miscarriage).
How was your periods? Regular, irregular?
Have you ever had unprotected sexual contact? Do you think you are pregnant? Do you feel sick? Is there any breast discomfort, pain, or enlargement?
Do you use contraception? What kind? (IUCD & progesterone only pills® Ectopic pregnancy).
Have you ever had ectopic pregnancy before? Any miscarriages?
Have you ever had vaginal discharges before? Or recurrent pain in lower part of your tummy? Have you ever had any operation before, especially in your tummy (ask about appendectomies, Cesarean section).
Differential diagnosis:
1. Ectopic pregnancy
2. Miscarriage (Threatened or Inevitable).
3. Chronic PID.
4. Dysfunctional Uterine Bleeding.

Q.6 Amenorrhoea of nine months, Take history to reach a diagnosis.
Introduce yourself, and then you may say: “As far as I have been told, you did not have your periods for the last nine months. I would like to ask you few questions about your condition”.
How old were you when you had your first period? Were your periods regular before? Have you become pregnant before? How many times? When was the last time? Have you ever had miscarriages before? Have you ever had problems during your pregnancies? Have you ever had any kind of Termination Of Pregnancy? Any D&C? (think of Ascherman Syndrome).
Were your deliveries normal? Any difficulties? Any bleeding following deliveries? (Sheehan Syndrome.).
Do you use contraception? What kind do you use? (Post pill amenorrhea and amenorrhea after injectables).
Do you feel tired, sleepy? Have you had any (temperature) fever recently? (General illness).
Did you notice any change in weight? Are you on any kind of diet? (Decreased in Anorexia Nervosa, general illness, increased in Polycystic Ovary Syndrome).
Any recent dislike of hot weather, sweating, tremor, diarrhoea? (Hyperthyroidism).
Any recent increase in hair growth in your face, on your breasts or on your tummy? Did you notice any deepening of your voice? (Virilization).
Have you notice any milky discharge from nipple recently? Any disturbance of vision? (Hyperprolactinoma).
How have you been feeling in yourself for the last year? Any stress in job or at home? Any change of environment? (Stress may cause amenorrhoea).
Are you on any medication? Do you feel any mass in your tummy?

Differential diagnosis:
1. Ectopic pregnancy.
2. Miscarriage (Threatened, inevitable).
3. Chronic PID.
4. Dysfunctional Uterine Bleeding.

Q.7 Hormone Replacement Therapy (HRT): Counseling.
Introduction, then you may begin by saying: “I have heard that you are here to discuss HRT. You know every woman goes through the menopause. This occurs when a woman’s ovaries produce no more the female sex hormones, which are oestrogen and progesterone. Oestrogen has an effect on every cell in the body, whether it is in the skin, bone, blood vessels, womb and vagina. So when the level of oestrogen in the body fall, women get features of hot flushes, night sweats, mood changes, forgetfulness, sleep disturbances, and loss of concentration. In addition, lack of oestrogen causes a type of protein, called collagen, to be gradually lost from the skin, so the skin become thinner, drier, and easily bruised. Also the vagina becomes thinner, less flexible, drier leading to painful sexual intercourse, and less resistant to infections. But the most important effect of oestrogen lack, is on the bones causing what we call osteoporosis, which means that the bones loose mass so they become weak, brittle, and much more likely to break causing number of minor injury such as a fall. Another important effect is on the heart, where before menopause women rarely get heart diseases, while after menopause, the possibility of getting heart attack increases. And within 10 years they catch up with the heart attack incidence in men. Fortunately, there is an effective way of dealing with the problem that is the use of HRT, which consists of these lacking hormones, oestrogen and progesterone.
There are many ways of taking HRT; the first is tablets, which are taken by mouth every day, the second is patches that stick to the skin and should be changed twice weekly. Another way is implants that are inserted under the skin under local anesthesia and their effect lasts for 3-6 months. The fourth way is the gel, which is applied to the skin daily. But you should not bath after application for 1 hour. If vaginal dryness is the main problem, we could give you cream or pessary to place inside the vagina.
With HRT, hot flushes usually disappear within few weeks. It also helps dryness of vagina, improves mood, and sleep disturbances. And the most important effect of HRT is that it can dramatically decrease the risk of osteoporosis, hence fractures. And substantially decreases the risk of heart attacks.
There are very few reasons why a woman cannot take HRT, such as in liver disease, cancer of the womb, or cancer of the breast, and in case of abnormal bleeding from vagina that has no obvious cause. Like any other medication HRT has some side effects, most of them are minor and often disappear if you stop the treatment. Some women feel sick, that is with tablets. Some may put on weight, some may get breast pain and mood changes before periods, which will re-appear with HRT. Some may get skin irritation with the usage of patches. With the use of oestrogen hormone there is a slight increased risk of womb cancer and to decrease that risk we add progesterone, which has protective effect on the womb. Therefore, in women who have had their womb removed this combination of drug is not necessary. The most common reason people are worried about in HRT, is breast cancer, however if you use HRT for five years the risk still minimal. But once you get beyond that e.g. 10-15years then risk tends to increase bit more and we usually teach women how to do self-examination of the breast. Also, we tell them to report, immediately, any vaginal bleeding if happens. One more thing is that HRT is not a contraception method and the woman should continue to use her usual contraception method for one year after the last menstrual period.
Patches, implants, and gel can be taken with liver disease.





Q.8 a female patient asks for permanent sterilization. Take history & counsel her.
Introduction, then you may say: “As far as I know you want to do permanent sterilization. I would like to ask you a few questions, and discuss the condition with you.
How old are you? Do you have children? How many? Do you have a partner? Does he know about your decision? Does he agree?
Why do you want to be sterilized? Do you know about contraception methods available, such as OCP, coils, condoms, diaphragm and cups?
Female sterilization is a procedure by which the fallopian tubes that are the tubes between the womb and ovaries are cut, sealed or blocked. This stops eggs moving down them to meet sperms. The operation can be done in several ways; the most common method is by the use of laparoscopy. This is usually done with the use of General Anesthesia, where you will be put to sleep; a doctor will make two tiny cuts, one just below your navel and the other and the other just above the bikini line in the lower part of your tummy, they will then insert a laparoscope which is a thin telescope-like instrument with magnifying lenses to look at your reproductive organs. The second way is by what we call it mini-laporatomy, usually done under General Anesthesia, the doctor will make a small cut in your tummy, just below the bikini line to reach the Fallopian Tubes. The third way is to reach the reproductive organs through the vagina. The fallopian tubes are then blocked either by tying (ligation), or by removal of a small piece, and then sealed by heat, Or by applying clips or rings.
The period you need to stay in hospital depends on type of anesthesia and operation. It is usually around couple of days. After operation if you have General Anesthesia you may feel unwell for few days and you may have some bleeding and pain, which are slight. You must consider sterilization as permanent method of contraception.
However, there is an operation to reverse sterilization, but it is complicated and may not work. The failure rate of female fertilization is 1-3 per 1000. Pregnancy rate after reversal is around 50% with high risk of ectopic pregnancy.
The advantage is that it does not interfere with sex; your womb and ovaries will remain in place. Ovaries will still release an egg every month. Your sex drive and enjoyment will not be affected. Actually they may improve, as fear of pregnancy is no more an issue. Occasionally some women find their periods to be heavier, but it is usually because of their age and stopping contraceptive pills. You can start sex as soon as comfortable. You must continue contraception until time of operation and if you use ICUD, it should be left till the next period. You should contact your doctor if you think that you are pregnant, of if you missed a period and especially it’s accompanied with tummy pain.
Q.9 A girl on the pills. Explain.
Introduction, I have heard that you are here to discuss OCP. There are two main types of OCP.
The first type is Combined Oral Contraceptives (COP): Where the tablet contains two hormones, Oestrogen and Progesterone. This type stops woman releasing an egg each month.
Advantages: A very reliable method of contraception with less than 1/100 will get pregnant in a year. It does not interrupt sex, often decreases bleeding, period pain and Premenstrual Tension. It also protects against cancer of womb and ovaries.
Disadvantages: The most important disadvantages are the risk of vascular diseases as clot in the leg, heart attack, and stroke. That is why it should not be given to women at risk of these diseases. Women with cardiac diseases, liver diseases, some cases of migraine, gross obesity and immobility also abnormal vaginal bleeding. It should be stopped in a smoker at age of 30 yrs and should not be used by breast-feeding mothers.
How to take the pills: they should be taken daily for 21 days, and stopped then for 7 days. Taking pills should starts on the first day of cycle (the first day when blood is seen), on the day of Termination Of Pregnancy, 3 weeks postpartum (if the mother is not breast-feeding the baby), and 2 weeks after major surgery (if the patient is immobilized). If the pills are forgotten for more then 12 hrs, you should keep taking the pills as usual thereafter, but you should use another type of contraception for seven days. This is also applied in case of diarrhea where you should use another type of contraception on the day of diarrhea and for another 7 days thereafter. It is also applied in case of taking of drugs known to interfere in the action of Combined Oral Contraceptive pills like anticonvulsants, and antibiotics.
If you start taking OCP you have to come for follow up every 6 months to check your BP, and do Breast exam (if >35 yrs).
OCP should be stopped in case of severe headache, severe chest pain, and tummy pain.
The second type is POP (Progesterone Only Pills): this type contains only the Progesterone hormone which causes changes making it difficult for sperm to enter the womb or for womb to accept a fertilized egg, and in some women it prevents the release of eggs.
Advantages: it is a reliable method, with careful use; the failure rate is 1/100 per year. It does not interrupt sex. It is useful for women who smoke and those who cannot take COP for any cause. Also it can be taken in breast-feeding mothers.
Disadvantages: it has some side effects like headache, acne, putting on weight. The periods may be irregular with some bleeding in between. And it is less reliable than COP.
How to take the pill: the same as COP, and should be taken at the same time of everyday. If you miss by 3 hours, you should use another type of contraception for a week and also if you get diarrhea, use another type of contraception for the period of diarrhea and for one week thereafter.
Any woman on OCP should have every 6 months check of: BP, breast exam, cervical smear.

Q.10 Vasectomy, explain the operation and the side effects.
Introduction, then you may say: “As far as I know you asked about sterilization that is what we call vasectomy.
Vasectomy is the procedure by which tubes that carry sperms from your testicles to the penis are cut and blocked. This operation is usually done under local anesthesia. That is the type of anesthesia that numbs the (sac) scrotal area. So you will be awake during the procedure but you will not feel pain. The doctor will make a small cut in the skin of the scrotum, which is the sac of the testicle to reach the tubes, then will remove a small piece of each tube and close the ends.
The cuts will be very small and you may not need any stitch, but if needed, dissolvable stitches will be used. The operation takes 10-15 minutes and you will be able to leave the hospital shortly afterward. But you should not drive yourself home; you should rest for the remainder of the day. The stitches used are dissolvable and will disappear within a week. After the operation the scrotum may feel bruised, swollen and painful. You can help that by wearing tight-fitting underpants to support your scrotum day and night for one week. Avoid heavy exercise for at least a week.
Some men may get bleeding or infections. If this happens you should contact your doctor. You can have sex after the operation as soon as it is comfortable; however, you have to use another method of contraception until sperms disappear from your seminal fluid, and this may take up to 2-3 months. We have to have 2 clear semen tests so that you can rely on vasectomy for contraception. Your testicle will continue to produce male hormone as before, your sex drive, ability to have erection and climax will not be affected. The appearance and amount of semen should be the same as before. There is a suggestion about link between vasectomy and cancer of testicle and prostate but it is not yet proven.
You should consider vasectomy as a permanent method of contraception. Reversal is complicated and may not work. Failure rate is 1/1000-2000 and reversal rate is as 50%. You should not attempt vasectomy if you are not sure that you don’t want more children and you should discuss it carefully with your partner as well as the possibility of the use of available method of contraception.
It doesn’t protect against STD.

Q.11 a 30 years old with cervical smear results of severe dyscaryosis (CIN-III). Counsel, give explanation and advice about colposcopy, and biopsy
Introduction, then you may start as follows: “Now we have had the results of your cervical smear test back and it showed some changes in the lower part of your womb, that is the neck of your womb.
Now we need to do further exam called colposcopy, which is a simple exam that allows the doctor to have a closer look at the changes on the neck of your womb. You will lie comfortably on bed, and the doctor will gently insert a speculum into your vagina just as when you had your cervical smear done. After that the doctor will look by a colposcope that is a specially adapted type of microscope. It is just a large magnifying glass with a light source attached to it. It does not touch you nor gets inside you. The doctor will then dab liquids onto the neck of your womb, which helps the area with changes to appear white and if any such area appears then the doctor will take a sample of tissue (which is just a size of pin head). The exam takes about 15 minutes it should not be painful, may be a bit uncomfortable. You may feel a slight stinging during the tissue sample taking.
After colposcopy, if you have had a biopsy, you may have a light blood stained discharge for few days, this is nothing to worry about and should clear by itself and it is better to avoid sexual intercourse for 5 days to allow site to heal.
You will get the results back of your biopsy after one or two weeks, they will tell you about that. If the result showed any condition that needs treatment, the doctor will tell you about the treatment, which is simple, and virtually 100% effective. The treatment is usually carried out with the use of colposcopy and the procedure is similar to your initial exam. There are several ways of treatment, either to apply heat or freeze the area or apply laser. All treatment types aim at destroying the cells with changes. After treatment you may need to have blood stained discharge for 2-4 weeks during which and with periods you will need to use sanitary towels rather than tampons and it is better to avoid heavy exercise and sexual intercourse to allow the area to heal.
The treatment will have little or no effect on your further fertility, nor on risk of having miscarriages. After treatment you will have a follow up visit after 6 months during which you will have a cervical smear and colposcopy exam and if everything is satisfactory you will have a follow up smears every year for the following 4-5 years.
NB: you are welcome to arrange for a friend or relative to come with you for colposcopy. You may need to bring a sanitary towel with you just in case some discharge appears.
Intercourse does not make the condition worse, enjoy sex as usual but use effective contraception, it is important not to get pregnant until the condition is dealt with. This is because hormones during pregnancy make treatment more difficult. You cannot pass changes or abnormal cells to your partner.
Abnormal smear does not mean cancer, it is very common 1/12, it is just a warning sign and the treatment is simple and virtually 100% effective.
Colposcopy is performed in lithotomy position and liquid used is 5% acetic acid.

Q.12/A A patient is diagnosed to have ectopic pregnancy. You decided to do laparoscopy. Explain that to her.
Introduction, then you may start by saying: “Now, we have had a good look at your tests that we run. And according to the results of the tests, the examination, and what you complained of, there is a high possibility that you have what we call ectopic pregnancy that is a pregnancy outside your womb. This can be in the tubes between your womb and ovaries as in most cases, or at the ovary or inside the tummy, which is very rare.
And since the pregnancy is not in the usual place, it cannot continue to term. In addition, it may bleed suddenly or even cause damage to the tube, which could cause you some harm.
To avoid these problems, we have first to be sure that you have ectopic pregnancy and the best way to do this is by laparoscope. That is the procedure by which we insert a tube with lenses within a small incision in your tummy, after we put you into sleep. So we could look at your womb and tubes. And to treat the condition, there are two ways. Either by laparoscopy, where we could either, inject a medication called methotrexate or remove the pregnancy by incision. The second way to deal with this condition is by operation to remove the pregnancy. And in either ways of treatment we will try to conserve the tube, but if it is damaged by this condition, then the only way to deal with it, is to remove the tube.
Is everything clear or do you want me to repeat anything for you?
Are there any questions that you would like to ask me?
You will remain for 2-3 days in the hospital.
You can return to work after 6 weeks (sick leave).
The doctor will make 2 incisions, one just below the navel and the second above the bikini line.

Q.12/B a female patient with left lower abdominal pain with vaginal bleeding, suspected to have ectopic pregnancy. You want to do investigation, and the patient wants to go home. Counsel her.
Introduction, then you may begin by saying: “According to what you complain of and the examination, there is a high possibility that you have what we call it ectopic pregnancy, which is a pregnancy outside the normal place that is the womb. And this could be either in the tube between the womb and ovaries or less commonly on the ovaries or inside the tummy. And the pregnancy in these positions could not go to term and what is important is that it could bleed suddenly or even cause tear to the tube with bleeding inside your tummy. And these conditions could be avoided by early treatment.
So first, we have to confirm ectopic pregnancy, so we want you to do pregnancy test on sample of your urine. Then we would arrange ultrasound of your tummy and we might need to do laparoscopy, which is a tube passed inside your tummy through small incisions to look at your womb and tubes.
There are 2 ways to deal with this condition by laparoscopy with injection of medication called methotrexate or removal of pregnancy. The second way is to remove the pregnancy by operation and in either ways we try to conserve the tube but if it is so damaged then we need to remove it.
Is everything clear or do you want me to repeat anything for you?
Are there any questions that you would like to ask me?
You will remain in hospital for 2-3 days.
Return to work in 6 weeks.
The doctor will do 2 incisions, one just below the navel, and the second above the bikini line.

Q.13 Baby Blues, and Post natal depression, take history and do counseling.
Introduction, then you may start with: “I have heard that you are finding life a bit difficult; tell me about what has been going on.
Is this your first pregnancy? How do you feel in yourself? Do you feel tired? Do you cry often? How is your sleep? How is your appetite? Do you enjoy things you used to enjoy before (TV, films, visiting friends, etc.)? Do you have any concern about your health or your baby’s health? Do you think life is worth living now a days? Do you think that someone else or yourself may harm the baby?
Have you had any problem during your pregnancy? Was it normal delivery? Any difficulties?
Do you have any pain in your breast or in your down below?
Do you have a partner? How is your relation with him? Did you try to get help from your mother or sister? How have you been feeling in yourself before? Have you felt like this after previous pregnancies?
Do you have any problem at home? Or at work? With your partner’s work?
Then in case of Baby Blues:
(It is commonest in first 3-4 days after delivery and lasts for few days). You may explain: “Well, Mrs. (the patient) what you have is what we call Baby Blues, it is a very common condition, occurs in more than one of every 2 mothers after delivery, what you need is just rest, try to have more sleep, eat healthy food with lot of vegetables and fruit and try to get out with your partner. Have fun with him and you will be OK in few days, and as for the child the doctor has seen/will see him/her and said that nothing is wrong with him/her, so there is nothing to worry about, and you can contact us at any time you feel the need to”.
In case of Post Natal Depression:
(It is commonest in the first month up to 6 months). You may start by saying: “Well Mrs. (the patient), what you have is what we call Post Natal Depression, we will refer you to another department in this hospital, they will give you some medication. You will get better, but it takes some time and meanwhile we will arrange support for you. It is common condition and can be treated so don’t worry about it.
Q.14 A patient will undergo an operation for ovarian cyst removal. Explain, and do counseling.
Introduction. And then: “I have heard that you will have an operation to take out a cyst from your ovary. Do you know anything abut cysts in the ovaries?
Well, cysts in the ovaries are quiet common, a cyst is a fluid filled sac that arises from the ovary, and it is important to take it out as infection may happen, blood might get collected into it, it might became twisted or even burst, so this could affect health.
The operation to take out the ovarian cyst is usually done under General Anaesthesia, that is we are going to put you to sleep, the doctor is going to make a cut, take out the cyst and leave the ovary in place, and we can arrange for you to have what we call subcuticular suturing so that the scar will be faint and will fade away with time. The operation with the anaesthesia will take around one hour. And you will stay in hospital for 4 days and return to work in 6 weeks.
Don’t worry Mrs. (the patient) you are in good hands. One more thing, this condition will not affect your future fertility.
Is everything clear, or do you want me to repeat anything for you?
Are there any questions that you would like to ask me?
We will try not to take the ovary out, but in very rare conditions we might be obliged to do, so we have to take your consent for that.
Some complications: Bleeding, infection.
Vertical cut.

Q.15 Sexually Transmitted Diseases (STD). Counseling.
Introduction. Then you may say: “I have heard that you are here to discuss STD. They are infections that can pass from one person to another during sexual contact; anyone can get STD from an infected partner if no protection has been taken. There are several types of STD:
Some are common: genital warts, genital herpes, chlamydia, none specific urethritis, gonococal infection.
Less common: trichomonas vaginalis, syphilis (the pox), HIV (the virus that causes AIDS), hepatitis B & C, infestations like scabies, and pubic lice (crabs).
Method of spread: STDs usually spread when an infected blood, semen, or vaginal fluid comes into contact with another person during sex, but some infections can be transmitted by blood or sharing needles as AIDS or Hepatitis. Some of them like none specific urethritis, gonorrhea, hepatitis and HIV spread by penetrative sex, some as trichomonas vaginalis by vaginal sex, some as warts, herpes, and syphilis by body contact.
Safe sex: this can be achieved by preventing infected person’s blood, semen, or vaginal fluid from getting inside their partner’s body. This can be done by use of male or female condom, which can even protect from AIDS. When using condom be sure if you want to use a lubricant to use water-based ones as KY jelly or boots lubricant jelly. And do not use oil-based lubricants such as Vaseline. For anal sex use stronger condom as Durex, and plenty of water-based lubricant.
How do I know if I have STD?
There are some features to look for:
1. Unusual thick, cloudy or smelling discharge from vagina.
2. Discharge from penis.
3. Itchy, rash, sores, blisters, or pain in genital area.
4. Pain or burning sensation when passing water.
5. Passing water more than usual with little quantity.
6. Pain during sex.
But remember that STD can have no feature at all, or features that may not appear for months. Some features may disappear and you may still have the disease, and this could lead to many problems if untreated.
The patient may ask: Where can I go for help?
You can go to Genitourinary Medicine Clinics; they offer free check-up and treatment of STD. All information is kept strictly confidential; you can go to any clinic anywhere in the country. You will complete a registration form and they will give you a number to retain your anonymity. A full sexual health check includes:
1. Examination of your genitals and sometimes the lower part of your body, mouth, and skin.
2. Taking swabs, which is a type of cotton bud used to take sample from any secretion or discharge from genitalia.
3. Urine sample for examination.
4. Blood test for syphilis
You also may be offered:
1. HIV test with your consent.
2. Cervical smear in women.
3. Blood test for hepatitis B & C.
It better not to have sex until it is all clear. When you have STD it is important to tell your sexual partner so he/she can have a sexual health check up too.
Incubation Period:
• Gonorrhea: 2-10 days
• Syphilis: 9-90 days
• None specific urethritis: few days to few weeks.
• Hepatitis B: 2-6 months
• HIV, take sample at 3-6-8 months.

Q.16 A patient with low back pain, examine the back.
Introduction, then you may start: “I am going to examine your back, please get undressed to your underwear, and stand up so that your back is in front of me.
1. Inspection: with patient standing, observe from behind for scoliosis, and from the side checking that there is normal lordosis.
2. Palpation: palpate with fingers for tenderness on spinous processes and paraspinal muscles. Then perform light percussion with the fist to elicit bone tenderness.
3. Movement: Ask the patient to extend backward, bend forward with leg straight, then on each side trying to touch side of knee. Then ask the patient to sit on couch and rotate to right and left with fixed hips.
4. Tests:
a. Straight leg raising test (SLR): the patient is lying supine. With knee flexed. Check passive hip flexion. With knee extended, raise leg on unaffected side by lifting the heel with right hand while preventing knee flexion with left hand. Repeat this on the affected side asking the patient to report any pain or paraesthesia. (Normal straight leg raising test are 90؛). When this limit is reached, now gently dorsiflex the ankle if the patient feels pain, Bragaard test is positive.
b. Bow string sign: perform SLR test at the limit, flex the knee, reducing tension on the sciatic roots and hamstrings. Now further flex the hip to 90؛. Gently extend the knee until pain is once again reproduced (Lasegue’s sign). Apply firm pressure with thumb first over the hamstring nearest the examiner, then in the middle of the popliteal fossa and finally over the other hamstring tendon. Ask the patient which maneuvre exacerbates the pain. The test is positive if the second manoeuvre is painful and if the resultant pain radiates from the knee to the back.
c. Sitting test: Ask the patient to sit up from the lying position, ostensibly to inspect the back. Only in the absence of sciatic nerve irritation will the patient be able to sit up straight with legs flat on the bed.
d. Flip test: Ask the patient to sit with hips and knees flexed to 90؛ on the edge of the couch and test the knee reflexes. Then extend the knee, ostensibly to examine the ankle jerk. When there is genuine root irritation the patient will flip backwards to relieve the tension. The malingerer, distracted by attention to the ankle jerk test, may permit full extension of the knee, which is the equivalent of full 90؛ SLR.
The accompanying neurological signs of L5 and S1 nerve root irritation are: (L5): weakness of dorsiflexion of ankle, big toe and inability to walk on heel. Numbness on dorsum of foot and lateral aspect of calf. (S1): weakness of plantarflexion, and inability to walk on toes. Numbness of sole and 5th toe. Weakness of ankle jerk.
e. Femoral stretch test: ask the patient to lie prone, or on the unaffected side if there is a painful flexion deformity of hip. Flex the knee slowly asking the patient to report onset of pain. If this fails to produce pain gently extend the hip with the knee still flex.
The accompanying neurological deficit in femoral roots compression: numbness on anteromedial aspect of the thigh and weakness of knee jerk.
Examine sacroiliac joint with patient in prone position, apply firm pressure over the sacrum.
Femoral nerve: L2, L3, L4
Sciatic nerve: L4, L5, S1, S2, S3
Useful language: I’m going to tap your back (percussion)
For prone position: lie on your front, or tummy.



Q.17 Painful knee, examine the knee.
Introduction, then you may say: “ I’m going to examine your knee, please undress your bottom half to your underwear, and stand up for me (Slip your trousers and leave your underwear/ don't worry about it).
Inspection: with the patient erect, then supine for limb alignment, bony contour, erythema, swelling, muscle wasting, and any genu valgus or varus.
Measures: muscle girth at 10 cm above patella (both sides).
Palpation: with knee extended palpate soft tissue, collateral ligaments for tenderness and temperature with dorsum of your hand. With knee flexed palpate along the joint line anterior and posterior for tenderness.
Movement: with patient supine, put your left hand on the knee to detect crepitation; ask the patient to fully flex knee and then to extend it. With patient in prone position, thigh supported on the couch and legs projecting from couch. Observe level of heels (test minor limitation of extension).
Test:
1. Massage test: (for effusion) with knee extended, massage any fluid in the anterior compartment of thigh into suprapatellar pouch. Then firmly stroke the lateral side of the joint with the palm of your hand. Observe any fluid impulse on medial side of the joint.
2. Patellar tap: (for effusion) with knee extended, empty suprapatellar pouch with pressure from the palm of your left hand. And with index of right hand, press patella firmly against femur.
3. Patellar apprehension test: (stability of patella) with knee extended, apply pressure with both your both thumbs on medial border of patella, and maintain pressure while slowly flexing the knee passively to 30؛.
4. Anterior and posterior draw test: (cruciate ligament test) flex the knee and sit on the patient foot. Grasp upper tibia with your both hands and try to draw it forward (anterior cruciate ligament). Try to push it backward (posterior cruciate ligament).
5. Lachman test: (isolated cruciate ligament tear with intact collateral ligament) flex the knee to 20؛, push the lower part of thigh in one direction and pull tibia in other direction, then reverse directions.
6. Collateral ligament test: with knee fully extended, hold the patient ankle between your elbow and side with both hands on upper tibia and attempt to abduct and adduct femur on tibia with knee straight.
7. Pivot shift test: (rotation in stability) with knee extended, hold the patient’s heel with right hand and fully internally rotate foot and tibia while apply valgus pressure to knee with your left hand. Flex the knee from 0؛-30؛ to detect palpable or visible reduction.
8. McMurray test: (for menisci) flex the hip and knee to 90؛, hold the patient’s heel with your right hand and hold the knee steady with your left hand. Externally rotate the tibia and slowly extend the knee. Repeat with internal rotation. If positive, clunk can be felt with some discomfort to the patient.

Q.18 Painful and stiff shoulder. Examine the shoulder.
Introduction, then you may say: “I’m going to examine your shoulder, if you don’t mind expose your top half, please”.
Inspection: inspect the shoulder from the front, side and back for deformity, swelling, muscle wasting, and skin lesion.
Palpation: swelling, tenderness in anterior aspect, bicepital groove, tip of shoulder, subacromial space and sternoclavicular joint.
Movement: ask the patient to place the palms at the base of neck with elbows pointing laterally. Then put arms down and reach between shoulder blades with dorsum of hands. Ask the patient to flex elbow to 90؛ and to do external and internal rotation of shoulder joint.
Test:
1. Glenohumeral joint movement: firmly hold tip of scapula. Ask the patient to flex arm (normally it can be flexed to 90؛), and ask the patient to abduct the arm (normally it can be flexed to 90؛).
2. If cannot abduct the arm, passively abduct it to 40؛, the patient should now be able to abduct it (supraspinatus rupture).
3. Test for painful arc: (40؛-120؛) passively abduct arm. Ask the patient for any pain during this movement, and then ask him/her to bring the arm down.
4. Elicit impingement pain by passively flexing the shoulder to 90؛, and then internally rotate it (Hawkin sign).
5. Test for bicepital tendonitis by asking patient to do flexion, and supination of elbow against resistance.

Q.19 A patient with right hip pain, examine the hip joint.
Introduction, then you may say: “ I’m going to examine your hip, please undress your bottom half to your underwear and stand for me”.
Inspection:
1. Ask the patient to walk and inspect the gait. In fixed flexion deformity, the buttock is prominent. And in abduction deformity, the patient swings the apparent long leg out and round with each step.
2. Ask the patient to stand up and inspect from back for scoliosis. From side for pelvic tilt which may conceal hip deformity.
3. Trendelenburg test: ask the patient to stand on one leg with flexing the lifted knee to 90؛ and observe. In normal conditions the pelvis is tilted up on the lifted side. In abnormal conditions, the pelvis is tilted down.
4. Ask the patient to lie on couch in supine position with pelvic brim at right angle to spine and inspect for deformity (abduction, adduction, flexion), swelling or redness, muscle wasting, and sinus formation. Compare.
Palpation: palpate for local tenderness over front of hip and greater trochanter.
Measurement of leg length: in case of apparent shortening. With legs parallel, do the measurement from xyphosternum to medial malleolus. In case of true shortening, place the normal leg in comparable position of abduction or adduction to abnormal one and measure from anterior superior iliac spine to medial malleolus.
Movement:
1. Stabilize iliac crest with left hand and use right hand to flex hip with knee flexed to 90؛ and note range of movement. The normal range is 0؛-120؛.
2. Thomas’ test: place one hand between patient lumbar spine and the couch. Flex the unaffected hip to its limit and continue to push to straighten lumbar spine. In normal condition, the opposite leg will remain flat, whereas in abnormal one the leg will rise from the couch and the degree of rise is the amount of flexion deformity.
3. Stabilize the opposite iliac crest with left hand, then abduct with right hand (normal is 45؛) and adduct (normal is 25؛).
4. Roll each leg on couch and measure range of rotation of foot as indicator (90؛).
5. Flex hip and knee to 90؛ and rotate internally, the normal is 30؛. And rotate it internally, the normal is 45؛.

Q.20 A patient with Rheumatoid Arthritis, examine the hand.
Introduction, then you may start: “I’m going to examine your hand”.
Inspection:
1. Nails: for splinter hemorrhage, and nail fold infarcts.
2. Skin: colour changes, pallor or cyanosis (Raynauld’s phenomenon).
3. Subcutaneous tissue: for nodules.
4. Tendons: for swelling.
5. Joints: for deformity (swan neck, Boutonniere, Z deformity of the thumb), ulnar deviation at MP, wrist, and sublaxation of MP and wrist.
6. Muscles: for wasting of s.m.s of hand.
Palpation:
1. Joints of hand, wrist, and periarticular tissue for tenderness, osteophytes and swelling.
2. Savill pinch test: pinch skin at palmar aspect of proximal phalanx. In normal condition it is lax and can be pinched, whereas in synovitis it is firm and tense.
3. Fell for local swelling and thickening of flex tendons at base of fingers while asking the patient to flex and extend the fingers.
Movement:
1. Ask the patient to grip two of examiners fingers and make a pinch.
2. Ask the patient to put hands in position of prayer and then lower the hands (wrist dorsiflexion).
3. Ask the patient to place backs of hands together and raise hands (wrist flexion).
4. Ask the patient to flex DIP while holding finger in extension at PIP (Flexor Digitorum Profondus).
5. Ask the patient to flex PIP while other fingers held in full extension (Flexor Digitorum Sublimis).
6. Ask the patient to extend IP while MP held in flexion (lumbricals).
7. Ask the patient to grip a card between two fingers while the examiner attempts to pull it (palmar interossei, adduction).
8. Ask the patient to spread fingers and press sides of index fingers against each other (dorsal interossei, abduction).
9. Ask the patient to abduct thumb and maintain against resistance; and to touch the terminal phalanx of little finger with thumb and maintain against resistance (thenar muscles, median nerve).
10. Ask the patient to hold a card between radial sides of index fingers and extend thumbs (adductor pollicis). The normal condition is when the thumb is extended, whereas it flexes if muscles are weak.
11. Ask the patient to place palm on flat surface and to lift the thumb like a hitchhiker. The patient is only able to do this if the tendon is intact (extensor pollicis longus).
Carpal tunnel syndrome:
1. Phalen’s sign is positive if pain is symptoms are increased when flexing the wrist passively for a minute or two.
2. Tinel’s test: is positive if percussion over carpal tunnel increases symptoms.
Finkelstein test for De Quervian’s tenosynovitis (tendon of abductor pollicis longus, and extensor pollicis brevis): move the wrist passively into ulnar deviation while patient holds thumb clenched into palm, if he/she feels pain the test is positive.
Test sensation: (check the dermatomes from any clinical examination book).

Q.21 a 25 year old patient fell on outstretched hand, now he/she complains of pain in the right wrist. Examine, look at x-ray, put a diagnosis, and do management.
Introduction, then you may say: “As far as I know you have pain in your right hand since yesterday”.
Ask about site, radiation, and aggravating and relieving factors. Any associated symptoms and severity.
Inspection: any swelling, deformity or bruises on the radial side of wrist.
Palpation: palpate for tenderness over the carpal bones in general, then in the anatomical snuff box, and apply axial pressure on the extended thumb or index finger.
Movement: ask the patient to flex and extend the wrist. Look for pain.
Investigation: request x-ray: anteroposterior, lateral, and 2 oblique views.
Diagnosis: Fracture of scaphoid bone.
Management: if the fracture appears on the x-ray, then immobilize in scaphoid plaster from below the elbow to beyond knuckle including the thumb to base of nail until union occurs, which is usually around 8 weeks.
If no fracture appears on x-ray, and scaphoid fracture is strongly suggested on clinical ground then apply scaphoid plaster for 2 weeks. Repeat x-ray, then, which may show the fracture as bone resorption occurs in that period. If fracture is detected, then use plaster for 8 weeks. If fracture does not appear and if bone scan is available, then we may use it. Also give the patient analgesic for pain relief. Some surgeon prefer internal fixation.
Complication:
1. Malunion: managed by bone graft or internal fixation.
2. Avascular necrosis of proximal fragment, which gets its blood supply from distal part. May cause osteoarthritis of wrist later on.
Check x-ray of wrist.

Q.22/A An overweight patient with severe pain in big toe, take history.
Introduction, then you may say: “As far as I know you have pain in your foot, I would like to ask you a few questions about your condition.
How long has the pain been there? (Duration). Is it there all the time or does it come and go? (Periodicity). Can you tell me exactly where the pain is? (Site). Does it spread? (Radiation). Do you have pain in other joints? Do you feel any heat over the toe? (Septic arthritis). Any skin rash? (SLE). Any redness of eye or pain on passing water? (Reiter’s syndrome)
Associated features: Have you had a similar pain before? Ask about predisposing factors to gout: have you had any injury or surgery recently? Do you have any disease, blood disease? Any recent illness? Are you on any medication? Aspirin? Do you eat a lot of red meat? Are you on any diet? Do you drink at all? How much of alcohol? Has anyone else in your family had similar condition? Do you have any tummy pain? Any kind of problem? Is it painful when you touch it, any swelling, and any redness?


Q.22/B A patient with knee pain and history of pain in big toe. Take history.
Introduction, then you may say: “As far as I know you have pain in your right knee. I would like to ask you a few questions and then I will explain to you what we will do.
How long has the pain been there? It is the first time? Is it there all the time or does it come and go? Have you sought medical advice in the first time? Did the doctor then, tell you what was it? Can you tell me exactly where the pain is? Does it go anywhere else? (Radiation) What brings on the pain? (Precipitating factors). Does anything seem to make the pain better or worse? Do you have pain in other joints (elbow, wrist, hand, back)? Is the pain worse when you get up in the morning and becomes better at the end of the day, or better in the morning and gets worse at the end of the day?
For gout ask:
Did you have any accident injury or surgery? Do you have any disease (blood disease, Rheumatoid Arthritis, Osteoarthritis)? Do you have any kind of problem, passed stone before with water? Are you on any medication? Aspirin? Do you eat a lot of red meat? Are you on any diet? Do you drink at all? How much of alcohol?

Q.23 A patient who feels dizzy on standing up. Measure blood pressure.
Introduction, then you may start by saying: “I’m going to measure your blood pressure. I will wrap this cuff around your arm and inflate it. This will cause you to feel your arm squeezed a little bit. Then I will deflate the cuff and get your blood pressure figures from this device. Then I would like/need to take it when you are standing up. Now would you tuck/pull the sleeve of your shirt up please.
Choose the right cuff and wrap it around the upper arm. Palpate brachial artery to put your stethoscope later. Put your hand on radial pulse and inflate cuff until pulse disappears (rough estimate of systolic pressure). Now inflate cuff another 10 mmHg and apply stethoscope over brachial artery. Deflate cuff and record systolic and diastolic blood pressure (deflate by 1mm/Sec) Ask the patient to stand up (nurse will support you) and repeat the procedure. Or ask the examiner to hold the device for you while the patient is standing.
N.B.: cuff size (child 5cm, adult 15cm, obese 20cm, thigh 25cm) Sphygmomanometer should be at the same level of eye, support arm with your thumb on stethoscope and fingers around the back of elbow at about the heart level.
In normal individuals the systolic pressure measured on standing decreases by less than 20mmHg from the bp measured on sitting. And the diastolic pressure increases by less then 10mmHg. If the systolic pressure decreases by more then 20mmHg then the patient is having postural hypotension, which has several possible causes:
1. Hypovolaemia (haemorrhage, dehydration, diarrhoea).
2. Autonomic neuropathy (DM, amyloidosis).
3. Drugs (Tricyclic Antidepressant, Ca channel blockers, ACE inhibitors).
4. Prolonged bed rest.
Treatment: stop or decrease the dose of the drug, teach the patient to stand in steps, compression stockings, drugs (NSAIDs, fludrocortisone).

Q.24 Blood pressure of 170/ 90mmHg. Comment.
British Hypertension Society defined a patient to be hypertensive if he/she has 3 readings of high blood pressure (systolic ³140mmHg, diastolic ³90mmHg) each a week apart. And suggests that treatment is needed when blood pressure measurements are:
1. Systolic ³200mmHg
2. Diastolic ³100mmHg
3. Systolic ³160mmHg + diastolic ³95mmHg
4. Systolic ³160mmHg + end organ damage
5. Diastolic ³90mmHg + end organ damage or other risk factors
So in this case we must exclude other risk factors:
1. Ask about family history, smoking, DM, hyperlipidaemia and look for obesity.
2. End organ damage: ask about, dyspnoea, chest pain or discomfort upon exertion (heart failure, angina, etc.).
3. Past history of MI.
4. Tiredness, lethargy, facial and foot swelling (right heart failure).
5. Past history of stroke.
6. Pain in the limb on walking (intermittent claudication)
If no end organ damage nor other risk factor: follow up for 3-6months, if systolic pressure remains ≥ 160mmHg, give medical treatment.
Exclude secondary causes of hypertension:
1. Renal:
a. Renal artery stenosis: listen to renal bruit.
b. Chronic pyelonephritis: past history of loin pain, burning micturation or haematuria, stones.
c. Glomerulonephritis: face or foot swelling, change in the colour of urine.
2. Endocrine: Cushing syndrome (change in weight, redness of skin). Pheochromocytoma (recurrent headache, sweating, palpitation).
Treatment of hypertension:
1. No drug treatment:
a. Stop smoking.
b. Optimize weight and healthy diet.
c. Encourage exercise.
d. Cut alcohol to nearly 1 U/day
e. Reduce stress.
2. Drug treatment: needs long term treatment, and compliance.
Thiazide diuretic: side effects: hyperuricaemia, hyperglycemia, hyperlipidaemia, hypokalaemia, hypomagnesaemia. Beta blockers: side effects: bradycardia, bronchospasm, fatigue, cold extremities, bad dreams, hallucination. Ca channel blockers: side effects: headache, flushing, ankle oedema. ACE inhibitors: side effects: postural hypotension, renal impairment, cough.

Q.26 A patient with central chest pain given 5mg Diamorphine by GP. You are given ECG, CXR, choose from drugs on table the ones you would use. & Management. (Contraindiction to Thrombolysis).

1. ECG: Changes of anterolateral MI (leads V1, V6 with leads aVL and I). ST elevation within hours. Formation of Q wave and inversion of T wave within days. Normalisation of ST segment with persistence of Q wave over months. (ECG changes depend on time from onset of infarct, generally:
a. Wide spread ST segment elevation.
b. T wave changes with Q wave appearance.
c. Bifid QRS complex.
2. CXR: Pulmonary oedema: hilar opacity, distended upper lobe veins, Kerly B lines, effusion at costophrenic angles, and cardiomegaly.

3. Management:
a. Manage the patient in CCU.
b. Continuous ECG monitoring.
c. Sit the patient up.
d. O2 %100, by face mask (if no lung diseases).
e. Insert IV cannula, give Frusemide 40-80mg IV Slow infusion.
f. Anti-emetic: Metoclopromide 10mg IV or Cyclizine 50mg IV.
g. GTN Nitroglycerine: 2 puffs sl or 2 tablets of 0.3mg Sl
h. If fast AF: Digoxin 0.5mg PO or IV.
i. If blood pressure > 110 Systolic. give Isosorbide DN IV infusion
j. If blood pressure < 100 Systolic, give Dobutamine 2.5-10 خ¼g/Kg/min. If worse, venesection 500ml and ventilation.
k. Monitoring: Frequently blood pressure, PR, heart sounds, Input/Output (every 4 hrs). Daily: ECG, U&E, weight, and cardiac enzymes.
l. Aspirin 300mg.+ Thrombolysis (if indicated)
Thrombolysis:
Indication:
a. Chest pain within 12 hrs + ST elevation (> 2mm on chest leads, > 1mm on limbs leads) or R wave + ST depression in V1-V3 (post MI).
b. 12-24 hrs with chest pain and ECG evidence of evolving MI.
Contraindication:
a. Risk of Bleeding:
i. General: thrombocytopenia, heamophilia, severe liver disease, patients on warfarin with INR > 3.
ii. Local: recent stroke (within weeks), recent surgery (within weeks), trauma, Resucitation, eye bleeding (vitrous heamorrhage), peptic ulcer, GI bleeding, pregnancy, severe vaginal bleeding, tooth extraction, TB with cavitation (STREPT).
b. Hypertension: systolic > 200mmHg, diastolic > 120 mmHg.
c. Thrombus which might embolise, like in endocarditis, aortic aneurysm,
Warn the patient of %1 of possibility of stroke. Side effects: hypotension, anaphylaxis. If no response, consider angiography + angioplasty or CABG.


Q.27 A patient with chest pain. Take history and examine.
Introduction, then you may say: “As far as I know, you have pain in your chest. I would like to ask your several questions concerning your complaint.
How long has the pain been there? (duration). Is it there all the time or does it come and go? (periodicity). Can you tell me exactly where it is? (site) Does it spread? (radiation). Can you describe what it feels like? (nature) Does anything seem to make it worse? (aggrevating factors, like walking in cold weather, heavy meal, climbing stairs, or hill) How much can you do before you have to stop? Do you ever feel pain or discomfort at rest? Does anything seem to make it better (reliefing factors) Any shortness of breath, cough, fever?
Examination:
1. Check: Temperature, pulse rate, respiratory rate, blood pressure (vital signs).
2. Auscultate the heart and lung bases.
3. Ask the patient to take a deep breath and cough (pain aggrevates in patient with pleurisy).
4. Auscultate the area of pain and do vocal resonance.

Q.28 A patient is to be discharged after MI. Give advice about medications (Aspirin, GTN, Beta blockers).
Introduction, and then you may say: “Now you are feeling much better, and you are ready to go home today. I would like to have a little chat with you about your medication.
Take the Beta blocker bottle and show it to the patient: This is propranolol. It prevents chest pain. You should take one tablet every 6 hours for the first 2 days, and 2 tablets twice a day afterwards. Swallow the tablet with a glass of water. It is a long term treatment (usually for 2-3 years). Please do not stop taking this medication suddenly. Because this may cause the pain to worsen and will affect your condition. This medication sometimes causes side effects in some people. If you get any of the following symptoms tell your doctor immediately: headache, sleepiness, bad dreams, dizziness, light headedness, shortness of breath, wheeze, slow pulse, skin rash, dry eye, tiredness, cold hands and feet.
Show the patient the bottle of Aspirin. This is Aspirin, you should take it once a day with a glass of water, sometimes it causes irritation of stomach, and it to prevent this it should be taken after meal (on full stomach). This is a long term treatment. This drug prevents blockage of the blood vessels of the heart, which may result in another heart attack. The side effects are mainly stomach irritation then it might cause tummy pain, blackish discoloration of stool. Other unusual bleeding also it might cause shortness of breath and wheeze. If you notice any of these features, or if you notice any bleeding contact your doctor immediately.
Show the patient the bottle of Glycerol Trinitrate. This is GNT, you should take it in case if you have chest pain, also you can take it before exercise, it will increase your exercise limit. Put 1 tablet under your tongue and wait till it dissolves in your mouth. Don’t swallow it. The possible side effects include headache, flushing, dizziness especially when you get up suddenly (postural hypotension). These side effects are usually short term. If you notice any of these consult your doctor. I would like to assure you that it is not habit forming or addictive.and it has very short expiry date.

Q.29 Give advice about changing life style to overweight patient, who had MI ready to discharge tomorrow.
Introduction, and then you may say: “You remember that you came few days ago with sudden chest pain, you are coming along very nicely and you are ready to go home tomorrow. I think it would be a good idea if we have a little chat before going home.
The tests showed that you had heart attack, which is a condition where one of the vessels which supply blood to the heart becomes blocked by a clot. That area is damaged and is replaced by a scar. This process takes from days to weeks and it is better not to put a great strain on the heart at this time. Within 2-3 months at most, the hearts of many patient are functioning just about, as well as they were before the attack.
A part from medication which I’ll talk to you about later. There are some points about a little change in your life style:
1. Diet: it would be a good idea if you consider reducing your weight and avoid saturated fat especially high fat diary product as butter, fatty meat, palm, coconut oil. You can eat more fresh fruit and vegetables, chicken (without skin), fish, skimmed, and semiskimmed milk, grill, don’t fry.
2. Exercise: you can start exercise gently and increase it with time. Try to avoid walking in cold winds and climbing up steep hills. About sports you can take up with golf, cycling, swimming, beside walking; but avoid sports with vigorous exercise as squash and weight lifting.
3. Smoking: you should give up smoking as it increases risk of recurrent attacks.
4. Alcohol: 1 or 2 glasses of wine or ½-1 pint of beer/ one measure of spirit don’t affect the heart but more than this may give harm to the heart.
5. Sexual intercourse: it increases the work of the heart and in some people causes chest pain or shortness of breath. But in majority of cases, sexual activity can be resumed as soon as you are able to take other forms of moderate exercise as walking up stairs without symptoms. GTN tablet before intercourse, can help but you should give up immediately if you get chest pain.
6. Driving: you can start after 4 weeks and it is better if you try short runs in the neighborhood accompanied by a friend. Inform your driving license authority.
7. Work: you can go back to work in 4-12 weeks depending on type of work.
8. Stress: It would be a good idea if you take up relaxation therapy and avoid stressful condition as much as you can.
9. Avoid air travel for at least 6 weeks.

Q.30 A patient with heart failure. Examine cardiovascular system.
Introduction, and then may begin by saying: “I would like to examine your heart and vessels:
1. Examine the face:
a. Eyes: for corneal arcus, xanthelasma, palpebral conjuctiva for pallor and ophthalmoscopy (hypertension, endocarditis).
b. Cheeks: for malar flush (Mitral Stenosis).
c. Tongue and mucous membrane of mouth, for central cyanosis.
2. Examine the hands: note wether warm (vasodilation) or cold (vasoconstriction), dry or moist, any pallor, cyanosis, and any tobacco staining. Look for xanthomas. Examine nails for clubbing and splinter heamorrhage.
3. Radial pulse:
a. With opposite 3 fingers (right fingers for left hand and vice versa). Check rate and rhythm. Calculate radial pulse for at least 15 sec.
b. For collapsing pulse: raise the arm while feeling across the pulse with fingers of other hand.
4. Brachial pulse: use thumb (left thumb for left arm and vice versa), for character, just medial to biceps tendon.
5. Measure blood pressure: sitting and standing.
6. Carotid pulse: ask the patient to lie down. Use the thumb (right thumb for left carotid and vice versa). It gives more information about character.
7. Examine JVP: patient supine at 45؛ (semi-recumbant position) with head supported and turned slightly to the left (deep to sternal and clavicular heads of sternocleidomastoid muscle). Measure height in cm from venous pulse to sternal angle. JVP is raised if measured height is beyond 4cm.
8. Examine chest:
a. Inspection: Skeletal abnormalities such as pectus excavatum or kyphoscoliosis, check for any scar. And for any pulsation (double apex, HOCM, diffuse anterior MI).
b. Palpation: of parasternal area for thrill and parasternal heave; place the hand on the left chest, with long axis of hand paralell to anterior axillary line. Palpate cardiac impulse, place the hand perpendicular to the anterior axillary line. Check for sustained hyperkinetic or diffuse. Localise the apex beat with one finger. Ask the patient to roll onto left side while palpating.
c. Auscultation:
i. Apex: with the bell of the stethoscope, while the patient is lying in left lateral position.
ii. Tricuspid valve: with the diaphragm, on the lower left sternal edge and patient lying flat.
iii. Pulmonary valve: second left intercostal space.
iv. Aortic: second right intercostal space.
v. Aortic regurgitation, pericardial rub: sit the patient up, make her/him lean forward, and ask her/him to expire and listen with diaphragm at lower left sternal edge.
vi. Aortic stnosis: listen at the second right intercostal space.
9. Examine the back: listen for basal crepitation, check for sacral oedema.
10. Examine the abdoman: check for enlarged or pulsatile liver, enlaged kidneys, aortic pulsation and renal bruit.
11. Femoral pulse: check for radio-femoral delay.
12. Lower limbs: check popliteal, posterior tibial, dorsalis pedis pulses and check for oedema.

Q.31 A patient with intermittent claudication, examine pulses of lower limbs.
Introduction, then you may say: “I have heard that you have pain when you walk. I would like to examine your legs. Could you please slip off clothes form your bottom half to your underwear. And pop up on the couch.
Inspection: look for any hair loss, shiny red skin, ulcers and gangrene; especially behind the heel, between toes, in bunion area, and on dorsum of foot.
Palpation:
1. With dorsum of hand for heat changes.
2. For pulses: dorsalis pedis: lateral to extensor hallucis tendon proximally.
3. posterior tibial: 1-2cm below and behind medial maleolus.
4. popliteal: flex the knee to 30؛ and feel with fingers of both hands.
5. Femoral: midway between anterior superior iliac spine and pubic tubercle.
6. Peroneal: 1cm medial to lateral malleolus (replaces anterior tibial artery in %5 of cases)
N.B.: if dorsalis pedis is not felt, feel for anterior tibial artery: just above level of ankle anteriroly in midway between 2 malleoli.
If history is typical of intermittant claudication and pedal pulses are present, ask the patient to walk for few minutes and then re-examine the pulses which may disappear, because the increased blood flow decreases pulse pressure.
Buerger’s test: ask the patient to lie on her/his back, and to lift both legs and keep knees straight, supported by examiner’s hands while the patient is asked to flex and extend the ankle and toes to a point of mild fatigue. The test is said to be positive if the sole of foot became cadaveric pallor and veins on dorsum of foot gutter. Then ask the patient to sit and lower feet, in minutes they become reddened, cyanotic colour over affected foot.
Investigation:
1. Blood tests: FBC, U&E, ESR, lipid profile, syphilis serology.
2. Ankle brachial pressure index: it is normally around 1, in intermittent claudication: 0.9-0.6.
3. Arteriography.

Management:
1. Conservative: stop smoking, loose weight; treat DM, hypertension,and hyperlipidaemia.
2. Angioplasty and arterial reconstruction.
3. sympathectomy.

Q.32 A 50 year old patient with rectal bleeding. Take history and make diffrential diagnosis.
Introduction, and then you may say: “As far as I know you are passing bood (have bleeding) from your back passage. I would like to ask you a few questions then we will talk about what we will do.
How long have you had the bleeding? (Duration) How much blood did you pass? (amount) Is the blood mixed with or on the surface of stool? Can you tell me the colour of the blood? Is it bright red or dark red? Or black? Do you feel urge to pass motion? Do you feel the need to pass motion and when you try nothing comes out? Does the blood come before, during or after passing motion? Any blood on toilet paper or pants? Do you have any pain during passing motion? Have you passed any pus, mucous or discharge with stool? Did you notice any lump passing from your back passage? Do you have any tummy pain? Do you have any changes in your bowel habit? Any diarrhoea? Constipation? Do you feel any distension of your tummy? Passing wind more than usual? Felt sick? (nausea) Been sick? (vomiting) Have you had similar condition in the past? Do you have bleeding from any other site?
Are you on any medication? Has anyone else in your family had similar condition? Any bowel disease or tumour in your relatives? Do you eat a lot of vegetables and fruits? Do you have any disease? Any fever (temperature)? Have you lost weight recently? Have you traveled abroad?
Differential diagnosis:
1. Colon and rectal carcinomas.
2. Diverticular diseases.
3. Haemorrhoids.
4. Inflammatory Bowel Disease (Crohn’s disease and Ulcerative Colitis).


Q.33 & 34 A 35 year old patient with diarrhoea. Take history and make differential diagnosis.
Introduction, and then you may say: “As far as I know you pass loose motion. I would like to ask you few questions about your condition.
How long have you had this? Is it watery or loose stool? How many times do you open your bowel? Is it always watery or sometimes you get formed or hard stool? Is there any blood, mucous, pus with the stool? What colour is the blood? Is it bright red or dark? Is it mixed with stool? Any unusual smell of the stool? Do you feel urge to pass motion? Do you feel the need to open bowel and nothing comes?
Do you have any tummy pain? Any wind? Have you felt sick? Have you been sick? Have you lost weight recently? Do you have any fever (temperature)? Have you traveled abroad recently? Have you had similar condition in the past? Do you take any medication regularly? Do you have any joint pain, skin rash, redness of eye? Has anyone else in your family had a similar condition? How is your appetite?
Differential diagnosis:
1. Inflammatory bowel disease as Crohn’s disease and Ulcerative colitis.
2. Infections (bacillary or amoebic dysentery).

Q.35 A patient with right upper quadrant pain. Take history and make differential diagnosis.
Introduction, and then you may say: “As far as I know you have pain in your tummy. I would like to ask you few questions about that.
How long has the pain been there? (Duration). How long does it last? Is it there all the time or does it come and go? (Periodicity). Can you tell me exactly where it is? (Site). Does it always stay in the same place or does it spread? (Radiation). Can you describe what it feels like? (Character: aching, comes and goes, colicky, gripping, burning, stabbing). Does anything seem to make it better (Relieving factors) Does the pain feel better when you lie down or roll around. Does anything seem to make it worse? (meals, fatty meals, hunger). How is your appetite? Do you feel sick? Have you been sick? Any change in your bowel habit? In colour of stool? Do you have fever (temperature)? (always, comes and goes, recently?). Any cough, chest pain? (Pneumonia). Do you pass water more than usual? Any burning sensation? Any change in the colour of urine? (UTI). Do you have any itching of your skin, or any change in colour of skin and eyes? (Jaundice). Have you had any recent blood transfusion?
Have you had any similar condition in past? Are you on any medication? Have you travelled abroad recently? Has anyone else in your family had a similar condition?
Differential diagnosis:
1. Acute cholecystitis.
2. Acute hepatitis.
3. Liver abscess.
4. Pyelonephritis.
5. Basal pneumonia.
6. Peptic ulcer.
7. Acute appendicitis (Sub-hepatic).

Q.36 Examine the upper abdomen of the patient (of Q.35) and give differential diagnosis.
Introduction, then you may start by saying: “I would like to examine your tummy. Would you please pop up on the couch and undress your tummy”.
Lie the patient supine on couch with head supported to relax muscles of the abdomen. Then expose the abdomen form xyphosternum to mid-thigh.
Inspection:
1. Check the shape and symmetry of abdomen (scaphoid, or distended), any skin lesions like scar of previous operations. Check the hair distribution. Look of any tortuous dilated superficial veins.
2. Movement: respiratory, peristalsis, pulsation. Inspect tangentially for any abnormal movement.
3. Hernia: epigastric, umbilical, incisional, inguinal, femoral (ask the patient to cough, and to stand to inspect the hernial orifices).
Palpation:
1. Light palpation: ask the patient to report any soreness (tenderness) and look at the patient’s face for grimace. Ask him/her if there is pain and where it is exactly, and begin from area remote from the pain area. Place the hand on abdomen, test muscle tone by light dipping movements starting from left in the order showed on the figure:

xyphoid

pubis


2. Deep palpation: the same technique for superficial palpation but more deeply. To detect organs.
3. Palpation during inspiration:
a. Liver: place hand in right upper quadrant with fingers pointing upward. (towards the left axilla) lateral to rectus muscle. Palpate while patient takes a deep breath and go up with each inspiration till it reaches right costal margin. Murphy’s sign: place fingers over gall bladder area (at the cross point of midclavicular line and costal margin, at the nineth costal cartilage) and ask the patient to take a deep breath. If he/she feels pain the sign is positive.
b. Spleen: place hand in right upper quadrant and palpate as the patient takes deep breath (ask him/her to look to other side). Go up with each inspiration till it reaches left costal margin. If still not palpable lie the patient in left lateral position with left hip and knee flexed, support lower rib cage with left hand and palpate with the right hand. Normally the spleen lies in a posterolateral postion beneath 9th-11th ribs with anterior border extending to midaxillary line.
c. Kidneys: bimanual technique: place one hand posteriorly below the lower rib cage and the other hand over the upper quadrant (both hands are perpendicular to anterior axillary line position) push your two hands together as the patient breathes. Palpate the right kidney first then the left.
d. Ask the patient to cough while palpating hernial orifices (inguinal).

Percussion:
1. For upper border of liver: percuss on mid-axillary line starting from right lower costal margin. Normally the liver extends to beneath the 5th rib.
2. Spleen: percuss with patient holding breath in full inspiration, form below to above left costal margin in posterior axillary line.
3. Urinary bladder: in supra pubic area.
4. Shifting dullness: percuss from centre of the abdomen to left flank until getting dull note. Keep finger in place and ask the patient to roll to right side, wait few seconds, and percuss. Ascites is suggested if note becomes resonant and is confirmed if dull note is noticed towards the umbilicus.
5. Fluid thrill: ask the patient to put his/her hand on his/her abdomen in sagital plane. With your left hand in patient’s left flank, flick the skin of right flank with right hand. If impulse is felt the thrill is positive and it indicates the presence of ascites.
6. Percuss the renal angle for tenderness.
Auscultation: For bowel sounds, around umbilicus, (for 3 minutes before saying it is abscent). Look for bruit over renal angle and aorta.
Digital Rectal Examination: is essential and must not be omitted.
During examination of the abdomen if there is pain, check for rebound tenderness, and if there is ascites consider dipping technique of palpation.

Q.37 A patient with pain in the right upper quadrant of the abdomen. Take history and examine him/her.
Introduction, and then you may begin by saying: “As far as I know you have pain in your tummy, I would like to ask you a few questions about your condition.
History: how long has the pain been there? (Duration). How long does it last? Is it there all the time or does it come and go? (Periodicity). Can you tell me exactly where it is? (Site). Does it spread anywhere? (Radiation). Can you describe what it feels like? (Character). Does anything seem to make it better or worse?
Have you noticed any change in your weight recently? How is your appetite? Do you feel sick? Have you been sick? Did you notice any change in colour of stool? Any fever? Do you have any cough or chest pain? (Pneumonia). Any burning sensation when passing water? Any change in colour of urine? (UTI). Do you pass water more than usual? Any similar condition in the past?
Examination: I would like to examine your tummy, would you please pop up on the couch, lie on your back and undress your tummy? (Expose for xyphisternum to mid thigh).
1. Inspection: while standing for symmetry, movement with respiration. And hernial orifices. Tangentially for movement with respiration.
2. Palpation: light palpation: start from left upper quadrant; leave the right upper quadrant till the last. Test for muscle tone. Keep looking at the patient’s face for grimace. Palpate during inspiration for liver, spleen, right and left kidneys.
3. Percussion: of upper border of liver, spleen, urinary bladder, shifting dullness, fluid thrill, percuss renal angles.
4. Auscultation: for bowel sounds, and for bruit over the renal angle and aorta.
5. Do Digital Rectal Examination.
6. Examine the lower right chest:
a. Percussion for dullness (consolidation or pleural effusion).
b. Auscultation: for bronchial breathing or absent breath sounds (consolidation or pleural effusion).
c. Vocal resonance (which increases in consolidation, and decreases in pleural effusion).

Q.38 A patient who is about to have laparoscopic cholecystectomy. Explain treatment.
Introduction, and then you may say: “So you will have your gall bladder taken out by laparoscopy, do you know anything about this procedure?
This operation takes about 1-2 hours. A general anaesthetic is given, so you will be asleep during the procedure.
The doctor is going to make 4 small cuts on your tummy, each is less than 1cm. One is below the breast bone, one just below the right rib cage, one is near navel and the 4th one is on the lower part of the right side of the tummy, near the bikini line. A telescope like instrument is passed through one of these cuts and the instruments are used by the surgeon through the other cuts.
In the past we used to take out gall bladder by open surgery with a cut of 10cm long, but this new procedure has many advantages over the previous one: first the cuts are smaller and they cause less upset to the body. Muscles are not affected. It is less painful. You can return home and to work quicker. However, sometimes during the procedure conversion to open method is necessary.
We have to put a what we call N/G tube through nostrils down to the stomach, and another tube in your arm to give fluid to your blood.
After operation you may feel pain in your tummy, chest and shoulder (caused by air inflation).
As any surgical procedure, this operation may have some complications:
1. Infection: of the wound is the most common complication and antibiotics are given to decrease the chance of this from happening.
2. Bleeding: there may be some bleeding from the wound.
3. Pain: at the wound site and often pain is in the right shoulder for a day or two after operation and you will be given medication to relieve the pain.
4. Damage to bile duct: may happen during the procedure.
5. Blood clots: may develop in the vein of the leg and prevent this from happening you will wear elastic stockings before, during, and after the procedure. And you will be encouraged to walk as soon as possible.
Usually we use dissolvable (absorbable) stitches. After the operation, you will be able to drink after 4 hours and, usually you can start eating the day after the operation, and you may go home on the day after. In general, you will be kept in hospital until you are able to eat, drink and your pain is controlled.
After discharge:
1. For diet: initially you should decrease fat in your diet.
2. At work: you are able to return to light work after 2 weeks.
3. Driving and sex: you can start as soon as you don’t have pain and is confortable.
4. Wound care: you can bath/shower as normal but avoid rubbing the wound or wearing tight cloths. That may irritate it.
5. Appointment after 6 months.

Q.39 A patient with intestinal obstruction, x-ray of abdomen displayed. Call the registrar and explain the situation.
Hello, Dr (Registrar), I am Dr (you), Senior house officer in A&E. I have a patient who is 72 year old female, she is presented with a history of abdominal pain of 24 hours duration. The pain is central, was first colicky in nature then became more diffuse aching, she vomited twice, and she has constipation since yesterday.
On examination (O/E): vital signs: she is conscious, pulse rate, blood pressure, temperature all are normal (mention figures according to those given in the exam chart).
Talk about sings of dehydration (according to instructions). Fluid Input/Output values. Abdomen is distended with tenderness all over the abdomen. Check movement with respiration.
Investigation:
We took blood for FBC, U&E, Blood chemistry. Results showed increased urea level, increased haematocrit, increased globulin.
We did plain AXR, erect which showed multiple fluid level, the supine film showed dilated large bowel (ascending and transverse colon are located at the periphery. The haustra are on 2/3rd the way from one wall to another and irregularly spaced.
N.B.: For small intestines valvulae conniventes were seen all the way from one wall to another, regularly spaced and located centrally. Barium enema and meal are contraindicated.
Management:
1. We put N/G tube to decompress the bowel and to prevent aspiration.
2. We give N/S to correct fluid and electrolyte imbalance.
3. We took blood for grouping and cross match and save.
4. We gave antibiotic cefuroxime.
5. Analgesia, morphine.
6. Why do you call me? Because I suspect intestinal obstruction with strangulation (may be right inguinal hernia), and an urgent surgery may be indicated.
Q.40 You are the surgical SHO, you have been asked to see a patient who had right hemicolectomy 6 hours ago. You have temperature, pulse rate, blood pressure chart, call your registrar and report the case.
Hello, This is Dr (you) the surgical SHO on duty.
I am on ward 14 and I have been called to see a patient of Mr (consultant). The patient’s name is Mr/Mrs/Ms (patient), he/she is 59 year old, who had a right hemicolectomy procedure done 6 hours ago by Mr (consultant), due to localised neoplasm of the bowel. From the operation note it seems that the operation was relatively straight-forward and that there was no macroscopic evidence of metastasis outside the colon. The liver, lymph nodes seemed clean and there was no ascites.
She came from recovery about an hour after the operation. The results of her monitoring were fine until about an hour ago. Over the last hour her blood pressure dropped from 120/80 mmHg, to 90/60mmHg/min.
I am not sure of what is going on, but it looks most likely that she is bleeding and may have to be taken back to the theatre.
Action taken:
I asked the nurses to continur the quarter-hourly observation. The laboratory already has serum grouped and saved. I have asked them to cross match four units of blood and Haemaccel. I have already started O2 by mask and infusion. She is already on heparin and has no chest pain, cough nor problems with her leg to suggest DVT&PE. She has a history of mild angina and I am arranging to do ECG. She is already on cephaloridine and metronidazole.
I tried to get in touch with Mr (consultant) but he has not answered my bleep.
I think you need to see her within ½ hour or so, I have feeling that she has bleeding and we may need to take her back to the theatre. And I have not done anything about it yet. Are you going to be late. If so, would you like me to contact the theatre and anaesthetist on duty or would you like to see her first?

Q.41 The nurse on duty bleeped you and told you that a patient who had right hemicolectomy is not doing well. Her blood pressure decreased and pulse rate increased. What would you tell her on telephone, on ward and after examining the patient.
I am now examining a patient in the casualty, but I will come as soon as I can. (You go to the ward as soon as possible).
Who was the nurse who bleeped me about the patient whom she was worried about? The one who is now six hours after having right hemicolectomy and now he/she is unwell? The nurse said that that the patient’s name was Mrs Simpson. In which bed is she? (to make sure that you see the right patient).
Check the case sheet for the notes (history and examination) and read the operation note. Then go to bed, check the chart, take brief history and any exam needed. (check the abdomen, and auscultate heart, lung, and look at the legs).
Who is the nurse looking after Mrs Simpson. Can somebody, please, tell me where you keep the request forms on this ward?
I realise how much pressure your are under, but I am really worried about Mrs. Simpson. It is very important that we keep a very careful eye on her. I think she may be bleeding and she may have to go back to theatre.
1. I am just arranging for some blood to be cross-matched for her.
2. I will be getting in touch with the registrar on duty.
3. Could you change the drip to Haemaccel. I will write this in the chart. She is already on antibiotics and heparin, so I don’t think that we need to give her anything else at present.
4. Could you make sure that the observations are taken regularly every 15 minutes?
5. Can you please tell me where I can find the ECG machine? I have not contacted the theatre or anaesthetist yet. I thought I would better to wait until she has been seen by the registrar, but it seems pretty likely that she may need to go back to the theatre.
6. Do you know if any of her relatives are here? I need to speak to them.
Good morning, I am Dr (you), the doctor on duty. As far as I know you are Mrs Simpson’s daughter. I need to have a word with you. (Take her to a side room). What is your name? So Ms (the daughter), your mother’s operation went very well and we think that we have removed all of her growth. However, unfortunately, she developped another problem, which we think will only be temporary. It seems possible that she may be bleeding. We arranged for her to have blood transfuson and hopefully that will be enough. But we may need to take her back to theatre.
You know this may happen sometimes, but should not make any difference in the long term. She should be well. As soon as we know more, I will let you know. I am sorry but I have to go to sort things out.

Q.42 Obtain an informed consent from a patient for a herniorrhaphy and give post-op advice
Introduction, and then you may say: “I am going to have a word with you about your hernia and possibility of surgical treatment. And to take your consent about the operation”.
Do you know what a hernia is?
In anyone there are weak areas in the lower part of the front of the tummy. The coverings of the tummy contents together with some of these contents, such as part of the gut, may push through these weak areas into the upper part of the thigh, groin area or sometimes down the scrotum that is the sac of the testicles.
The predisposing factors that can lead to hernia are: lifting heavy objects, straining as in constipation, being overweight, and chronic cough.
As the gut and coverings pass through these weak areas, it might happen that the inside of the gut get blocked, and in this case we need to do emergency operation with higher possibility of complications than if we do planned operation.
In the operation we return the contents of the tummy, as gut and covering, back into the proper position and the weak area is repaired either by the use of synthetic mesh or darning by nylon or reposition of the muscles.
About anesthesia, well, you will have either general anesthesia, where you will be put to sleep and then wake up after the operation. Or spinal anesthesia where you will be given injection into the backbone and you will feel numb from waist below.
You will wake up from general anesthesia in the recovery area and once you wake up you will be taken back to ward. You will probably feel sleepy for a couple of hours, you may feel sick, get headache or sore throat, this will pass but be sure to inform the nursing or medical staff should this become worse.
As any operation this may have complications like:
1. Wound infection.
2. Bleeding and collection of blood in the area.
3. Recurrence of hernia.
4. Pain, sensation of pins and needles in the area of operation.
5. Infertility. (Very rare< %1) and as you are in good hands, we will find the structures related to fertility and put them away from the work field.
6. General: urine retention, chest infection, clots in the leg and lung.
You will remain in hospital for 1-2 days after operation, if dissolvable suture are used then, they will dissolve by themselves if not removed within 7 days.
1. You have to rest for one week.
2. Back to work within 2 weeks (desk work), after 3 months (manual work).
3. Drive within 1-2 weeks or when comfortable
4. Sex: as soon as it is comfortable.
5. Diet: a lot of vegetables and fruits.
6. Smoking: stop it, if possible.
Is everything clear to you? Do you have any questions to ask me? This is the consent from for operation would you mind reading and signing it please?

Q.43 A 22 year old patient with a past history of migraine, now the pain is different. The patient has vomited, following head injury and a period of loss of consciousness. And wants to have painkiller’s prescription and go home.
Introduction, and then you may say: “As far as I know you have headache, I would like to ask you a few questions about your condition”.
How long have you had the headache? Is it similar to, or different from the previous headache? Did the headache come suddenly or gradually? Is it there all the time or does it come and go?
N.B.: if chronic we can ask: How often do you get headaches? How long do they last?
Can you tell me exactly where you feel the pain? Does it spread anywhere? Can you describe what it feels like? Does anything seem to make it better? Or does anything make it worse? Does anything seem to bring on the headache? Do you see spots or flashing lights? Do you feel sick? Have you been sick? Does light or noise irritate you? Were you aware all the time or did you feel sleepy or lost consciousness? Do you feel weakness in an arm or leg or get double vision? Do you feel pain or difficult to move your neck? Do you have any problem with vision, hearing, giddiness, dizziness, weakness, numbness? Sinusitis, ear pain?
Exclude meningitis, chronic headache, space occupying lesion.
Well Ms/Mrs/Mr (patient), It seems that your headache now is different from the previous headache, that is the migraine. There is possibility that you have a condition we call it Subarachnoid Haemorrhage (SAH), that is bleeding between the brain and its covering. This condition is important to treat early, so it is very important to remain in hospital and we need to run some tests for you. So we will do an x-ray scan of your head and we may need to take a tiny drop of fluid from your back.
Q.44 A patient presenting with epilepsy. Take history and examine him/her.
History:
Introduction, and then you may say: “As far as I know you had a seizure. Is it the first time or you had seizures before? How did you feel before you had the seizure? Any mood changes?
Did you feel any warning beforehand? Strange voice, smell, flashing light, or upper tummy discomfort? Where were you when the seizure happened? Do you remember anything about the seizure? Did you fall over and injure yourself? Did you bite your tongue or wet yourself? Any limb pain or weakness? Headache? Drowsiness after the seizure?
Do you drink at all? How much? Any injury to the head? Any fever (temperature)? Any prolonged headache? Any history of DM, hypertension, renal diseases, liver diseases? Any family history of epilepsy?
Examination:
1. Head: any bruises, laceration or depressed fractures.
2. Eye: size of pupil and reaction to light, jaundice, pallor, bruises around eyes, ophthalmoscopy.
3. Nose: blood or discharge.
4. Ear: Blood or discharge, bruises on mastoid process.
5. Mouth: tongue bite, cyanosis, acetone smell, alcohol smell.
6. Neck: stiffness, and carotid bruit.
7. Chest: respiratory rate, auscultate for abnormal sounds.
8. Heart: auscultate for murmur and arrhythmia.
9. Abdomen: distension, tenderness and hepatosplenomegaly.
10. Upper limb: pulse rate, blood pressure, sensory sensation and motor power, reflexes.
11. Lower limb: sensation, motor power, and reflexes.

Q.45 Take history from a patient, whose epilepsy is getting worse.
Introduction, and then you may begin with: “As far as I know, you had some fits recently. And before that you had no fits. I would like to ask you several questions.
Are you on medication for epilepsy? What kind of medication? Do you take the medication regularly on their times? How is your sleep? (Sleep deprivation) Have you done any unusual exercise? (Physical stress) Do you have any stress in work or at home? (Psychological stress) Were you feverish? (Infection) Do you drink at all? How much? Did you have any recent changes in your drinking habit? Is there a special time when the fits happen? Did you notice anything that brings on the fit? Like watching TV for long-time, disco, hard music? Have you had any injury to your head? (Secondary cause) Have you had headache for a long period of time? Have you been sick? (Secondary cause, as increased intracranial pressure) Do you feel thirsty more than usual? Passing water more than usual? (DM) Any weakness in the leg or arm? Do you take any medication? Any recreational drugs?

Q.46 A 56 year old female patient presenting to A&E with numbness in her left hand. Take history and give an advice.
Introduction, and then you may say: “As far as I know you had sensation of pins and needles in your hand. I would like to ask few questions and then I will explain to you what we will do.
1. When did that happen?
2. How long did it last?
3. Have you had similar conditions in the past?
4. Have you had any weakness in the arm or leg?
5. Have you had any change or loss of vision?
6. Have you had any giddiness or dizziness? Any difficulty with hearing?
7. Have you had any difficulty with speaking?
8. Do you have any headache?
9. Have you had any loss of consciousness?
10. Have you had any trauma to the head?
11. Do you have any pain in the neck, joint, or heart problem?
12. Do you have DM, hypertension?
13. Do you smoke? How many cigarettes a day?
14. What about your diet? Do you eat a lot of fatty meals or salt?
15. Has anyone else in your family had similar condition?
16. Do anyone in your family have hypertension, DM, CVA, early death, or hyperlipidaemia.
17. Are you on any medication? Did you use contraceptive pills?
Well it seems likely that you have a condition called TIA. It is a condition where a blood vessel of the brain becomes blocked temporarily and then re-open again. I will now examine you and then do some tests. After that it is important that you stop smoking, do more exercise, eat more vegetables and fruits, less fatty meals, salts and try to loose weight.
Also we will give you some medication to help preventing clot formation in the future and so prevent stroke or heart attack.
You should not drive for one month.

Q.47 Examine lower limb in a patient with peripheral neuropathy.
Introduction, then you may say: “I would like to examine your legs. Would you please undress your bottom ½ to your underwear and pop up on the couch.
Inspection:
1. Foot: look for atrophic changes (loss of hair and shiny skin), check pressure areas for ulcer, gangrene and callosities. Look for small muscle wasting, pes cavus, and claw toes.
2. Ankle: deformity (charcot joint).
3. Leg: muscle wasting.
4. Knee: deformity (charcot joint).
5. Thigh: muscle wasting.
Sensation:
1. Touch: ask the patient to close eyes, test segments and compare (cotton piece).
2. Pain: ask the patient to close eyes, use pin, compare (baseline sensation on the sternum). Ask the patient if quality changes (hypo or hyperaesthesia).
3. Deep pain: firm pressure to toe nail, and squeeze the calf.
4. Joint position: ask the patient to close eyes, check interphalangeal joint of hallux if impaired move to proximal joints till sensation is felt.
5. Vibration: ask the patient to close eyes, check the baseline sensation by tuning fork on the sternum, then on base of big toe, medial malleolus, tibial shaft and tuberosity, and iliac crest.
6. Temperature: mentioned.
7. Two point discrimination:
Reflexes:
1. Knee jerk (L3, L4): flex the lower leg at knee joint of 60؛
2. Ankle jerk (S1): flex the leg at the knee joint and extend at the ankle.
3. Plantar reflexes: (S1, S2).
Motor System:
1. Power: (grading of muscle power is set between 0-5) flexion, extension, adbduction, adduction of hip joint against resistance. Flexion, extension of knee against resistance. Dorsiflexion, plantar flexion, of foot with inversion and eversion. Dorsiflexion and plantar flexion of toes.
2. Co-ordination:
a. Heel shin test: ask the patient to put right heel on left knee and move it down and up (touch examiner finger before place it on knee).
b. Heel toe test of gait: ask the patient to walk on straight line.
3. Tone:
a. Flex and extend the knee passively.
b. Rotate internally and externally of the leg with knee extended.
c. Test for clonus: sharply push the patella down with knee extended and maintain pressure. Support flexed knee with one hand and with the other, briskly, dorsiflex the foot and maintain pressure.

Q.48 Examine cranial nerves II-VII of this patient.
Introduction, then you may say: “I would like to examine your cranial nerves, or I will examine the nerves of the head”.
Optic nerve (II):
Ask the patient: do you use glasses, or contact lenses? He/she should put these on during the exam if any.
Do you have any problem with your vision?
Sit directly opposite to the patient:
1. Visual acuity: ask the patient to close one eye with his/her hand and to read anything available in the room (e.g. exam paper).
2. Colour vision: with one eye still closed ask patient to tell the colour of anything available (shirt, tie).
3. Visual field: ask the patient to close opposite eye with one hand and to use the other as follows:
a. Ask the patient to look at examiner’s opposite eye.
b. Examine the outer aspect of visual field with a waggling finger, bring it into field of vision in a curve not straight-line approach from periphery at several points (upper, lower, nasal and temporal) and ask the patient to respond when seeing the moving finger.
c. Test control visual field by moving finger across visual field.
Repeat the 3 exams on the other eye.
4. Mention the need to examine retina by ophthalmoscope.
5. Pupillary reflexes:
a. Inspect for size and symmetry of pupils.
b. Reaction to light: ask the patient to look at a distance. Put your hand in the middle, in front of nose. Shine torch from one side and below. Look for direct and consensual reaction. Repeat for the other.
c. Reaction to accommodation: ask the patient to look at a distance. Then to look at an object held close to eye. Observe change of pupil size. (Normally it is smaller).
6. Visual inattention: ask the patient to look at your nose. Stretch your hands and move first a finger then another one. Then move both and ask the patient to report which finger is moving.
Oculomotor (III), Trochlear (IV), and Abducens (VI) nerves:
1. Inspection: for any abnormality: squint, nystagmus.
2. Eye movement: ask the patient not to move the head and just move eyes and to report any double vision. Ask the patient to follow your finger held 60cm away. Move the finger up down, to right up, to right down, to left up and left down. (If the patient has diplopia, test each eye separately).
3. Test convergence: ask the patient to focus on finger as it is brought from a distance to tip of nose.
Trigeminal nerve (V):
1. Sensory: ask the patient to close eyes, test touch (cotton) on front of nose and forehead. (V1 Ophthalmic). Cheeks (V2 Maxillary). Jaw area (V3 Mandibular). Check on both sides. Repeat for pain with pinprick Ask the patient to respond verbally. Mention the need for temperature and two-point discrimination.
2. Motor:
a. Inspect: muscles of mastication for wasting (temporalis).
b. Ask the patient to open jaw against resistance (pterygoides, mylohyoid and anterior belly of diagastric).
c. Ask the patient to clench teeth and palpate masseters.
3. Relexes:
a. Corneal Reflex: ask the patient to look to other side and approach from side with cotton.
b. Jaw jerk: place the index finger over tip of patient’s mandible with mouth slightly open. Tap examiner finger with a hammer.
Facial (VII) nerve:
1. Inspect the patient’s face for any asymmetry, blinking and eye closure.
2. Motor function: ask the patient to raise eyebrow, and then to close eye as strongly as possible and try to open it by finger. Ask the patient to show teeth, blow out cheeks against closed mouth. Purse mouth and whistle.
3. Sensory: taste sensation in the anterior 2/3rd of the tongue (mention it).
4. Lacrimation (shrimer’s test): put botting paper for 5 minutes. If the wetting is more than 10mm the lacrimation is normal. (Mention it).

Q.49 Unconscious patient. Perform primary and secondary survey.
Firstly, you have to stabilize the neck if there is any risk of neck injury.
Primary survey:
1. Hello, how are you, would you please open your mouth and put out your tongue? (Check airway if it is clear. If not, remove any obstructions, such as blood, teeth, and foreign bodies.
2. Inspect respiratory rate, bilateral chest movement. Then auscultate to check for air entry on both sides. If there is no respiration intubate and ventilate. If respiration is compromised put O2 mask. If there is tension pneumothorax, insert a wide bore cannula in second intercostals space at mid calvicular line.
3. Check pulse pressure, and blood pressure. If pulse is absent then consider the patient is arrested and treat accordingly. If in shock start shock treatment.
4. Determine level of consciousness according to GCS, or AVPU:
GCS:
a. Best motor response: obeys commands (6), localizes pain (5), withdraws or pulls limb away to painful stimulus (4), flexor response to pain “decorticate posture” (3), Extensor response to pain “decerebrate posture” (2), no response to pain (1).
b. Best verbal response: normally oriented (5), disoriented (4), inappropriate speech (3), incomprehensive sounds (2), none (1).
c. Eye opening: spontaneous eye opening (4), eye opening to voice (3), eye opening to pain (2), none (1).
N.B: response to pain is best tested by pressure on supraorbital ridge.
AVPU: Alert, response to Vocal stimulus, response to Pain, Unresponsiveness.
5. Exposure to check for further injuries, and covering the patient to avoid hypothermia.
N.B: Ask the patient if he/she feels any pain (assess verbal response), ask him/her to raise hand and to squeeze your fingers (motor) and look for eye opening.
Secondary survey:
1. Head: Signs of injury as bruising, laceration, bony deformity, depressed skull fracture.
a. Eyes: any foreign bodies, redness, perforation, size of pupil. Papillary reflexes, corneal reflexes, bruises around the eye. (suggestive of anterior cranial fossa fracture).
b. Nose: blood, discharge, (bright red discharge suggestive of rhinorrhoea).
c. Ear: blood, discharge (let blood discharge on sheet, and look for double ring: mixed blood and CSF). Bruises over mastoid (consider middle cranial fossa fracture).
d. Mouth: check stability of maxilla and mandible. Check for airway, any unstable false teeth or foreign body.
2. Neck: check for subcutaneous emphysema, cervical spinous processes, venous dilatation, tracheal deviation.
3. Chest: inspect respiratory movement, check for any penetrating or sucking injury. Paradoxical movement of flail chest. Palpate for tenderness, crepitus or rib fracture. Percuss and auscultate checking for heamo/pneumo-thorax.
4. Heart: auscultate for heart sounds.
5. Abdomen: inspect for injury or echymosis, laceration, distension. Palpate for tenderness, guarding. Auscultate for bowel sounds. Do digital rectal examination, check sphincter tone, and prostate.
6. Diagnostic peritoneal lavage: (if in doubt) below umbilicus, put drip of 1L N/S and aspirate.
7. Pelvis: compressed and distracted manually to check for stability or pain, examine penis for blood drops (if present, do not catheterize).
8. Extremities: inspect for bruises, laceration, or deformity. Palpate for tenderness and stability. Check pulses, sensory exam, reflexes, motor exam and muscle tone.
X-ray of spine (cervical), CXR, pelvic x-ray, blood for hematocrit, grouping and cross match, electrolytes, urea, glucose and ABGs. Do ECG.

Q.50 Epileptic young lady on carbamazepine, going on holiday. Give advice.
Introduction, then you may begin by saying: “ you are going to have a wonderful time in the next few weeks. Where are you going? With whom, are going? Before you go, I would like to say a few words about what you should avoid while being on holiday.
Advice about medication:
First make sure that you take enough medication with you. You are going to a very sunny place and you are on carbamazepine treatment. Remember that this medication makes you more sensitive to sunlight. Therefore you can easily get sunburn. To avoid this, don’t stay in the sun between 11:00am and 3pm; keep yourself covered especially during this hottest time of the day. Don’t wear clothes that you can see through if you hold them up to the light, they let UV light through. Try to wear a hat (especially if light coloured hair). Always use high-factor sun-protection cream. Apply regularly especially if you are swimming.
General advice:
Let other people with you know that you have epilepsy so that they can help if necessary.
It is a good idea to wear Medic-Alert chain or bracelet, which is very useful way of letting other people know that you have epilepsy, so that they can help, should this be necessary.
Sports:
You can play tennis, basket ball, go jogging, running, swimming and what is important about swimming, that you shouldn’t do it alone. Always go with a strong swimmer who can help you in case an attack occurs. Also avoid excessive exercise and allow yourself enough time to rest.
Sports that could be dangerous are those where people cannot reach you easily, should a seizure happen. Such as horse riding, parachuting, hang-gliding, para gliding; or those involving water such as scuba diving.
Sleep, TV, and disco:
Sleep is also very important, less sleeping hours would trigger an attack, this is most likely to happen after getting up early following late nights. A regular pattern of sleep should reduce this risk.
The flashing light of disco, and flicking light of TV can trigger an attack. Try to limit the period of time you spend in disco and try to stay away from flashing light. When watching TV stay at least eight feet away form screen and three feet away when playing computer games.

Q.51 A patient with epilepsy. Give an advice on medication.
Introduction, then you may begin by saying: “I would like to say few words about your medication.
1. Aim and blood level: the aim of medication is to control fits. It is not a cure for epilepsy. The medication works by abolishing or reducing the excessive electrical activity within the brain. Fits can be completely abolished in up to 80% of people with epilepsy using currently available drugs. Medication can be successfully withdrawn in some people after they have a period of years free from fits.
2. After absorption from intestine, the medication travels in the blood to the brain where it produces its effect. And as the rate of elimination of the drug differs from one person to another we usually measure the blood level of the medication and according to the level we adjust the dose that suits each individual.
3. How to take it: because the effect of most anti-epileptic drugs wear off quickly they have to be taken twice or three times a day. The exception is phenytoin and vigabatrin, those drugs maintain their effect longer and can be taken once daily.
4. It is important to take the medication at the same time each day. Taking it before or after a meal should not affect performance. If you miss a dose, take it as soon as you realize but do not take double dose. You should continue to take the medication as prescribed, don’t try to stop the drug by yourself. Otherwise the fits may return and even worse than before.
5. Side effects: as any other medication, anti-epileptics have some side effects. Most of the unwanted ones are proportional with large dose being taken. The symptoms produced by over dosage of these medications are: sleepiness, dizziness, feeling sick, double vision, and unsteadiness of feet, skin rashes and itching. These effects can be eliminated or minimized by decreasing the dose of the drug.
6. Anti-epileptics make some medications less effective than usual because they speed their breakdown in the liver. The best example of this is CCP that is why people on those medications need to increase the dose of Oestrogen pill. Also they have effect on medication that prevents blood clots (or medication that thins blood). Alcohol can reduce the effect of anti-epileptic drugs and by doing so, provokes fit in some people. Therefore alcohol consumption should be kept to a minimum. A pint of beer, 2 glasses of wine, or 2 measures of spirit should be considered the maximum alcohol intake in 24 hours.
7. Stopping the drug: the medication should be taken regularly and should not be stopped or changed abruptly. And if you will be free of fits for 2 years, we may try to stop the medication by decreasing gradually its dose. This process should be carefully planned for, because there is a chance for fits to return and unfortunately, there is no way to predict those in whom the fits may return.
8. Complementary treatment: which relieves stress and promote relaxation as yoga and hypnosis.
Is everything clear to you? Do you want me to repeat anything for you? I will bring a leaflet about anti-epileptic medication, which you can keep and read, and have a good idea about those medication.

Q.52 Epileptic patient started on carbamazepine. Counsel.
Introduction, and then you may start by saying: “I would like to have a word with you about carbamazepine, the medication you need for epilepsy (fits).
1. Aim and blood level: the aim of this medication is to control fits. It is not a cure for epilepsy. It works by abolishing or reducing the excessive electrical activity in the brain. Fits can be completely abolished in up to 80% of people with epilepsy on medication; which can be successfully withdrawn later, if the patient has epilepsy free period of 2 years. After absorption from the intestine the medication travels in the blood to reach the brain where it produces its effect. And as the rate of elimination of the drug differs from person to person, we usually measure the blood level of the medication. And according to that level we adjust the dose that suits each individual.
2. How to take it: you start by taking one tablet twice a day and it is important to take the tablet at the same time each day, say at 08:00 am and 08:00pm. After 2 weeks, start by taking 2 tablets twice a day, and then we will draw blood from you to check the blood level of the medication. This will allow us to determine the dose that you need. You should be careful to take the medication at time and don’t try to stop it, or decrease the dose by yourself, otherwise fits may return and be difficult to control. If you miss a dose just take the tablet as soon as you remember but don’t take double dose.
3. Side effects: as any other medication, this drug causes some side effects, most of which are related to intake of large doses. And can be minimized or eliminated by decreasing the dose of the drug. These side effects are, headache, dizziness, drowsiness, feeling sick, double vision, and unsteadiness of gait, skin rashes especially upon exposure to sun. And in few people, the drug may affect the blood cells production, which leads to recurrent fever, sore throat, mouth ulcers, widespread skin rashes, and bruising of skin. So if any of these symptoms occur, consult the doctor immediately.
4. Carbamazepine makes some medications less effective because it speeds their breakdown in the liver. The best example is CCP. That’s why people on this medication need higher dose of Oestrogen pills. Also it decreases effect of some drugs that prevent blood clotting. So it is important that your doctor knows whether you are taking such drugs or not. Alcohol can reduce the effect of carbamazepine therefore, may provoke fit. So alcohol consumption should be kept to a minimum. A pint of beer, 2 glasses of wine, 2 measures of spirit should be considered as maximal intake in 24 hours.
N.B: some over the counter drugs interact with anti-epileptic medications, so contact your doctor before buying any none-prescription drugs as well.
Offer the patient to provide a leaflet about carbamazepine, and ask if he/she understands what has been told.

Q.53, 54 A young female patient with epilepsy. Give advice about life style.
Introduction, and then you may say: “As far as I know you have epilepsy. I would like to have few words with you about a minimal change you may need to do in your life style.
1. General advice: it is a good idea to plan your day to allow enough time for work, rest and different activities. Eat regular meals, and avoid prolonged period without food. Regular pattern of sleep reduces the probability of seizures, which are more likely to happen when getting up early following late nights. Make sure that you have sufficient medication with you when you go away form home. It is a good idea to wear Medic-Alert chain or bracelet to let people know about your condition so that they can help you, also let people living with you know that you have epilepsy and teach them how to deal with seizures.
2. At home:
a. Living room: stay away from fire, and if possible choose a soft carpet. Fit safety glass in windows and doors.
b. In kitchen, don’t cook on your own. In general, microwaves are safer than cookers, but if you use cooker then use the back burners and turn the sauce pan handle towards the back of the cooker to make them less likely to knock over. Carry the plates to the pan and not vice versa. In bad room: choose a wide-low level bed.
c. In bathroom: let people, living with you, know that you will have a shower or bath, and don’t lock the door. In general, showers are safer than baths. But if you use bath, don’t have the water too hot and turn off the tap before you get in. and it is better to keep the water shallow.
d. At work: avoid works that involve operating machinery or going up to high open spaces.
e. Driving: you must not drive by law until you are one year fit free, with or without medication and you need to inform Driving and Vehicle Licensing authority.
f. Leisure time: It is a good idea to carry on sports such as jogging, tennis, basketball, and swimming. But for swimming you have to be always with a strong swimmer who can help you. Avoid being overtired, dangerous sports such as horse riding, parachuting, paragliding. As it is difficult for people to reach you when help is needed.
3. About alcohol: Same advice as in previous question.
4. TV: stay 8 feet (3m) away from screen, and 3 feet (1m) away when playing pc games.
Q.55 A patient with (COAD) chronic obstructive airway disease. Examine the respiratory system.
Introduction, then you may say: “I would like to examine your chest, would you please undress to your waist and sit on the couch”.
Inspection:
1. Hands: check for cyanosis, clubbing. (Inspect the fingers laterally, test for fluctuation of the nail bed). Check for nicotine staining, wasting of interossei, flapping tremor. Palpate for wrist tenderness (for arthritis of Pulmonary Osteoarthropathy), take pulse pressure and at the same time take respiratory rate (normally it is 14/min).
2. Face: Eyes: check for ptosis and constricted pupil (Horner’s syndrome). Ophthalmoscopy for dilated veins, and papillaedema of hypercapnia. Mouth and tongue: for central cyanosis.
3. Neck: examine cervical lymph nodes from behind Submental, submandibular, tonsillar, anterior triangle, supraclavicular, and scalene (at sternal head of sternocleidomastoid muscle, and ask the patient to turn head slightly to same side).
Chest:
1. Inspection: of respiration for
a. Depth.
b. Pattern (any cheyne stokes breathing, intercostals or diaphragmatic, abnormal respiration: asymmetrical, like in flail chest. Indrawing of supraclavicular, intercostals muscles, and contraction of cervical muscles).
c. Shape: increased AP diameter (barrel chest), Kyphoscoliosis, Pectus excavatum, Pectus carinatum, scar, bruises, discharging sinuses, dilated veins. (Inspect posterior chest as well).
2. Palpation:
a. Trachea. Position with index finger. Cricosternal space with 2 fingers, and normally it is 4-5cm.
b. Palpate apex beat to get idea about site of mediastinum. Palpate lightly for tenderness for fracture, or for tumour or crepitus of subcutaneous emphysema.
c. Check for Chest expansion: from behind with two hands just below the scapula for symmetry and range, normally it is 5cm.
d. Check for vocal fremitus: in two different places anteriorly, posteriorly and at the axilla.
3. Percussion:
a. Anteriorly in supraclavicular, clavicular, infraclavicular, and from 2nd to 6th intercostal spaces.
b. Laterally: from axilla down for 3 intercostal spaces.
c. Posteriorly: at the apex by placing finger vertical on border of trapezius muscle medial to border of scapula at level of spine (do it 3 times).
4. Auscultation:
a. Anteriorly: supraclavicular, infraclavicular, (do it 2 times).
b. Lateraly: axilla, do it once.
c. Posteriorly: below spine of scapula, for 3 times.
N.B: Avoid auscultation within 2-3cm of midline, because sounds of bronchial vocal resonance are heard at that place.
When examining the back ask the patient to fold arms across anteriorly.
Examine bilaterally and compare.

Q.56 Teach a patient how to read Peak flow meter, and comment on results.
N.B: Peak flow meter is the instrument used to monitor the progress or response to treatment. PEER is the maximal speed in L/min which a patient can blow air out of his lung. It changes with sex, age, height, and time of the day (lowest in the morning in asthmatics).
Introduction, then you may say: “Now I would like to examine your lung function. You should stand up in order to breathe more easily. This instrument is called Peak flow meter; you should put your mouth here around mouthpiece. And catch the instrument from the side to allow the marker to slide freely. Then blow or breathe out into it sharply. This will cause the marker to fly up and show me the result which we call PEER. Please breathe out into it as hard as you can.
(After the patient breathe). Thank you, one more time please.
After breathing for second time). Thank you and for the last time.
(After breathing for the third time) Thank you.
We take the result and plot it on the chart. There are two types of charts, one for men and another for women. Each has the horizontal axis showing height, and left vertical showing PEER. The graph in the middle shows the age.
Remind the patient of important clues:
1. You must hold it horizontally.
2. You must take a deep breath.
3. There are charts for two weeks, and one month.
4. Ask the patient to repeat the reading in the morning and evening for 2 weeks at home.

Q.57 A patient with fever for 7 days. Take history and make a diagnosis.
Introduction, then you may start by saying: “what seems to be troubling you? (The patient complains of chest pain and fever). How long have you been like this? Do you have fever all the time or does it come and go? Do you have any chills or sweating?
Could you tell me more about your chest pain, where is it exactly? Does it spread anywhere? Can you describe what it feels like? What brings the pain on? Does anything seem to make it better or worse?
Do you have cough? Any phlegm? Amount, smell and colour? Any blood with phlegm? Do you have shortness of breath? Any wheeze or noisy breathing?
Questions for atypical pneumonia:
Do you have headache, joint pain, and muscle pain, have you been sick? Do you have frequent bowel motions? Bleeding from any site? Do you keep birds at home, like parrots, pigeon or turkey? Did you travel abroad recently? Did you stay in hotel?
Questions for predisposing factors for pneumonia:
Do you have any problem with your lung, asthma, and frequent flues? Do you have any disease, DM, heart disease? Have you been admitted to hospital recently? Do you take any medication? Do you have any allergy? Do you smoke? How many cigarettes a day? Do you take any IV drugs?
Well Mr/Mrs (the patient), you seem to have a chest infection which could be pneumonia, but first we need to run some tests, we are going to take a tiny drop of your blood and do CXR for you and I will see you again after that.

Q.58 A patient presenting with worsening asthma for the last 3 months. Take history.
Introduction, and after that you may begin by saying: “As far as I know you have asthma, and you got shortness of breath many times in the last 3 months”.
How long have you had asthma? Is your shortness of breath more likely to occur in the morning, afternoon or evening? Do you use peak flow meter? Does it affect your sleep? Do you wake up short of breath? Is it more likely to occur in weekdays or weekends? Did you have sick leave from work because of shortness of breath? Do you feel short of breath when you walk or climb stairs? Did you have eczema, hay fever?
Questions to assess precipitating factors:
Check inhaler technique.
What medication do you take for asthma? Do you take your medication regularly? Did you have any fever (temperature), cough, phlegm, flue, and chest pain?
Do you take any other medications (خ² agonist, NSAIDs)? Any stress at home or at work? Did you change your work? Did you change your accommodation? Do you keep pets? Do you have any new carpet, furniture, pillow or duvet? Do you smoke, and how many cigarettes? Have you had any unusual exercise?
Trigger factors: infection, stress, exercise, allergens, drugs, and cold air.

Q. 59, 60 teach a patient or parent of a child how to use a spacer device.
Introduction, and then you may begin by saying: “I would like to say a few words about the spacer device.
This device is used with the metered dose inhaler, it has 2 openings, and one of them is fashioned to attach the inhaler opening to it. The other is for the patient to put his/her mouth around it.
At first, breath out fully, then put your mouth around mouth opening and the inhaler in its opening. Push the canister once, and then take a deep breath. The device has a click, which produces a sound when someone takes a breath.
In children: the same technique is applied, just that after pressing the canister and the child exhales. Let the child breathe in and out for 10 seconds (or count 5 clicks).
How to clean it: when you want to clean this device just rinse it out with tap water and don’t use detergents and after that leave it to dry in air and don’t wipe it.
Advantages and disadvantages: this device has many advantages as: it is easier to use, since you don’t need to synchronize pressing the canister with breathing in as when using the inhaler alone. It improves delivery of medicine to lung. It reduces the possibility of mouth candida infection with steroid. The only disadvantage is its large size.
For inhaler technique: the patient should exhale fully, then putting the mouthpiece between his teeth. Press the canister once just after beginning to inhale through the mouth. He/she should hold his breath in inspiration for 10 seconds if possible. One deep breath, or 5 usual breaths, clean it at least once a week; keep the inhaler away from other children.

Q.61 Inform a woman that her husband has inoperable mesothelioma, and counsel.
Introduction, and then you may say: “I would like to have a few words with you about your husband’s condition.
As you know your husband came to us with shortness of breath and has been with us for some time. We examined him and ran all the necessary investigations, and I am sorry to have to tell you that he has a nasty growth in the lining of the lung that is the air tubes that has already spread, so we cannot take it out by surgery.
I understand that this is not easy to come to terms with, but I can assure you that we will do our best to make his life better. He may get some pain and fortunately we have many effective medicines to deal with pain. First we start with Pracetamol, which is given as two tablets 4 times daily, we may need to give him NSAIDs such as Apirin, Ibuprofen. Those may irritate that stomach and may cause some tummy pain so it should be taken with food. And these drugs may cause some blood to appear in stool. We may combine these with weak opioids such as Dextropropoxyphene and if the pain is not controlled we can use strong opioid such as Morphine, which is effective. And we have now slow release preparations, which can be given twice daily. But it some side effects such as feeling sick, being sick, sleepiness, constipation and respiratory depression. However, we can adjust the dose of treatment, should these side effects occur.
Another thing, that is from time to time your husband may get shortness of breath because of fluid being collected in the lining of the air tubes. So if he gets this you can bring him to the hospital so that we can take out some of the accumulated fluid to improve his breath.
Is everything clear? Do have any questions? (The wife may ask: is he going to die?)
Well, we cannot give him anything that could cure his condition. But we do not know for sure how long he has got. (Median survival is around 2 years).

Q.62 A patient with dementia. Do mental state exam.
Q.63 A patient with Alzheimer disease. Assess the cognitive function.
See OHCM 4th edition page 77.

Q.64 A patient presenting after care accident. Take history.
Introduction, then you may start by saying: “I have heard that you had a car accident recently, and you feel low now.
Could you tell me more about this accident? When did it happen? How did it happen? Do you think it was just an accident? Who were with you? Had anyone injured in the accident? What you were thinking at time of the accident?
Could you tell me more about the morning of the accident? Did you have any problem with your family? Any stress? Were you feeling so low then? Do you drink and how much?
When did you start to feel low? Before the accident or after? Is it your first time?
Ask about symptoms of depression:
Loss of interest or pleasure, loss of appetite, loss of weight, early weakening, diurnal variation in mode, loss of interest in sex, psychomotor retardation (slowness). Loss of concentration, worthlessness, feeling of guilt, suicidal thoughts. (Do you think that life is worth living nowadays? Have you felt so low that you have considered harming yourself? (Have you ever had the thought of harming yourself?).
Do you like to be with people or do you prefer to be alone? Do you smoke? Do you drink? Do you take any drugs?
Present circumstances:
Do you have any problem at job or with money? Do you have any problem with your partner or at home? Did you have any recent bereavement?
Past and family history:
Did you have any mental illness? Other illnesses? Any mental or other illnesses in the family? Do you take any medication?
Birth growth and development:
How were you at school? Did you have many friends? What are your hobbies? Sport? Reading? Did you have any trouble with law?
Pre-morbid personality:
How have you been feeling in yourself?
It is quite natural for people to feel low when they have an accident. We can give you some help by referring you to one of my colleagues who is specialist in this area.

Q.64 A 16 year old girl with recent weight loss. Take history and put a diagnosis.
Introduction, and then you may start by saying: “As far as I know, you have some weight loss. I would like to ask you few questions about your condition”.
When did you notice that you are losing weight? What was your weight before? And what is it now? Through how much time you lost this amount of weight? Do you have any fever, any feeling of tiredness, cough, shortness of breath, chest pain, and infection?
Do you feel thirsty and pass water more than usual? (DM) Have you noticed any recent intolerance to heat, sweating, and tremor? (Thyrotoxicosis)
How many times do you open your bowel? And do you have diarrhoea? Did you notice that the waste couldn’t be flushed away easily? (Steatorrhoea).
Do you have any stress at home, at school? (Stress).
How is your appetite? Do you take any special diet? Do you think that you are thin, has usual weight or overweight? (Model, Ballet dancer). Do you ever induce vomiting or use medication to decrease weight? Do you exercise to lose weight?
What about your periods? Are they regular? How do you feel in yourself? Any mood changes during the day? What about your sleep? What about your concentration? Your memory? Do you still enjoy things you used to like them before? Do you think that life is worth living nowadays? Do you have any diseases? Do you take any medication? Do you have any disease in the family?

Q.65 a patient is referred to you by GP, with panic attacks. She has 2 children. Take history.
Introduction, then you may say: “Your GP says that you are worrying too much about things. What do you think?
Were you usually get worried? How do you feel then? What makes you feel better and what makes you feel worse? How long have you been like this? Any problem or stress at work or at home? Do you have a partner? Any problem with him/her or any problem with your children?
Your GP says that you have 2 children? How old are they? Are you worried about them? What do you do for living? Do you have any problem getting sleep, and relaxation? What about your appetite? Have you felt sick recently? Have you been sick recently?
Do you find that you have to do things repeatedly like washing your hand? (OCD).
Do you enjoy things you used to enjoy before? Do you feel low? Have you ever considered harming yourself or your children? Did you make any plan? What stops you? Have you left any notice? Do you feel sorry about that now or you still want to try?
Do you drink and how much? Any recent dislikes of hot weather? Any recent changes in your bowel motions? Your periods? Do you have any disease? Do you take any medication? Is there any one in the family with psychological illness?
Treatment: relaxation, cognitive and behavioural therapy. Medications: benzodiazepins, as Diazepam.

Q.66 a patient is planned for operation for ingrown toe nail. You performed routine FBC, and found out MCV to be high, and suspect alcoholism. Take alcohol history.
Introduction, then you may start by saying: “You may remember that we ran some tests. Well we have got them back and there is something we just need to check before we go any further. Do you mind if I ask you few questions about your daily routine. What you eat, drink, and such questions?
What did you have for breakfast today? Is it your usual breakfast? What do you have for lunch? Do you enjoy anything with your meals? Do you drink at all?
Go through average day of drinking. Ask about type of drink. Amount, ask if the patient mixes drinks, and ask about drink in weekends.
Where do usually drink? With whom? How long can you go without having something to drink? Have you ever considered cutting down? Are you annoyed by people comments on your drinking? Have you ever felt bad or guilty about drinking? Have you ever had a drink the first thing in the morning to get rid of hang over? (Eye opener).
Cutting down, Annoyed, Guilt, Eye opener (CAGE), if the patient has 2 or more it means he/she has an alcohol problem.
Ask the patient: Can you always control your drinking? Has alcohol led you to neglect your family? Have you been in trouble with law? At what age did you start drinking? Did you seek help to stop drinking? Dou you have any disease? Do you use any medication? Is there any disease in the family?

Q.67 a patient with running nose. You suspect morphine addiction. Take history and explain complications.
Introduction, then you may say: “As far as I know, you have running nose. I would like to ask you few questions about your condition.
For how long have you had this? Is it the first time or you had this before? Did you notice anything that brings on the running nose? Do you have any other complaints? If no response, then:
Do you smoke? Do you drink? Do you take anything else besides drinking to enhance your mood? Do you inject any drug? How long have you been using this drug? Is it continuous or you stop from time to time? How do you use drugs? Injection? Sniffing? Where do you usually use drugs? Do you share needles? Do you have a partner? Does she/he use drugs? How do you finance your drugs? Any problem at home? At work? With law?
Well Mr. (the patient), Drugs can cause many problems and can affect health:
1. There are the complications of the drug itself: as feeling sick, being sick, constipation, sleepiness, it also affect respiration, and in high dose it may cause the respiration to stop. And it may cause problems with vision. And difficulty in passing water.
2. There is another problem, when you use the drug for long time, you get what we call dependence; that when you do not use the drug you get irritable, and feel craving for it and also get running nose, running eyes, tummy pain, loose motion, yawning, disturbed sleep and muscular pain.
3. Then there is the problem of injections, if the drug user shares needles he/she may catch disease such as AIDS, liver disease, also chest infection, and infection of the heart lining.
4. Finally, using drugs can cause you financial problems, and problem with law.

Q.68 A patient with lymphoma. Complaining of pain not relieved by Ibuprofen. You are going to put her on morphine. Tell her.
Introduction, and then: “As you know you have lymphoma and we have been treating you with Ibuprofen, for pain relief. But you still have pain so we are going to put you on morphine, which is stronger.
I would like to tell you few things about this drug. Morphine is very good analgesic and we will start to give you one tablet every 4 hours until you get complete relief of pain. Then we will change to one tablet twice daily with the same dose of a longer acting medicine. (Sustained release).
In some cases, Morphine cannot be taken by mouth, then we can give it by muscle injection or injection into blood (IV injection) or can be given underneath the skin injection by syringe driver.
Like any medication, Morphine has some side effects, such as feeling sick, being sick, should this happen we can give you drugs to overcome it. Other side effects, like dry mouth, and this is overcome by artificial saliva. Constipation is another side effect, to avoid it we advice you to eat lot of vegetables and fruits especially those with high fibers, and even we can give you some laxatives. Other side effects are sleepiness, and respiratory depression, which occurs only in high doses.
Also this medication may cause difficulty to pass water and should this happen try to go to toilet and turn on the tap, relax and you may pass water. But if it did work you should come to hospital.
Is everything clear? Are there any questions in your mind you want to ask?


Q. 69 a patient, started recently on Dothiepin (TCA), is not feeling well. Counsel.
Introduction, then: “How can I help you? Do you take the medication regularly?”
As we have told you before, this medication takes sometimes to work, around 2-4 weeks. And as you take the drug regularly you will find improvement. The first thing you will notice, is that your sleep will be better, and then you will get improvement in appetite, mood, sex drive, concentration and so on. Just keep taking the medication and you will be much better.
Another thing is about the side effects, which we discussed before, but just I want to remind you that you may feel sick, or even been sick and in such case we can give you some medication to overcome that.
You may feel some dryness in your mouth, and to relief this we may give you artificial saliva. If you complain of constipation, I advice you to eat lot of vegetables and fruits containing fibers, and if this doesn’t work we can give you laxative. If you get blurring of vision, or sleepiness then you should avoid driving or being in high places. You may feel dizziness on standing, so try to stand up slowly from lying position. You may get difficulty with passing water, and in such case, turn on tap, and relax, should this not help, come to hospital.
There are some other side effects but rare, I need just to mention them to you: arrhythmia (disturbance of the electricity of the heart), and fits (convulsions).
Is everything clear? Do you want me to repeat anything for you?

Q.70 Examine the breast.
Introduction, and then you may say: “I would like to examine your breasts, is it ok with you?”. Ask for chaperon, ask to undress to the waist and draw the curtains to ensure privacy with the patient.
Inspection:
1. With both hands resting on the thighs, look for asymmetry, swelling, skin dimple, change in colour, dilated veins, and nipple discharge or nipple retraction or in drawing.
2. With both hands pressing firmly on hips, check for any changes.
3. With both hands rose above head, check for any changes.
4. With patient leaning forward, check for any changes.
Palpation:
Ask the patient to lie on a couch with the head supported by one pillow, and the hand on the side to be examined under the head.
1. Start palpation from 1 o’clock till 11 o’clock then palpate the tissue under areola and nipple (start with normal breast).
2. Palpate the nipple between finger and thumb, and try to express discharge.
3. Palpate the axillary tail.
4. Repeat the same with the other breast.
5. If any mass appears, mention it then continue palpation then return to it to define its characteristics.
6. While the patient is lying, examine the abdomen for hepatomegaly, and ascites.
7. Ask the patient to sit on side of couch: support the right arm with your right arm and examine right axilla with left hand for lymph node or lumps.
8. Examine supra and infra clavicular lymph nodes.
Auscultation: The chest.
Percussion: the spine.

Q.71 a patient with Ca breast, depressed. Counsel.
Introduction, then you may start by saying: “I would like to have a word with you about your condition, as far as I know you have a nasty growth in your breast. How do you feel in yourself now?
I understand that this is not easy to come to terms with, but I can assure you that with modern treatment. Thousands of lives have been saved and made comfortable.
Fortunately, we have a good management plan for this condition; first we have to do surgery. That is we remove the growth together with your breast, this operation called mastectomy.
This operation is done under general anaesthesia, where you will be put into sleep. It is a major operation, after which you may feel unwell for a few days. As for all operations, this one has some possible complications, like bleeding, pain, and infection. And for minimizing the chance of getting such complication we will give you medications.
You will, probably, be allowed up, the day after the operation. You should remain in the hospital for 5-7 days, and you can return to work in 6 weeks.
After the operation, we will give you a temporary breast form to wear under your bra until the site of operation heals completely, then we can arrange for a more lasting breast forms.
Since mastectomy was introduced, this operation is carried out all over the world, and women underwent mastectomy are enjoying normal useful and happy lives. No one needs to know that they lost a breast. There is no reason what so ever why you shouldn’t be exactly the same. You probably met someone with mastectomy, without knowing it.
After the operation, you may need radiotherapy for 4-6 weeks daily in hospital; side effects are redness of skin, local hair loss, and local effect.
We may need to give you a type of medication called Tamoxifen that reduces the effect of female hormone called Oestrogen, or instead we may give you chemotherapy.
N.B: chemotherapy best for premenopausal. Tamoxifen for post menopausal.
You are not alone; it is a common condition affection 1/12 woman in the UK.

Q.72 a young female patient presenting with palpitation. Take history.
Introduction, then you may say: “How can I help you? What do you mean by palpitation? Can you describe it for me, please? Is it fast or slow? Regular or irregular? Can you tap it on table for me please? Where and when do you usually feel it? How long does it last? Do you have any chest pain, shortness of breath, fainting?
Do you have any stress at home or in job? Did you notice any change in your weight? How is your appetite? How is your bowel motion? How is your period? Is it heavy? Do you prefer hot, or cold weather? Any recent changes? Any tremor? Sweating more than usual? Do feel any new easy irritability? Any change in your voice? Do you have any disease? Any anaemia? Are you on any medication? Any disease in the family?
Do you drink coffee, tea? Do you smoke? How many cigarettes? Do you drink? How much? What do you do for living?

Q.73 Examine a patient with suspected thyroid disease.
Introduction, then: “I would like to examine your neck gland”.
Start by inspecting the:
1. Hands: nail changes, check for sweaty, hot, coarse or dry skin. Ask the patient to outstretch both arms and fan fingers and look for fine tremor. To check that, you can put a paper on the hands and watch for tremors. Take pulses and mention about blood pressure.
2. Face: check for any hair changes, excessive sweating. Eye: examine from front: for lid retraction and chemosis. Ask the patient to follow finger up and down not too slowly. And look for lid lag (Von Graafe’s sign). Ask the patient to follow finger up, down, right, left as it moves towards point. And look for ophthalmoplagia. Ask the patient to tilt head down and to look upward, look for absence of forehead wrinkling (Joffroy’s sign). From back: tilt the head back and support it with right hand and remove the hair with left hand. Look for ptosis (Nafzinger method of examination).
3. Neck:
a. Inspection: for any mass (goitre) or lymph nodes. Ask the patient to take a sip of water and look, and ask to protrude tongue and look for any thyroglossal cyst.
b. Palpate: (from behind) ask the patient for permission to stand behind and palpate, for lymph nodes. And for the gland: first palpate both lobes, then stabilize one lobe and palpate the other. Ask the patient to take a sip of water and continue. Then ask to breathe in deeply and palpate (check for stridor), check the position of trachea. Percuss over the suprasternal notch. Auscultate for bruit.
4. Lower limbs: check reflexes of knee and ankle. Look for pretibial myxoedema.

Q.75 a mother with 3-4 years old child with polyuria, polydipsia, lethargy. Take history.
Introduction, then: “I would like to ask you a few questions about your child’s condition”.
When did you notice that she pass water more than usual? How many times does she pass water? Day or night? Is it just increase in frequency or is it also increase in the amount of urine? Any change in colour of urine? Any burning sensation while passing water?
Any tummy pain? Does she drink water more than usual? Has she lost weight recently? How is her appetite? Does she seem to be dry? Her mouth? Does she cry without tears? Does she seem to be feverish? Any recurrent infection?
Any whitish discharge or itch from down below? Any injury to the head? Any change in vision? Does she seem to be sleepy? Does she seem to be tried? Does she have any illness? Is she on any medication? Any family history of DM? Any disease?

Q.76 a mother bringing her 8 months old child crying all night. Take history.
Introduction, then you may start by saying: “What seems to be the trouble? How long has he been crying? Is he crying all the time or with periods of rest? Does he draw the legs to the tummy? (Signs of pain)
How is his feeding? Did you introduce any new type of food? Has he been sick? Did you notice any lump in his tummy? Any visible movement? How many times did he open his bowel? Is it normal motion? Any changes in stool consistency? Any changes in stool colour?
Does he seem to be dry? His mouth, tongue? Does he cry without tears? Does he have any fever (temperature)? How is his water works? Is he active, tired, sleepy? How is his breathing?
Well Mrs. (the mother), from what you have said it seems likely that your child has a condition what we call intussusception, it is a condition where part of your child’s gut is telescoped, i.e. has folded back in on itself, just like my sleeve. So first, I would like to examine him, and then we need to run some tests. The important one is to do what we call barium enema where we put tube in the back passage and push a contrast material which will make the condition appear on x-ray, and may treat it as well (cause the folded part to unfold). And if doesn’t unfold by this method, we will need to do operation which allow to look at that part of intestine, and if still healthy, we return it back to its original position. And if not, then we will cut that unhealthy part and re-join the ends.




Q.77 a mother worried that her child may have meningitis. You diagnosed upper respiratory tract infection. Reassure the mother.
Introduction, and then you may say: “I can understand how worried you have been, because I have heard from the nurse that you thought that your child might have meningitis.
You don’t need to be worried, because we examined him and we found that he has no signs of meningitis. He has some fever, but his temperature is 37.5؛C, which is mild fever (temperature), while in meningitis we have high fever. A child with meningitis usually has severe headache, whereas your child has just mild headache. And a patient with meningitis becomes so tired and sleepy, but your child can move and walk around. Besides, a child with meningitis can even develop fit. And becomes sick many times and doesn’t like food and as you know your child just has been sick once and he can eat.
Someone with meningitis usually dislikes light, shy away from light. And your child can look nicely to light. Also a patient with meningitis finds it difficult to move his neck, which may be painful, but your child can move his neck freely with no problem. Your child has no skin rash, as might occur in children with meningitis. And besides, after examining your child, we are pretty sure that he has pharyngitis that is inflammation of the throat. It is a good idea to be careful and to keep a careful eye on him, but as I have told you, there is nothing to worry about.

Q.78 a mother is on the phone, worrying about her child how has fever and his GP thinks it is ear infection. And gave him antibiotics. Reassure the mother.
Hello this is Dr (you), How can I help you?
How long he has been like this? Is it there all the time or does it come and go? Is it the first time? Any associated chills, sweating? Any fits? Any joint pain? Any headache? Are his hands or feet cold? Is he active, walking, playing or drowsy, sleepy all the time?
How is his appetite? Has he been sick? Did you notice that he would shy away form light, dislikes bright lights? Can he move his head freely? Any pain when moving the neck? Any skin rash (tell about the glass test)? Has he had any contact with other children who developed the same features? How are your other children?
Features to ask about in meningitis:
1. Fever with cold hands and feet.
2. Fits.
3. Headache, joint pain.
4. Tiredness and drowsiness.
5. Being sick, dislikes of food.
6. Neck stiffness.
7. Photophobia
8. Skin rash.

Q.79 A mother is seeking advice, over the phone, for her child with diarrhoea.
Hello, this is .Dr (you), how can I help you?
How long has he been like this?
How many times does he open his bowel? Is it watery, loose or semi formed? Any blood, mucous, pus? (mucous = slippery).
Any tummy pain or lump? Has he been sick? Any fever (temperature)? How is he feeding?
Ask about signs of dehydration:
How is his mouth? His tongue, is it dry or moist? Or cry without tears? His eyes seem to be depressed? Does he pass water as usual? How is his breathing?
Then if the dehydration is mild, give him ORS; if not available, teach the mother how to prepare one. 1 L of water (2pints of water), boil and let to cool, then add 10 TSF of sugar and TSF of salt. And give the child by spoons as much as he accepts. Don’t give ORS if breastfeeding continues.

Q.80 a mother is worried about her boy who had a needle stick injury. Take history and give advice.
Introduction, then you may say: “How can I help you?”.
How old is your boy? When did this happen? Were you with him? Did he bleed after that? Did you clean the area? Did you bring the needle with you? Was it clean or dirty? What about his immunization? Is it complete?
If he is fully immunized, and the needle was clean, there is no need for any tetanus toxoid booster.
If the boy is fully immunized, and the needle is dirty, give the boy a booster of tetanus toxoid.
If the boy is not immunized and the needle is clean, start immunization.
If the boy is not immunized and the needle is dirty, give tetanus IG, and start immunization.
For HIV and Hepatitis B, take blood sample for baseline then follow up:
For Hepatitis B the incubation period is 2-6 months.
For HIV, take blood sample after 3, 6, and 8 months.
Check needle stick in the hospital in OHCM 4th ed. Page 216.

Q.81 a 55 year old male patient presents with haematuria. Take history.
Introduction, and then you may start by saying: “As far as I know, you pass blood with water. I would like to ask you a few questions then I will explain to you what we will do.
How long have you been passing blood with water? Is it at the beginning, throughout or at the end of stream? Any change in frequency of passing water? Any change in amount? Do you feel urge to pass water? Any incontinence? Do you feel need to pass water and nothing comes? Burning sensation with passing water?
Do you have any tummy pain? Any temperature (fever)? Any lump in the tummy? Any discharge from penis? Any trauma to the tummy? Did you have similar condition in the past? Have you ever passed a stone before? Do you have any bleeding from other sites? Do you have any disease? Do you take any medication? Do you smoke? How many cigarettes a day? Do you drink? How much? What’s your work? Did you travel abroad? Did you eat beetroot?

Q.82,83 a patient with Ca prostate (explain to the patient or to the daughter of the patient). Discuss options of pain relief.
Introduction, then you may say: “I would like to have few words with you about your condition.
As you know you have growth in your prostate and this might cause you some pain. Fortunately, we have a wide range of medications for pain relief. First, you can use Paracetamol 2 tablets, repeated every 4-6 hrs. It has no important side effects at usual dose, but in higher doses, it may affect the liver. Secondly, we can use what we call NSAIDs as Aspirin, and Indomethacin. They are also effective given by mouth and should be taken with food to reduce their gastric irritation effect. They might cause some tummy pain, blood in stool or change of stool colour into black. Those medications can be combined with weak opioids, as Dextropropoxyhen, to become more effective. And if we need we can use opioids as Morphine, which can be given as slow release tablets twice daily. They are very effective but have side effects such as: feeling sick, being sick, constipation, sleepiness and depression. However, we can deal with these side effects by adjusting the medication dose or by giving laxatives.
Another option that we have, is to use radiotherapy, which is especially useful for bone pain; however it may have some side effects such as going frequently to toilet to pass water, feeling the urge to pass water suddenly, redness of skin and you need to come to hospital daily for 4-6 weeks to have the treatment.
Another method is to decrease the male hormone that is testosteron. And this can be brought down, either by giving some medications or by removal of both testicles. But this may affect sexual performance. Is everything clear, are there any questions?

Q. 85 a patient is on Minocycline for 2 years. Has read an article about the side effects and is now angry. Counsel.
Introduction, then you may say: “How can I help you?”.
Well, I didn’t read this article, but I read the original article in The Lancet, from which it is taken. You need not to get over anxious about matters in media, because as you know the newspapers tend to exaggerate things.
If you remember when we gave you this medication we talked about the side effects. And we said that it may make you feel sick or even been sick, may cause diarrhoea, some skin rash, dizziness, and giddiness. These are the common side effects, and we know that this medication, in very few cases, might cause liver damage and that’s why we take a tiny drop of blood from you every 6 months to monitor for any effect on the liver, so we keep an eye on this thing. As I have told you the media tends to take minor things and make major story out of that.
In addition, you know that this is a new medication, so there might be some new side effects. That might appear as the time goes by, but we keep following any new side effects that may occur and follow our patient up for it.

Q.86 Wound suturing.
1. Use anaesthetic.
2. Clean the wound with antiseptic from middle to edge.
3. Place needle in needle holder at 1/3 inner end of the needle, so 2/3 of the needle is outside.
4. Hold the skin with toothed forceps.
5. Pass needle beneath both sides of cut and pull it with needle holder.
6. Tie the knot with needle holder. Make sure to tie it on skin and not on the wound.
Q.87 Digital Rectal Examination.
Explain the procedure to the patient, and mention that it may be uncomfortable, but should not be painful. Obtain oral consent and ask for chaperon, if a lady is examined.
1. Ask the patient to position himself in left lateral position, with buttocks at the edge of the couch, and both knees drawn to chest.
2. Wear gloves, and put lubricant, separate buttocks, and examine for discharge, ulcer, external haemorrhoids, tags, fissure, and fistula.
3. Tell the patient that you are going to introduce finger and insert it in twisting movement. Ask the patient to breathe out and relax.
4. Ask the patient to squeeze his sphincter on the finger.
5. Examine posterior, left lateral, right lateral, and anterior wall of rectum.
6. Examine prostate gland.
7. Withdraw finger and examine for stool colour.
The prostate has, normally, smooth firm lateral lobes with median groove. In BPH it is symmetrically increased in size. In ca prostate, the gland feels hard irregular, and the median groove is undetected.

Q. 88, 96 Cannulation:
1. Check the patient’s name on the armband and drug chart.
2. Select an appropriate giving set.
3. Put on gloves.
4. Things needed to be in the dish: swab, cannula (green), plaster, syringe, ampule N/S, towel.
5. Tourniquet should be at site.
The steps:
1. Put tourniquet around the upper part of arm and put towel under the arm.
2. Palpate for veins and clean with swab.
3. Inject cannula and when blood comes open tourniquet.
4. Insert cannula with counteract movement.
5. Remove cover before taking stellate out and put finger to occlude, remove stellate and put cover.
6. Flush with N/S from above.
7. Stabilize with plaster.
8. Disposal of stellate in sharp bin.

Q.97/A a patient is depressed, after having a stillbirth. Counsel.
Introduction, then you may say: “How do you feel in yourself now? I understand that it is not easy to come to terms with, but you know it happened to many people.
Do you want to see your baby, hold or take a photograph with him? You can even take a lock of hair or palm print, if you want.
You can name him, and for funeral you can make private one if you want, or the hospital can arrange a funeral for him.
I want to take a blood sample from you, also to take a swab from vagina, blood from the baby and send it for examination that would help us to know the cause of what has happened.
It would be so useful for us to know the cause of what has happened and to arrange for future pregnancy if we can send him to post-mortem examination, that is an operation-like examination. This may help avoiding such condition in the future.
If refuses, then ask her for permission to take a type of x-ray (MRI) and a sample of tissue for examination.
I’m going to give you a medication to decrease breast milk secretion. You need to use it, one tablet today, then 2 tablets daily for 2 weeks and we will give you an appointment to discuss future plans when the results of these tests come back.
We will give you a certificate of stillbirth that you need to take it to the registrar of birth and death within 42 days.
I will give you the address of the local branch of bereavement counseling which might be useful for you.
It is preferable not to get pregnant in the next 6 month to 1 year.

Q.97/B Explain to the husband of a pregnant woman that his wife had a stillbirth.
Introduction, and then you may start by saying: “Now we have had a good look at the tests we ran, and according to the results of these test and to the examination of your wife and the fetus. I’m sorry to have to tell you that the fetus showed no signs of life, that he is dead inside the womb. And in these cases it is so important to initiate delivery, because if the fetus remains inside, it may cause the mother some harm and affect her health.
I understand that this is not easy to come to terms with, but you know it happened to many people and after delivery you can see, hold, take a picture with the baby, and even you may take a lock of hair or his palm print.
You can name him and make private funeral or the hospital would make a funeral for him and tell you about the time of it.
After the delivery we will do some examination on blood sample of the mother and the baby. And examining the baby would help us to know the cause of what has happened to avoid it in the future and it would be so useful if you agree to send your baby for postmortem examination.
After that we will give you an appointment for follow up visit with the doctor to arrange for following pregnancy according to the results of the tests.
We will also give you the address of the local branch of bereavement counseling which might be useful for you.

Q.98 a lady requesting termination of pregnancy (TOP). Take history and counsel.
Introduction, and then you may say: “As far as I know you want to end your pregnancy. I would like to ask you a few questions, and then I will discuss the matter with you.
How old are you? Why do you want to terminate your pregnancy? Did you consider other options, help from family, adoption. Remember that you will live with this decision for life.
Do you have a partner? Does he know about your decision, does he agree? When was your last period? Were your periods regular?
Now we need to do ultrasound to check the state of pregnancy and to run some blood tests to know your blood group, and to take swabs from your vagina to look for any infection (chlamydia). Then:
If the pregnancy is less than 9 months then we conduct 4-stage-medical TOP.
1. Counseling and ultrasound.
2. Anti-progesterone (mifeprestone) by mouth.
3. Prostaglandin (gemeprost) pessary in vagina.
4. Follow up and ultrasound after 12 days.
First trimester: D&C or D&V
Second trimester: intravaginal prostaglandin (gemeprost) pessary + Oxytocin IV
You need to give us consent for TOP. And remember that there might be some complications of TOP, which are: bleeding, infection, or damage to the womb or its neck and these could happen during the procedure or immediately after it. However, they are not common unless the doctor doing it is not skillful enough, but you need to know about them. And in the future it might affect your chance to get pregnant, and it might increase your chance to get miscarriage. We can give you contraception to use at day of TOP if you want.
Reasons for TOP (by law):
1. Risk to mother’s life.
2. Risk to mother’s physical or mental health.
3. Risk to physical or mental health of other children.
4. The child, if delivered, would be physical or mentally handicapped.

Q.95 perform a cervical smear.
I will greet the patient, introduce myself, and explain the procedure and purpose of it. Tell her that is not painful, but may be a bit uncomfortable, make sure that she is not menstruating now, and she did not use spermicide or lubricant jelly in the previous 24 hrs. Then:
Wear gloves; prepare the slide (write the name of the patient, date and time of taking specimen with pencil not pen, where writings disappear with fixation). And prepare the fixator (50/50 mixture of alcohol and ether).
Hold Cusco’s bivalve speculum with the right hand and separate the labia with the left hand (do not lubricate with jell). Tell the patient that you are introducing the speculum and ask her to relax. Gently insert the speculum on its lateral side and when you are in turn it up for 90؛. Handle anteriorly when patient in supine position and fix it. Try to identify the cervix and use the notched end of spatula and rotate it 360؛ to scrape off cells from cervical os. Spread the sample on the slide and fix it immediately with the prepared fixator (50/50 mixture of alcohol and ether), either put a drop or put the slide in a container with the fixator. You should not allow the sample to dry.
Tell the patient that you finished and you are going to take speculum out. Take it out in the same way. Give a towel to the patient to wipe herself.
N.B: If there is discharge:
1. If any ulcer, take swab from base of ulcer.
2. If chlamydia infection is present, take the swab from the cervix.
3. If there is vaginal discharge, take swab from fornix.
4. Send for cervical smear and examine under microscope (unstained for Trichomonas vaginalis, Stained for gonorrhoea, and thrush).

Q.93 perform PV and bimanual examination and state findings. Explain to examiner.
First, I will greet the patient, and introduce myself, and will explain the procedure and purpose of it telling her that I will examine in front passage by finger and telling her that it should not be painful, and ask her to let me know if she has any pain. I should obtain her verbal consent, and ask her if she needs a chaperone. I will ask her to empty bladder and draw the curtains. I will ask her to pop on the couch and undress from waist down and position her on her back with hips and knees flexed and thighs abducted.
Put on gloves, examine abdomen for any mass, and be sure bladder is empty. Lubricate index and middle fingers of right hand, and separate labia with left index and thumb and look for any discharge, ulcer, rash and any abnormalities of Bartholin’s gland.
Inspect vaginal wall and ask the patient to cough and look for urinary incontinence and bear down, look for uterus prolapse.
Introduce your index and middle finger of right hand into vagina and palpate vaginal walls for any cyst, mass or foreign bodies. Palpate anterior, posterior, both lateral walls of vagina, and fornices to see whether they are obliterated or made bulge by swelling in pelvis and for any scar and palpate the pouch of Douglas. Palpate cervix, normally it is downward and slightly backward and feel like nose tip, move it and note any tenderness which is called cervical excitation.
Do bimanual palpation, with 2 fingers in the anterior fornix, place left hand flat on abdomen above pubis. Identify, size, position, and surface character of uterus.
If uterus is not palpated, move fingers into posterior fornix, and it may be retroverted.
Palpate lateral fornices in turn, bimanually for any tenderness or swelling of fallopian tube or ovaries. Draw your fingers, and give her a sheet to wipe the area.
In case of retroverted uterus: we find that the womb is tipped back which is very common and does not seem to be of any importance.
Q.99 a patient with pre-eclampsia: counsel her to remain in hospital for treatment and observation. She was worried about her daughter at home.
Introduction, then you may say: “Now we have had a good look at the tests we did and they showed that you have what we call PET, that is high blood pressure during pregnancy with some other changes and in these cases we admit the patient to the hospital so we can give her the treatment she needs. And do all the investigations needed and keep an eye on her; the period needed to remain in hospital depends on the condition of the patient and response to treatment. And in some cases, if the patient does not respond to treatment, we may even need to end pregnancy earlier, and that is important reason to remain in hospital as we can take care of the mother. And there is a baby doctor who will take care of the baby. In addition, in some severe cases the mother might develop fits, so in hospital we can act quickly to manage her condition. And about your daughter, do you have a partner? If yes, your partner can look after the daughter while you are in hospital, you can get help from your mother, sister, relatives, friends, and if not we can arrange for social services to look after her during that period.
The condition can affect the child’s well being, growth, and even his life may become in danger.
Tests to be run: ultrasound, cardiototograph, kick chart.
Monitor: mother blood pressure, urine output, oedema.
Blood tests to be run: serum uric acid, U&E.

Q.100, 74 a patient had hysterectomy 8 days ago. She developed sudden chest pain, and died yesterday. Obtain an oral consent from her sister for post mortem examination.
Introduction, and then you may say: “I am so sorry for your sister, and I’ve got a rather delicate matter that I want to discuss with you. It is about your sister. You know she was coming along very well after the operation, but she suddenly had a chest pain and we tried to save her life, we did everything we could, but she passed away.
The relative may ask: “did she suffer pain?”
Your answer may be as follows: “When she had that chest pain, we gave her analgesic, along with the treatment she needed. And I can assure you that she passed away peacefully. I was there at that time. Actually, we are not quite sure why it has happened and what has caused the death; that is why we are asking your permission to do what we call it postmortem examination. It is just like a surgical operation, and done by special doctors. And during this examination we are going to look inside her body and take a samples from organs and fluid to examine it in order to allow us to know the cause of death. We are not going to take any organ out and we will not disturb the body. Your relatives and other members of the family may want to know what went wrong and caused death. Besides, if we know the cause of death we might be able to prevent it from happening in the future, and so save many lives.
The whole process doesn’t take more than a few hours. If you prepared for funeral you can carry on with your preparation.
I understand that this is hard on you, but try to think about it, discuss it with other members of the family and I’ll come to talk with you again after a while.
If you have any questions please feel free to ask me at any time.