2006 (1)

1 yr old child had diarhoea for 6 times in a day. Clinical examination was normal. A diagnosis of AGE was made. Treat with ORS. The patient has mild dehydration. Vital sign stable. Explain to mother the diagnosis: What food can be taken: Explain about ORS and how to prepare:

Ans 2006 (1)

Introduction and greet Assess causes:
Changing of breastfeeding to formula milk (lactose intolerance) Boiled water for milk preparation Pacifier usage and hygience

Explain:
AGE, usually self limiting, complication (dehydration, malnutrition), cause (diarrhoea, vommiting, abd pain, seizure, fever, malaise)

Assess severity
Frequency of diarrhoea, volume of stool, urine output reduction, loss of weight, fever, convulsion, P/e: hydration status.

Cont ans 2006 (1)

Mild dehydration self limiting AGE

Advice on ORS: Dissolve 1 sachet in 250ml drinking water (boiled/cooked water of estimated 1 glass) Feed baby every time of diarrhoea Continue breast feeding Lactose intolerance (change to lactose free milk/semi elemental formula) If baby already weaning (allow semi-solid food, drink water a lot)

Advice mother to keep good hygience on milk preparation Advice mother to monitor babys progression
If show dehydration (convulsion, weak, crying, not feeding)

Ask mother for any question?

2006 (2)
Patient is schedule for chelecsystectomy. However, an emergency operation on liver laceration had to be done and her operation was postponed. All operation on that day has been cancelled. As houseman, break the bad news to her.

2005 (1)
Consultation with patient. Patient, fever for 3 days and generalised body ache. Investigation results showed tarchycardia (120bpm), low Bp(80/70mmHg), febrile (38oC), thrombocytopenia(30), neutropenia, high haematrocrit. Suspected dengue fever. Advice patient for admission. However patient refused. Try to

Ans 2005 (1)

Intro: greeting, introduction Explain the diagnosis : Dengue fever Review the investigation result Emphasis the severity, sympathy Advise admission with reason: severity, risk of bleeding and shock, need close monitoring, immediate resuscitation if needed Access patient social circumstances: house-hospital distance, access to hospital, family member (other children)

Cont ans 2005 (1)

Emphasis the need of admission, but express respect on patients autonomy Reiterate possible complication Give overview, what will be done in ward (iv fluid, frequent blood taking)

2005 (2)
Patient has asthma. You need to start her on beclomethasone inhaler 2 puff bd (MDI). Explain to her about your plan of management. Teach the patient how to use the inhaler and what you should advice the patient.

Ans 2005 (2)

Greeting and introduction Reiterate diagnosis Explain what medication you prescribed :steroid MDI Explain purpose: frequent attack, reduce frequency of attack, prophylaxis, improve quality of life Give the patient the beclomethasone inhaler and you have the placebo inhaler Explain and demonstrate to the patient the technique (ask the patient to observe first):

CONt ans 2005 (2)

Technique:
Shake well Exhale to expiratory reserve volume Put inhaler into mouth (over tongue, well into mouth), no leakage Press 1 puff (press top of cannister firmly between forefinger and thumb) inhale quickly and deeply at the same time Hold breath for 10 s/as long as comfortable Take out the inhaler from mouth, Pause between 1st and 2nd puff (10s for becotide, 1 min for ventolin) shake again, repeat for 2nd puff

Ask the patient to demonstrate Emphasis the need of regular use despite absence of attack Inform the side effect: oral thrush, hoarseness of voice

2004
Consent and Demo on how to take blood culture (aseptic) Demo handwash

Ans 2004
Blood CnS:

Universal precaution

Assemble equipment

Wear gloves (aseptic glove) Do not recap Proper sharp disposal handwash

Syringe (10ml) Special container Blue cap (aerobic) Black cap (anaerobic) 2 needles Aseptic garments Povidone Cotton swab forcep

Cont ans 2004

Site
Antecubital fossa Emphasis not poking around

Steps
Wear mask, aseptic gloves Apply povidone to cotton swab (use forcep, apply on puncture site) Apply aseptic garment on antecubital fossa Puncture and take about 10ml blood Change needle Remove cap from culture and sensitivity bottle and swab with alcohol Puncture blood in syringe with changed needle into each bottle -5ml each Apply sticker for dx, date and signature

Cont ans 2004

2003
Female, 60, Indian, high cholesterol. (LDL, TG, HDL)-normal, bMI (23), HPT. Counsel:

AnS 2003 (1)

Greet,intro (1/2) Full explanation (blood result) (2) Need to decrease cholesterol [eg.hypertension, age, post menopause]-(1) One day dietary recall (2) Dietary details, (eggs, mutton, coconut, milk) (2) Diet control for HPT, crease salt and fat, increase fibre intake (2) Substitute deep fry with steam, boil/ grill Clear language, approppriate advice (2) Querries time (1/2)

2003 (2)
Patient complained of foul smelling vaginal discharge for 5 days, 1st episode. You would like to find out whether she is sexually active. Obtain sexual history.

Ans 2003 (2)Sexual history

Introduce, comfortable Try to keep confidential Explain the use of sexual history Ask few sensitive questions to be able to help you Age at first coitus, last coitus How many sexual partners Protected/unprotected (condom); contraception Homosexuality Pregnancy history PV discharge, growth, other constitutional Sx Sexual abuse

Cont sexual history

Setting: privacy, dr comfortable Intro: hand shake, touch, stress of confidentiality Start with presenting problem:anything else to discuss?sexual matter want to talk? Be purposeful Comprehensive sexual history:
Age of first intercourse Nature of activity History of pregnancy/miscarriage Contraception STD Sexual abuse Psychosexual problems: Erection (ED), ejaculation (PE), loss of desire, dyspareunia Psychological problem Culture and religion

Refer to appropriate specialty Non judgemental

Health education

Ques (sexual history)

50y/o, male/Malay, DM, c/o: penile discharge, obtain sexual history Ps: +:
Discharge
Foul smelling, colour, ithcy, inflam, skin changes

UTI symptoms

Insulin injection (Novopen)

Wash hand with soap and clean Open casing, take out the pen Turn and pull off cap, unscrew penfill holder, insert penfill, screw it back Turn pen upside down before injection x10 Uniformly cloudy: insulatard/mixtard only Remove cap, if new x4 units, inject to expel air Choose a site and inject Count to 10 before withdrawal of pen (if not, insulin wasted) Used needles ( limited to 3-4 usage) throw into (metal)bin with label Actrapid yellow, insulatard green, mixtard brown What to do after penfill finish? Overturn dose req?Cx of insulin injection

Peak flow technique

Check equipments: peak flow meter, dispossible mouth piece, chart (weight, height vs volume) Move indicator to base Stand up Take a deep breath Put mouthpiece into mouth Ensure no leakage Inhale as deep as possible Exhale as fast and hard as possible Take reading 3 times Demonstrated by candidate Interpret: ask patient for height, weight, plot on chart

Breaking bad news

Intro, greet Put patient at ease Result are out, sorry to tell you that you have been diagnosed with- (pause) do u know what that is? Assess knowledge Explain diagnosis and prognosis Treatment available and eg. Of pts who live good lifes > Rx Important of tx and compliance Complication of tx Allow for normal grief response Support group I understand it must have been a difficult time for you. Querry time

Cont Breaking bad news

Major: terminal illness, handicap, chronic progressive ds Minor: no bed, case notes misplaced, cancel op Personal preparation: emotion, presence of relative for patient Physical setting: privacy eg. Room, position, no distraction Talking to patients
Establish rapport and trust Empathy What does patient already know Find out what they want to know

Cont Breaking bad news

Give info: incrementally (start with facts and add), conclude what they mean Check understanding Respond to question and concerns Elicit own resource for copy Instill realistic hope Arrange for follow up and referal

Cont Breaking bad news

SPIKES approach:
Setting up: quiet room, less interruptions, support present, eyes contact, 2 support persons Perception: level of comprehension Invitation: to break news Knowledge: use simple language, small bolus of information, allow questions Emotions: empathy, delibrate silence Strategy and summary: summarising main points, checking comprehension, maintain availability, offer follow up (call available, follow up again in clinic, write question on paper, come again tomorrow)

Informed consent
Introduce yourself Explain diagnosis/problem, procedure recommended and indication Details of procedure and duration/timing What would happen if procedure not done (benefits) Risk of procedure Progression Alternatives Second opinion, change mind Any doubt/questions?

Smoking cessation
Introduce yourself and greet Ask, assess, advice, assist, follow up Duration, frequency Any previous attempt/will to stop now Advice strongly to stop: own health, family and offer help Assess current will Set date, offer reading materials, nicotine replacement Doubts, follow up in one week

Teenage pregnancy
Introduce and greet Tell mum to wait outside Explain pregnancy Elicit: rape, bf Persuade pt to inform mum (benefit) Options Support group (single mother) Explain to mum Legal acts ( <16 yo consider rape case) Report to police (medicolegal)

Venepunture for blood investigation before operation

FBC, RBS, GXM Introduction and greet Explain procedure to pt Prepare gadget (syringe [5ml], needle, alcohol , tourniquet, FBC bottle (purple), gloves) Wear gloves Check pts name, RN, apply sticker on FBC bottle Apply tourniquet Ask patient to make a fist Choose suitable vein Swab site with alcohol Insert needle at 30-45o angle through skin Take about 5 ml Insert into FBC bottle Fill in FBC bottle Fill in form, apply sticker on form Tick CBC, differential Fill in diagnosis, date, signature Re check patients name + RN Thks to patient

Referal letter
Kepada: medical officer (surgery department, ummc) Daripada: (Dr Nadia, house officer) Tarikh: 18/2/09 Dear sir,
Thanks for seeing this patient, mr_____, age___, race_____, gender______, who has c/o:_______, since________. From hx_____, p/e______, Ix_______, found that ________, impression_______. Medication her is on now __________. No other medical illness. The patient requested surgical removal (intention) and further mx from you. Please kindly follow up this patient for her/his needful/problem Thank you, your sincerely, _______(signature and name)

Clerk & mx pt in front of examination(Advice patient with scabies on how to apply medication)
Greet-ask problem, assess source/Cx Explain-skin inflammatory ds, allergic reaction, asthma Education: may occur when there is trigger allergic (onset, duration) Reassure: not severe/life threatening if avoid allergen.can be prevented. Any family member/friend have similar problem Counselling: good hygiene, avoid allergen, do not scratch (scar) Non-phamaco: avoid seafood/allergen, avoid direct contact to affected ppt Phamaco: topical medication, anti histamine Prevention, follow up

Prescription letter
Name: Age: Rn: C/o: Diagnosis: Tx:
Tabs paracetamol 500ml tds x5/7 Tabs ponstan 11/11 PRN

Advise patient who just had a myocardial infaction

If uncomplicated, discharge in 5-7 days Work: mar return to work after 2 mths, unless pilot, air traffic controller, diver or driver of public transport or heavy goods vehicles; heavy manual labour should seek lighter job Diet: high in oily fish, fruit, vegetable, fibres, low in saturated food Exercise: encourage regular daily exercise Sex: avoid for 1 mth Travel: avoid for 2 mth Review at 5 weeks: angina, dyspnoea, palpitation-if angina recur, treat conventionally and consider angioplasty Review at 3 mth: check for fasting lipid, give statin if indicated

others
Do ECG on patient AIDS-pretesting and post testing counselling Instruct patient to collect mid-stream urine Instruct patient on 24 hour urine collection Patient education: alcohol Mantoux test-how to perform and interpret

Counselling station
How to give ORS Breaking bad news Elicit alcohol dependence, CAGE Sexual history Advice on contraceptive Care of diabetic foot Informed consent Smoking cessation Dietary history Diet advice (DM, hpt, hypercholesterolemia, gout, renal failure, obesity Teenage pregnancy Advice for hospital admission AIDS: pre and post testing counselling Alcohol cessation