Selected Handbook

Cases AMC Clinical

Condition 011
• You are working in a general practice. A 60 year old man, whose father died of
colon cancer, consults you following a screening colonoscopy. This revealed a
lesion shown in the photograph given to the patient (illustration below). The
biopsy report confirms an adenocarcinoma of the colon. The patient insists he
has no symptoms and refuses to have any operative treatment. However, he is
still concerned enough to ask you what will happen if nothing is done. The
specialist who did the colonoscopy said the lesion was on the left side of the
colon.

• The patient also wishes to know what are the prospects of cure if he changes his
mind and has the lesion removed by surgery, and would the surgery ever entail
having a colostomy (which he dreads)?

TASKS
• Advise him what symptoms and signs may occur in the future, what
complications may develop, and how they would be treated
• Address his concerns and counsel him about surgery
• You are not require to take further history
• CLINICAL NOTES: biopsy of ulcerating tumor of rectosigmoid at
15cm from anus
• BIOPSY REPORT: the specimens show numerous fragments of a
moderately well differentiated adenocarcinoma of the colon, with
invasion into the submucosal tissues
• DIAGNOSIS: Adenocarcinoma of the colon
 Counsel
• Do you have any particular concerns?
• Any tummy pain, bowel habits: blood
• Do you know why the tests has been done to you?
• What have you been told about your medical situation so far?
• I'm sorry to tell you, but unfortunately I don't have good news
for you. Do you need somebody
to be with you while I discuss these with you?
• The sample of tissue that we had taken from your lump in
your gut has shown that it is a nasty growth or a cancer.
• I know that this isn't what you want to hear. And I also wish
that the news were better. I can see that this is an upsetting
news for you.
• Are you ready to discuss your condition and a possible
treatment plan now? Or should I arrange another
appointment for you?
• NATURAL HISTORY OF LEFT-SIDED COLON CANCER
• Carcinoma of the left colon usually arises from what we call
premalignant adenomatous polyps, or abnormal growths within the
bowel wall. The likelihood for a cancerous change increases with
increasing size of the polyp
• It is possible that you will not have any symptoms at the early part of
the disease, as what is likely in your case. But at certain times, left-
sided colon cancer usually presents with passage of red blood mixed
with stools, increasing constipation, alternating constipation and
diarrhea as well, and usually we see these at the later stages of the
disease already.
• There is a risk of spread of the cancer through direct invasion of the
bowel wall, which causes build-up of fluid inside the tummy (ascites).
It can also spread through the lymph vessels and go to your lymph
nodes. It can spread by blood and go to develop cancer in the liver
and other organs as well.
• However, you should not worry too much about this as I have said, it
is likely that you are in the early stages of the disease, and we can
make a management plan for you.
• If this is left untreated, possibilities of a bowel obstruction or
blockage of the bowels will occur. You will feel pain with
persisting constipation. However, this is what I am most
concerned about. Given that the growth is present on the left
side of your colon, there is a risk of rupture of gut.
• This would then require an urgent operation to decompress the
bowel from a "closed-loop" obstruction. A colostomy is a possible
procedure to accompany the intervention which will depend
upon the surgeon's discretion, but is usually temporary unless the
operation reveals extensive spread of the tumor. A tube through
the nose through the gut called nasogastric tube will be inserted
to decompress the pressure building inside as well.
• Given those possible scenarios, it is best to do an elective or a planned
surgery now to avoid these possible complications. This offers the best
prospect of cure, and colostomy is not usually required. Again, if it is done
under the conditions of an elective surgery, it would usually only be
temporary.
• After surgery, chemotherapy is also done as it was shown to improve survival.
It is usually done to reduce recurrence of the cancer.
• Again, generally, you will be managed by a multidisciplinary team once you
consent to go through this management plan.
• Pre-operative investigations will also be done to check for your fitness for
anesthesia, assess for other conditions such as anemia and assess your
kidney functions. Imaging of the tummy (CT scan) will be done as an aid for
the procedure to help assess for a possibility of a curative resection if
possible. Antibiotics will also be given to you prior to surgery to minimize
infective complications.
• I know that these may be too much information for you, but again I want to
reassure you that we will provide you with all the support you need during
these times.
• Just in case you develop severe tummy pain, bleeding, inability to pass wind
or stools, please come back immediately
• Here are reading materials to give you more insight about your condition.
• I can arrange another review with you to discuss further on our next steps in
the management of your condition
• Do you have any questions?
KEY ISSUES
• Discussion of natural history of left sided colon cancer if not
treated
• The candidate is expected to know
• Urgent operation is necessary if acute large bowel obstruction with
cecal distention ensues
• The general principles of surgical management for a rectosigmoid
cancer

CRITICAL ERRORS
• Failure to counsel patient on the natural history of untreated
colon cancer
• Failure to advise need for urgent operation in the event of
acute obstruction
Condition 17
• You are working in a general practice. Your next patient is a middle-
aged man booked for a total hip replacement. You referred him to an
orthopaedic surgeon who has arranged elective surgery for his
severely osteoarthritic hip. The patient has now come back to see
you, as he has some questions and in particular, is concerned about
the risks of blood transfusion (if required) and would like to find out
about using his own blood for the operation.
• The patient wishes to discuss this with you, as he did not take in
everything that was explained by the surgeon
• TASKS
• Explain the principles and indications for preoperative blood
collection and intra operative autologous blood transfusion.
• Answer any questions from the patient about the blood transfusion
procedure.
Autologous transfusion
• Patient's own blood is frozen and is transfused when required
• It is useful for patients expected to have blood loss due to surgery, and may have blood
stored some time before the surgery
• Explain the blood collection: weekly blood collection (can last for 5 weeks)
• We will collect 1-2 units of blood, around 4-6 weeks before your surgery. This is usually
done because it takes 4 weeks for your blood cells to recover and become restored.

• Indications of Autologous Transfusion (Australian Red Cross 2014)

• Rare Blood Group
• Transfusion requirements cannot be met with allogeneic blood.
• Religious belief: Jehovah’s witness
• If these are not present, we usually then recommend blood to be acquired from a
donor

• Implications/Complications of Autologous BT
• Lesser immunologic complications ,
• Non-immunologic complications might still occur.
• Risk of preoperative anemia.
• Higher cost.
Donor transfusion
• COMPLICATIONS OF TRANSFUSION (FROM A DONOR)
• Immunologic
• Acute hemolytic reaction:
• Delayed haemolytic reaction:
• Febrile non-haemolytic transfusion reaction
• Anaphylactic reaction
• Allergy
• Transfusion Related Acute Lung Injury (TRALI)
• Non immunologic (may still be present in autologous BT)
• Fluid overload
• Hypothermia
• Iron overload
• Infective
• HIV 1&2, hepatitis B&C, Human T Cell Leukemia virus 1 and 2, syphilis
• If high risk group: CANNOT DONATE BLOOD
 • 'How long is the blood good for?' ( Up to five weeks)
• 'How much do they take?' (Up to 2 litres over a period of 2-5
weeks)
• 'Don't I need all my own blood?' (Your blood rapidly regenerates,
being a renewable tissue from the bone marrow)
• ‘'Won't it make me very weak?' (Not significantly)
• Take blood every week to give your blood cells enough time to
recover
• ‘'What are the advantages of my blood over blood bank
blood?''(It is your own. which is fully compatible).
Condition 58
• Case:You are a GP and a 25 year old female comes to you.
She was referred to you byRed Cross and she was found to
be hepatitis C positive.

Task:
• History
• Relevant investigations
• Management
History
• How are you doing today?
• Nausea, vomiting, tummy pain
• Malaise, LOW,LOA
• Noticed any yellowish discoloration in eyes, skin
• Serum sickness syndrome: fever,rash,joint pain,lumps/bumps
• Water works: any color change, any pain
• Bowel habits: stool pale, diarrhea
• Risk factors: ABP FIT NO SEX
• If travel positive, detailed travel qtns
• Past medical history
• Family history of liver conditions
• Medications
Physical examination
• General App
• P*I*CC L* E D*
• Vitals
• Skin: rash,pruritis, spider nevi
• Cvs
• Resp
• Gynecomastia
• Abdomen: distension, dilated veins,guarding,rigidity,
organomegaly, bowel sounds
• If male, testicular atrophy
• Office test: UDS,BSL,ECG,UPT
Investigations
Diagnosis & Management
• Hepatitis C is a viral infection. It can inflame and damage the
liver.
• Hepatitis C is usually transmitted through contact with
infected blood. It can be spread through:
• Shared needles during intravenous drug use
• Shared devices used to snort cocaine
• Unprotected sexual intercourse (this is uncommon)
• Accidental stick with a contaminated needle
• Blood transfusions
• Childbirth, from mother to child during delivery
• Contaminated tattoo or body piercing equipment
• Sharing razors, tooth brush
• Clinical features
• Common condition
• About 20-25 % are able to get rid of the virus spontaneoulsy.
Here we need to make sure by doing viral load & LFT for every
2 months for 3 times.
• Sometimes you can become carriers which means virus stays
in your body without damaging the liver.
• At any point if LFT abnormal refer to specialist and would be
treated with peglated inteferons and antiviral like ribavirin.
• In 80 % people this virus remains in body for more than 6
months leading to chronic hepatitis.This can sometimes lead
to complications like cirrhosis (20%), HCC(1-5 %) or liver
failure.
• Females with Hepatitis C have specialised needs:
• Menstruation: body fluids contain Hep C so please make sure that
you dispose off sanitary napkins appropriately.
• HCV is not transmitted sexually unless you have menstruations
and your partner also have cuts or abrasions but it is
recommended to use precautions to reduce the risk of blood to
blood contact.
• OCP needs to be changed to other methods such as
Implants/injects or barrier methods Key issue
• Women with hepatitis C on treatment (pegylated interferon and
ribavirin) are required to use two forms of contraception (one for
each partner) to ensure they do not become pregnant during
their treatment, and for six months following the end of
treatment. This is because pegylated interferon and especially
ribavirin can cause birth defects. Key issue
• “Wants to get pregnant”: if on ART,can get pregnant after
stopping drugs for 6 months. If pregnant with viral load +,
chance of baby getting infection is 5 %. Can go for NVD. Breast
feeding is ok unless cracked nipples.
• “good thing to inform partner” chance of getting infection is
low but there is a possibility.
• Safe sex
• Do not share razors, tooth brush
• Avoid blood/organ donation.
• Do proper wound care.
• Always inform doctor/dentist about your condition
• Vaccinate against hep A & Hep B
• Notifiable condition
Condition 047
• You are working in a general practice. Your next patient is a 30 year old self-employed
landscape gardener who is complaining of disabling left sided low back pain. The pain came
on suddenly yesterday whilst lifting a heavy rock. The pain is also felt down the side of the
left thigh and leg and the outer side of the foot. It is made worse by coughing or
movement. The patient could not sleep last night despite taking two Panadeine tablets
(paracetamol 500mg + Codeine phosphate 8mg per tab). The patient has previously been in
excellent health and has no other relevant past or family history.

• Abnormal examination findings are

• He has difficulty standing or walking on his toes on the left side. He has severe limitation to
left straight leg raising with a positive stretch test, diminished left ankle jerk and diminished
sensation to light touch on the outer aspect of the left foot, and painful limitation of lumbar
spine movements, particularly flexion/extension and left lateral bending.

TASKS
• Advise the patient of the most likely diagnosis and management required
• Counsel the patient about when he can return to work and any necessary modifications
that may be required

• There is no need for you to take any additional history, nor request any further examination
findings. All the information you need is detailed above.
• Good morning, I'm Dr. . I am one of the doctors who will look after you today. How
can I address you?
• I'm so sorry to hear about the pain you're having. Are you comfortable enough to proceed
with the consultation? From a scale of 1-10, 10 being the most painful, how bad is your
pain right now? Do you need some pain killers? Do you have any allergies?
• ADVISE TO PATIENT
• Based on the history and examination findings, it seems that most likely you have a condition we call
a "slipped disc" or medically we call it an intervertebral disc prolapse with herniation of the nucleus
pulposus. I'm sorry for using the medical terms, but let me explain your condition to you
• [illustrate] Normally, your backbone are stacked on top of each other, and there's a disc that serves
as a cushion in between these bones, and there are nerves that run through these places. And since
you lifted a heavy object, sometimes because of uneven forces in the way that you have moved, the
parts of the cushion in between the bones tend to slip out of place or bulges out causing
compression or irritation of the nerves surrounding it. Collectively this is what we call intervertebral
disc prolapse. In your case, it is most likely that the slipped disc compressed the sciatic nerve, hence
the term "sciatica", which is responsible for the movement and sensation of your thigh, legs, and
feet, hence causing you to feel deep aching pain and weakness over these areas. Pain is made worse
when you sneeze, cough, strain, or lift as the pressure in your body from these actions tends to
further compress the nerve. Do you understand so far?
• This is a common condition, which is usually seen in manual laborers like yourself who tend to strain
their back in their work.
• Fortunately, most cases gradually get better in about 6-12 weeks. In some cases, sometimes the
pressure put on the nerve is so great that the leg, especially the foot
becomes weak and floppy and in such cases surgery is usually required to relieve the
pressure.
• MANAGEMENT
• This may be debilitating now, but rest assured that your condition is manageable,
and you will get better. I will help you get better. I can make a management plan for
you.
• Prognosis within a few weeks is good, as long as you follow our management plan
well.
• Adequate rest is essential, therefore you need to take at least 4 days rest at home,
• I will give you adequate pain relievers to relieve you of your pain
• Panadeine, panadeine forte
• I will refer you to a physiotherapist who will give you back strengthening exercises
to help relieve you of the pain and regain function. They will also teach you on
proper use of your back to avoid postures that tend to aggravate your symptoms
• Please avoid spinal manipulation by the chiropractor as of now, as this may worsen
your condition
• If your symptoms do not improve with our initial management, I can refer you to a
spine specialist who can further assess you. We need to have his full assessment
first before we could consider starting you with gentle traction of your spine. We
can consider further investigations such as an MRI if your pain does not resolve
after this initial trial of our management plan.
• Your return from work will depend on your progress of recovery. The
pain usually settles rapidly with adequate rest in 1-2 weeks. I can
write a medical certificate for you to inform your employer.
• To avoid aggravation of your back and leg pain, it is best that you
take precaution and observe proper back hygiene. I will give you
reading materials about proper bending, and lifting, and the
physiotherapist can help you with that as well. It is also best that you
engage in regular physical exercise like walking as tolerated and
swimming. Please adapt a healthy lifestyle as well, and maintain an
appropriate weight as obesity can also aggravate your symptoms
• Just in case the pain worsens further, or if you develop incontinence
of your urine or bowels, or if you are unable to move your legs or
lose sensation of your legs, please report back immediately
• Here are reading materials for you to give you more insight about
your condition. I will arrange a review with you in a weeks' time to
check on your progress.
• Are you happy with this plan?
 KEY ISSUES
• Ability to determine the likely cause of the sciatica and to
explain the cause to the patient
• Adequate knowledge of the management of a patient with
acute sciatica including what further investigations or referral
are required and when these should be done.
• Ability to advise the patient about work practice modifications
required to prevent a recurrence of the problem
• Ability to advise early rest and short term review

CRITICAL ERRORS
• Failure to make correct diagnosis of a likely disc lesion
Condition 067

• GP and 60 years old male patient comes to you complaining of

tiredness, weakness and urinary symptoms.
Tasks:
• History
• Selective and focused physical examination finding from the
examiner
• Most likely cause for his symptoms and first step in
management
• Positive history:
• Symptoms since last 6 months.
• More last few weeks, feels tired, cramps in your calf muscles.
• Urinary symptoms present: increased frequency, nocturia,
stream of urine is reduced, hard to finish, annoyed by
dribbling.
• Past H/o HTN and started with Dithiazide OD.
PEFE
• General App
• PICCLED
• Vitals
• Neurological : tone,power, reflex, sensation
• DRE: prostate
• Degree of enlargement
• Both lobes
• Consistency
• Tenderness
• Surface
• Nodularity
• Median sulcus palpable/not
• Office tests: UDS
INVESTIGATIONS
FBE, ESR & CRP
Renal function tests (s. Creatinine, eGFR)
Serum electrolyte level, blood glucose level
PSA
Urine MC & S, urine cytology
XRAY KUB (for assessing radio opaque renal, ureteric
stones, sensitivity 60%)
USG KUB
Non contrast CT of KUB
CT intravenous pyelogram/ CT urogram By
Cystoscopy urologist
Transrectal USG with biopsy(if needed)
 Diagnosis and Management
From history and examination, most likely you have a condition
called benign prostatic hyperplasia, which a benign enlargement
of the prostate gland.
This gland is a small gland located at the base of the bladder,
function is to form some part of semen. Sometimes this gland
enlarges with increased vasculatrity leading to blood in urine, also
partial blockage of the tubes (urethra)that passes through the
prostate gives rise to symptoms like frequency, weak stream,
hesitency with initiating urination
I would have to further (mentioned before) investigations and
refer you to the specialist/urologist to review and confirm
• BPH is not cancer, and does not turn into cancer.BPH seems to be
a normal part of ageing in men, but the degree of enlargement,
as well as the severity of symptoms varies greatly.

• The most important aspect of BPH and the symptoms it causes

is how much it bothers the man. Many men have minor
symptoms which are of no concern to them and therefore
treatment is not required.However, for those whose quality of
life is being affected, there are several highly effective
treatment options available.
• Medications can relax or shrink the prostate, alpha
blockers(tamsulosin, terazosin), 5 alpha reductase inhibitors
(finasteride, episteride)
• Sometimes BPH can lead to retention of urine in the bladder, causing
more than just bothersome symptoms. Bladder stones, recurrent urine
infections and impaired kidney function may all be due to bladder
outlet obstruction caused by BPH
• In these cases, surgery is required: TURP include laser prostatectomy ,
and open prostatectomy, where the inner portion of a very large
prostate is removed via an incision in the lower abdomen.

• The tiredness you are experiencing is most likely due to the side effect
of BP medication, so will stop it and review your BP and if required will
start with another one (ACE inhibitor)
Condition 140
Preparing a 30 year old woman with suspected acute appendicitis for surgery
• You are the intern on duty in the Emergency Department in a small country hospital. You
have just seen this 30-year-old woman who has presented with a six hour history of acute
worsening abdominal pain with vomiting. The patient is normally in good health and has
had no major illnesses in the past. She has regular normal periods, the last being three
weeks ago. She is on the oral contraceptive pill.
• Tongue coated, breath offensive, tenderness and guarding in the right iliac fossa with
localized release tenderness
• Rectal examination found tenderness high up on the right Urine normal on chemical testing
• You strongly suspect that the patient is suffering from acute appendicitis
Temperature 37.9C
Pulse 100/min regular
Blood pressure 125/85 mmHg

• TASKS
• Advise the patient of the diagnosis
• Counsel her on the need for operation
• Explain the implications of treatment to the patient in obtaining patient consent for surgery
• Answer any questions that the patient might have

• There is no need for you to take any additional history or perform any further physical
examination
• Good morning, I'm Dr. . I am one of the doctors who will look after you
today. How may I address you? I'm sorry to hear that you are having this
pain. Are you comfortable enough right now? Do you need pain
relievers?
• I am here to explain to you your condition, and our proposed plan of
management for you, and hopefully take your consent to proceed
with the plan.
• It seems that you have a condition we call appendicitis. Do you know
what it is? Let me explain the condition to you.
• [DRAW….] this is your gut, and this is the part we call the appendix.
Usually for some unknown reasons, some part of the contents of the
gut, especially the fecal material tend to get blocked here, causing
irritation and swelling, causing you to develop tummy ache, fever,
nausea, vomiting, etc. Usually if left untreated, such as in 30% of the
cases, this can lead to perforation of the gut, causing the contents to
spill out in the tummy. This then becomes an emergency condition.
To avoid this complication, the specialists
suggested that we do an operation on you which we call a
laparoscopic appendicectomy.
 • The laparoscopic appendicectomy is a painless key hole surgery which is
aimed to remove the diseased appendix in the gut. You will be put to sleep by
an anesthetist, and will adjust the dose according to your age and weight.
The specialist will put very small holes in the tummy to insert the instrument
with a camera to remove the inflamed appendix inside and also put the ends
together of the remaining gut.
• Don't worry, even after removal of this part, you will still have normal gut
function.
• Risks of the procedure
• The procedure also has some risks such as bleeding, infection, and possible
injury to other organs. But these are very rare, especially under experienced
hands
• However, sometimes if there will be difficulties in removing the appendix
through a keyhole surgery, the procedure might be converted to an open
procedure, which means a larger cut is made to remove the appendix. But
these cases are very rare.
• The outcome of either a keyhole surgery or the open surgery is the same for
the appendicectomy.
• Risks of not having the procedure
• If this irritated and swollen appendix is not removed immediately, it will be at
high risk of perforation, causing spillage of the gut contents in your tummy
that will cause an overwhelming infection.
• Tell the alternative procedure present (if available)
• We can give you antibiotics, but then it has certain limitations. At this
point, it is best advisable that you undergo surgery as it is life-saving
and more efficacious than just giving the antibiotics
??????:
• Return to work: roughly 2 weeks of rest, but it depends on how well
you recover after
• Surgery tomorrow morning instead of now: I'm sorry but we cannot
send you home right now, as what you have is an emergency
condition.

KEY ISSUES
• Counselling the patient regarding preparation for appendicectomy

CRITICAL ERRORS
• Failure to adequately explain the indications for and potential
complications of surgery
Condition 119
• A man requesting disclosure of his wife's medical condition
• You are a doctor working in a general practice. Your next patient, Bill,
aged 67 has been attending the practice for some time. Bill presents to
you today for his annual check-up. You have completed your
examination when Bill tells you he is concerned about his wife's medical
condition and wants to ask you about how you found her when she saw
you a few days ago.
• Background
• You last saw Bill's wife, Ann, aged 65, three days ago. You have been
looking after her for many years. Ann came to see you concerned that
Bill keeps telling her that she is becoming forgetful and vague. You took
a history and performed a mental sta te examination and a general
physical examination, with no significant abnormal findings. Ann told
you at that time that she was worried that Bill is telling her sons and
daughter that he will need to put her in a hostel or nursing home,
though she feels that she and Bill are managing well at home without
any assistance.
• TASKS
• 1. Respond to Bill's questions and requests about his wife's condition.
History
• Greet & Introduce . How are you?
• Do you have any particular concerns?
• I understand that you are very concerned about your wife. But before I
attend to your request, can I ask you a few questions first if that's okay?
• ASSESS RELATIONSHIP WITHIN THE FAMILY
• How long have you been married?
• How’s your relationship with Ann?
• How's your home situation? How are your kids' relationship with you and Ann?
How often do you see them? Do you have grand kids?
• Any particular stressors in your life? Do you have enough financial support?
• Any major changes in your life recently (children moved out, retirement, etc)?

• RULE OUT POSSIBLE CAUSES OF FORGETFULNESS

• Did Ann had accidents in the past?
• Does Ann have trouble with performing complex tasks?
• Does she has trouble with directions and recognizing places?
• Has she had any falls or recent head injury?
• Any particular incidents like leaving the stove on, or forgetting to close the faucet
when she leaves the house?
Counsel
• I’m sorry I cannot talk about your wife’s condition because of confidentiality
• Confidentiality is an important legal issue here because it supports a patient’s
privacy and help to establish good and honest relationship between a doctor and
his patient.
• Because of this, it is my legal obligation to keep all information given by patients
confidential, and I have to respect that right. I am sorry but I cannot disclose the
information regarding my meeting with Ann.
• Your concern for your wife is very natural but there are ethical issues involved
here. You could try to talk to Ann if she can share the information we discussed
with one another.
• If that doesn't work, I’m happy to arrange a joint consultation with both of you
where we can discuss this in further details. I can even arrange a family meeting
toinvolve your children to discuss everything, but again it should be done with
Ann's consent as well.
• I’m sorry I’m notable to help you in this matter. Do you have any other questions?

• Can you write a referral for her for the nursing home?
• I am sorry but I cannot give you a referral letter for Ann. This kind of decision
must be made between me and Ann as my patient, as she is the one
concerned in this situation.
Condition 150

Postoperative fever in a 45 year old woman

As part of your duties as the surgical intern, you are examining
the patients from the previous day's operating list. You are at
the bedside of a 45 year old woman who had a laparoscopic
cholecystectomy for gallstones yesterday. You note from the
chart that her temperature is 38.5C

• TASKS
• Assess the overall condition of the patient
• Provide a diagnostic and management plan
DD
• Atelectasis ( 1st day )
• UTI ( around 3rd day )
• Pneumonia ( 3rd day )
• MI (within 3 days)
• Superficial thrombophlebitis ( around 5th day)
• DVT ( 5th day ),
• PE ( 7th day )
• Wound infection/haematoma/dehiscence ( 7 days )
• Abscess ( 10 to 15 days )
History
• Rapport
• FEVER HISTORY
• When exactly did it start? How high was your fever?
• Is it always there or does it come and go?
• Were you given any medications?
• REVIEW OF SYSTEMS (DDx)
• Any difficulty of breathing? Shortness of breath? Do you feel any pain if
you breathe in deeply? Any cough?
• How are your water works? Is there any burning or stinging sensation
when you pass urine? Any smelly urine?
• Any tummy pain? How are your bowel motions? Are you able to pass
wind and stools?
• Any chest pain? Any pain in your limbs or swelling? Difficulty walking?
• How is your IV line? Is there any pain or redness over it?
• How is your wound? Is there any bleeding or discharge?
• Do you smoke, drink alcohol, any chance of using illicit drugs?
• Are you taking any medications? Any allergies?
• Do you have any other medical or surgical illnesses?
 PEFE
• General appearance: well-looking or not, any signs of distress, pallor,
lymphadenopathy, edema
• Vital signs
• CVS: S1, S2, any added sounds or murmurs?
• **RESPI: air entry, symmetrical chest movement? Hyperresonance?
Any adventitious breath sounds?
• Abdomen
• Wound
• Is the dressing soaked with blood or discharge? I want to remove the dressing
• Inspection for any erythema, discharge, bleeding or hematoma, wound
dehisence?
• Any distention?
• Any tenderness?
• Lower extremities: is there any calf erythema, swelling, tenderness?
• Examiner, I would like to know about the patient's case notes,
and the operative details of the patient
• OPERATIVE DETAILS and WARD CHARTS
• Previous medical or surgical illnesses present? Any significant
smoking history? (risks for atelectasis)
• What was the operation done?
• Any complications during the procedure?
• What medications were given to him so far?
• Chest physiotherapy done?
• When exactly did he have the fever? Were medications given?
• When was the IV cannula last changed?
Diagnosis
• Based on your history, exam, and findings, it seems that most
likely you have a condition called Pulmonary Atelectasis. Have
you heard of it? It is a collapse of an entire lung or a part of the
lung, mainly because of restrictions of the breathing movement.
• Major risk factors include your uncontrolled pain, preventing you
to breathe normally, and secondly prior lung disorders--your
previous history of bronchitis and significant smoking history. It is
usually common after surgery, and the pain from the surgery
causes you to breathe minimally causing the lung collapse.
• If not corrected, this might lead to pneumonia in the long run.
• However, just to rule out other possible causes of fever, I would
like to arrange investigations as well such as FBE, ESR/CRP, and
chest x-ray just to rule out infections as well.
• Now this is what we can do for you. We can start incentive
spirometry for you, where you will be able to practice deep
breathing exercises to re-expand your lungs. For that reason, I will
refer you to a chest physiotherapist who will teach you these
exercises. For now you would be hooked to oxygen support to
help you breathe, and give you a bronchodilator as well. This
condition usually gets better within 5 to 7 days.
• As for now, here are some information which can give more
insight to your problem. Rest assured, we will do everything to
manage you the best way we can.
Condition 108
• Your next patient in general practice is a25 year old Mr.Grant
Jones who had an ultrasound examination lastweek because
of a painless swelling of his right testicle. The report reads:
“The right testicle shows a 4 cm in diameter large, solid,
homogenous, hyperechoic mass which is well circumscribed.
The findings suggest that the lesion is malignant. The left side
appears normal.
Tasks:
• 1.Explain the U/S finding to the patient
• 2.Advise the patient regarding further investigations and
management
• 3.Answer patient’s questions
History

• Mr.Jones has noticed a pain free enlarged right testicle about

2 weeks ago with a heavy feeling and saw one of your
colleagues who organized an U/S examination and he
returned today to get the result.
• PHx., FHx.: FHx.: NAD
• single school teacher,shares a house with 2 friends
• Little alcohol, nonsmoker
• NKA,no medications.
• BBN
• Do you want someone to be with you before we proceed with the
reports??
• Inside muscular sac called scrotum males have reproductive organ
called testis which is responsible for formation of sperm and male
hormone.
• The reports shows there is an abnormal growth in your right testis
and on looking specifically it is showing a uniform solid mass with
increased density ( hyperechoic, homogenous with well defined
margins ).
• The reports says that is looks like a nasty growth called seminoma.
• Teratomas and mixed tumours are more hypoechoic and
heterogenous often mixed solid / cystic or areas of calcifications!
Investigations

• Blood: FBC, ESR/CRP, RFT, LFT.

• Tumour markers : alpha-feto protein, beta HCG,LDH :whichare
used for initial diagnosis and follow-up post surgery
• USG
• CT abdo, pelvis and chest(specifically searching for
metastases in para-aortic lymph glands and abdominal or
thoracic organs)

• Based on these, we get to know what stage and what type of

treatment to be initiated.
• MDT approach
• Surgery called orchidectomy to remove the testis along with
nasty growth by putting an incision in the groin. (no scrotal
approach because risk of mets)
• Might consider giving radiation therapy and mediactions to
make sure these nasty growth are not spread to any other
parts of the body.
• STAGE 1: tumour confined to the testicle: Orchidectomy
through an inguinal incision removing the testis with the cord
to the level of the deep inguinal ring followed by radiation
therapy.(NO scrotal incision, to avoid spread of tumour!!!!)
• STAGE 2: metastases have spread to para-aortic lymph glands
in pelvis and abdomen +/-metastases in abdominal organs:
Orchidectomy + radiation + chemo therapy.
• STAGE3: spread above the diaphragm: Orchidectomy + radio+
chemo+Follow-up: CT scans of pelvis, abdomen and chest are
done regularly every few months in the first 2 years, then less
often. Serum tumour markers are checked at each visit
Questions :
• Is it cancer?”“What is the name of the cancer?”
• “What is the prognosis?”(up to 95% cure rate!!!)
• “Do I need any other tests?”( Yes )
• “How about my sex life and will I be able to have
children?”(erectile function unchanged, fertility reduced with
radiation therapy and probably infertile with chemo
therapy–consider storing of semen before the procedure for
future IVF)
• “What are the side effects of the treatment?”
Condition 124
• You are working in a palliative care hospital. Your patient Sally
aged 65 was diagnosed with pancreatic cancer. Despite active
medical interventions Sally is now at the end of her disease.
Sally would like to stop her treatment and return home to die.
Sally has intravenous therapy, indwelling catheter and nasal
gastric tube in situ.

TASKS
• Counsel Sally
• Answer Sally's queries
History
• May you tell me the reasons why you want to go home/end your
life?
• Whatever you tell me will just be between the two of us, unless it
poses harm to you or to others. I will try my very best to help you,
but I would just like to ask you a few more questions, I will be quick.

PHYSICAL
• Do you have any pain at the moment?
• What pain medications are being given to you? Do you think your
pain is being managed well?
• Any side-effects with the medications? Any nausea, vomiting,
constipation?

PSYCHOLOGICAL
• How is this situation affecting you? How is your mood? Sleep? Is
your family visiting you? Do you have enough support? When was
the last time you saw your family?
• Discuss legal implications of this condition
• Okay Sally, we can give you some morphine. We will only give
this to relieve your pain, but not to end your life.
• Sally, I can see that you are really distressed, and I can only
imagine how much pain you are in right now. And I am telling
you, we are always here to support you and give you the best
possible care. However, what you're asking from me is not
legal here in Australia. We call this active voluntary
euthanasia, and we can be held liable if something happened
to you under our care.
• Yes sally, we are giving you a pain medication called Morphine,
and it can hasten death. However, we are giving it to relieve
your pain and not to end your life.
• How about this, I will help you manage the pain well, I will refer you
back to the pain specialist.
• Do you know what type of pain reliever is being given to you?
• I will look into it. There is what we call pain ladder.
• There are other types of pain medications specific for neuropathic
pain or pain due to nerve involvement. It is common to have this in
pancreatic cancer. These medications are gabapentin, amitriptyline
and carbamazepine. The specialist will review you and will give this
medications if needed.
• There are other options if these medications are ineffective such as
al procedure called neurolytic celiac plexus block wherein an
injection of local anesthetic will be administered for pain relief.
• Regarding your sore throat I will start you on lidocaine local spray for
the pain, for the constipation, laxatives will be given and for nausea,
I will start you on metoclopramide.
“Doctor, I want to remove my catheter and just go home. Can I refuse
treatment”
• If you are competent enough, it will be your choice as long as you know
the consequences of this action. And we will explain to you the
implications of this actions before you decide.
• Yes, if a patient is competent, voluntarily decided to refuse treatment
and all the complications, effects and outcome were discussed clearly,
then the patient can refuse treatment such as medications, catheter,
intravenous therapy and gastric tube.

“I want to return home.”

• We can arrange a community based palliative care.
• I will refer you to a social worker, occupational therapist and community
nurse. I can arrange family meeting with your consent.

• “I'm just really concerned that my family will see me deteriorating””

• Arrange a family meeting.. There is always respite care available for your
family.