OETリスニング練習模試 5
| GP: | Hello, Mrs Knowles. So, I see here that you came in by ambulance after an ? |
| P: | Yes. I mean, all evening and then I was watching the TV when I started . So I got up and went to the bathroom and everywhere. When I saw that it was blood, I was terrified. I yelled for my son, and when I tried to stand up to go get him, I started feeling even dizzier. Next thing I knew, I was on the floor and my son was beside me, calling an ambulance. |
| GP: | That does indeed sound quite terrifying. So, Mrs Knowles, ? |
| P: | It was fresh, red colour, doctor. But a cupful, I think. Like I said, it went everywhere. |
| GP: | And, is this the first time you have vomited blood? |
| P: | Oh, yes. before. |
| GP: | Okay, and what about ? Any blood in your stools? |
| P: | No. Everything’s been fine from that end. I’m sure you’re about to ask about medical conditions. I mean, at my age, this is not my first time at the doctors. |
| GP: | Yes, Mrs Knowles. Talking about age, you are , correct? |
| P: | Yes, but surprisingly healthy for my age. No medical conditions except for this , which I’ve had . |
| GP: | Do you take any regular medications safe for that back pain? |
| P: | Nothing from the doctors, just painkillers, to be exact. I’ve been taking every day for my back pain. For I would say the last three years, I never . |
| GP: | I see. So, Mrs Knowles, based on my initial assessment, I’m going to liaise with the gastroenterologist on call. Also, you are . So we’re going to draw some blood for a few blood tests and start you on a to replace the blood loss due to haemorrhage. Also, you need to be put crystalloids IV fluids because of your haemorrhaging |
| P: | So you’re going to take my blood and then give me some more. |
| GP: | Well, yes, it is exactly what we’re going to do. I need to get a full blood count to see your haemoglobin and blood urea levels amongst other factors. I mean, your blood pressure is lower than it should be at , and your pulse is a bit higher than normal at 100 beats per minute. |
| P: | So, what exactly is wrong with me, do you think? I mean, you must have some idea. |
| GP: | Well, it’s , but there are quite a few possible underlying causes. I mean, it could be a peptic ulcer or esophageal erosions as well as more serious possibilities. Once we get the blood test back and your vital signs going in the right direction, I will likely order an endoscopy to see what’s going on. |
| P: | What do you think ? |
| GP: | Well, actually, NSAIDs such as aspirin, ibuprofen, and naproxen are unknown to cause peptic ulcers because they interfere with the stomach’s ability to protect itself from gastric acids. |
| P: | Oh, no, I had no idea. I mean, it sounds like I could have caused this. |
| GP: | Well, was to tell you to discontinue your use of NSAIDs. As we work to find the exact cause of your bleeding, we can come up with an alternative pain management strategy for your back pain. You may also need further investigation of that problem, but one thing at a time. So now…[fade] |
| PH: | Mrs. Shepard, how are you today? |
| P: | Not well. Not well at all, I’m afraid. I woke up this morning and got a huge shock when I looked in my bathroom mirror. was dropping immediately. Panicked and called an ambulance. |
| PH: | Yes, that . So, I can see that the weakness is on the right side? |
| P: | Yes. I brushed my teeth before bed last night, and my face was completely normal on . Then I woke up at 8 am this morning and noticed it. |
| PH: | And are you ? |
| P: | The feeling is fine. No numbness or anything. I mean, in other ways, I’m fine. I can still close my eyes and blink. No problem seeing. And I can with no problems |
| PH: | And your speech also seems okay. You don’t seem to be doing or having any difficulty getting your words out. Also, I can see that your ear canal and tympanic membrane are normal. What about weaknesses in other parts of your body? |
| P: | All fine in my arms and legs. I haven’t had any . I mean, when I saw my face, I wanted to pass out from the shock but no loss of consciousness. |
| PH: | And any such as infections? |
| P: | No, not recently. In front, unusually fit and well. I mean, I take , so I guess I have high cholesterol, but nothing else. Oh, no, I did forget to mention one thing. Something else is a bit weird. I feel like . ? |
| PH: | So, Mrs Shepherd, the most likely diagnosis given your . |
| P: | And what is that, exactly? |
| PH: | It’s a form of facial paralysis that occurs as a result of . Legions of the facial nerve can result in paralysis of facial muscles, increased hearing volume, and a lot of taste. |
| P: | I see and what causes that? |
| PH: | Generally there is no known cause of Bell’s palsy. I do want to run a few tests to of facial paralysis, such as a brain tumor on stroke. |
| P: | And, if it is, what did you call it? Bell’s palsy? What is the prognosis? |
| PH: | Overall, the prognosis is good, with over of patients recovering entirely in . Those with partial facial nerve palsy such as yourself are much more likely to fully recover function compared to those with complete palsy. In the meantime, we need to talk about management. It is of the utmost importance to keep your eye on the affected side lubricated using eye drops and ointment at night. Bell’s palsy often affects the and stops the eye from closing completely, so it’s essential to take steps to protect it. |
| P: | So I’m guessing I need to wear sunglasses. |
| PH: | Exactly, and if you are , you should take it closed using microporous tape. |
| P: | OK, and is there any medication like I can take to speed up recovery? |
| PH: | Yes, steroids improved the speed of recovery, but first… [fade] |
Transcript
| GP: | Hello, Mrs Knowles. So, I see here that you came in by ambulance after an episode of vomiting blood? |
| P: | Yes. I mean, I had not been feeling well all evening and then I was watching the TV when I started feeling sick and dizzy. So I got up and went to the bathroom and threw up everywhere. When I saw that it was blood, I was terrified. I yelled for my son, and when I tried to stand up to go get him, I started feeling even dizzier. Next thing I knew, I was on the floor and my son was beside me, calling an ambulance. |
| GP: | That does indeed sound quite terrifying. So, Mrs Knowles, what did the blood look like? |
| P: | It was fresh, red colour, doctor. But a cupful, I think. Like I said, it went everywhere. |
| GP: | And, is this the first time you have vomited blood? |
| P: | Oh, yes. Never had anything like this before. |
| GP: | Okay, and what about changes in your stools? Any blood in your stools? |
| P: | No. Everything’s been fine from that end. I’m sure you’re about to ask about medical conditions. I mean, at my age, this is not my first time at the doctors. |
| GP: | Yes, Mrs Knowles. Talking about age, you are 70, correct? |
| P: | Yes, but surprisingly healthy for my age. No medical conditions except for this back pain, which I’ve had for ages. |
| GP: | Do you take any regular medications safe for that back pain? |
| P: | Nothing from the doctors, just painkillers, ibuprofen to be exact. I’ve been taking every day for my back pain. For I would say the last three years, I never miss a dose. |
| GP: | I see. So, Mrs Knowles, based on my initial assessment, I’m going to liaise with the gastroenterologist on call. Also, you are hemo dynamically unstable. So we’re going to draw some blood for a few blood tests and start you on a blood transfusion to replace the blood loss due to haemorrhage. Also, you need to be put crystalloids IV fluids because of your haemorrhaging |
| P: | So you’re going to take my blood and then give me some more. |
| GP: | Well, yes, it is exactly what we’re going to do. I need to get a full blood count to see your haemoglobin and blood urea levels amongst other factors. I mean, your blood pressure is lower than it should be at 100 over 70, and your pulse is a bit higher than normal at 100 beats per minute. |
| P: | So, what exactly is wrong with me, do you think? I mean, you must have some idea. |
| GP: | Well, it’s likely that you have gastro intestinal bleeding, but there are quite a few possible underlying causes. I mean, it could be a peptic ulcer or esophageal erosions as well as more serious possibilities. Once we get the blood test back and your vital signs going in the right direction, I will likely order an endoscopy to see what’s going on on. |
| P: | What do you think could be the root cause? |
| GP: | Well, actually, NSAIDs such as aspirin, ibuprofen and naproxen are unknown to cause peptic ulcers because they interfere with the stomach’s ability to protect itself from gastric acids. |
| P: | Oh, no, I had no idea. I mean, it sounds like I could have caused this. |
| GP: | Well, one recommendation I was about to make was to tell you to discontinue your use of NSAIDs. We work to find the exact cause of your bleeding. We can come up with an alternative pain management strategy for your back pain. You may also need further investigation of that problem, but one thing at a time. So now…[fade] |
| PH: | Mrs. Shepard, how are you today? |
| P: | Not well. Not well at all, I’m afraid. I woke up this morning and got a huge shock when I looked in my bathroom mirror. 1/2 of my face was dropping immediately. Panicked and called an ambulance. |
| PH: | Yes, that would be quite alarming. So, I can see that the weakness is on the right side? |
| P: | Yes. I brushed my teeth before bed last night, and my face was completely normal on both the right and left sides. Then I woke up at 8 am this morning and noticed it. |
| PH: | And are you experiencing normal facial sensation? |
| P: | The feeling is fine. No numbness or anything. I mean, in other ways, I’m fine. I can still close my eyes and blink. No problem seeing. And I can swallow fluids and solids with no problems |
| PH: | And your speech also seems okay. You don’t seem to be doing any slurring or having any difficulty getting your words out. Also, I can see that your ear canal and tympanic membrane are normal. What about weaknesses in other parts of your body? |
| P: | All fine in my arms and legs. I haven’t had any balance trouble or dizziness. I mean, when I saw my face, I wanted to pass out from the shock but no loss of consciousness. |
| PH: | And any recent history of illness such as infections? |
| P: | No, not recently. In front, unusually fit and well. I mean, I take a tablet for high cholesterol, so I guess I have high cholesterol, but nothing else. Oh, no, I did forget to mention one thing. Something else is a bit weird. I feel like everything sounds louder. Does that make sense? |
| PH: | So, Mrs Shepherd, the most likely diagnosis given your symptoms and clinical findings is Bell’s palsy. |
| P: | And what is that, exactly? |
| PH: | It’s a form of facial paralysis that occurs as a result of facial nerve dysfunction. Legions of the facial nerve can result in paralysis of facial muscles, increased hearing volume, and a lot of taste. |
| P: | I see and what causes that? |
| PH: | Generally there is no known cause of Bell’s palsy. I do want to run a few tests to rule out other causes of facial paralysis, such as a brain tumour on stroke. |
| P: | And, if it is, what did you call it? Bell’s palsy? What is the prognosis? |
| PH: | Overall, the prognosis is good, with over 70% of patients recovering entirely in 3 to 4 months. Those with partial facial nerve palsy such as yourself are much more likely to fully recover function compared to those with complete palsy. In the meantime, we need to talk about management. It is of the utmost importance to keep your eye on the affected side lubricated using eye drops and ointment at night. Bell’s palsy often affects the blink. Reflex on DH stops the eye from closing completely, so it’s essential to take steps to protect it. |
| P: | So I’m guessing I need to wear sunglasses. |
| PH: | Exactly, and if you are unable to close the eye at bedtime, you should take it closed using micro porous tape. |
| P: | OK, and is there any medication like I can take to speed up recovery? |
| PH: | Yes, steroids improved the speed of recovery, but first… [fade] |
| A: | So, Dr. Fellows, have we got the results back on the ascitic fluid we sent off for analysis? |
| B: | Yes, we just got the report back now. The SAAG calculation suggests the ascetic fluid is transudate. |
| A: | Interesting. Do you recall what commonly causes this type of result? |
| B: | Well, increased pressure in the portal vein, portal hypertension, so we can rule out pancreatitis and infection, which still leaves us with cirrhosis, hepatic failure. |
| A: | Yes, there are definitely a few possibilities left so further investigations are required. But given the patient’s history and our other clinical findings, what do you think is the most likely diagnosis? |
| B: | The patient denies being a heavy drinker. So while we cannot rule out cirrhosis or alcoholic hepatitis completely, we have to also be looking at other causes of portal hypertension. |
| A: | I agree. So now we need to… [fade] |
| GP: | Uh, so a common type of counseling situation in general practice is smoking cessation counselling, as GPS has the unique opportunity to harness, long term patient-doctor relationships and easily facilitate follow up appointments on progress check ins. However, as you’re probably already aware of, GP’S already have quite a lot on their plate, so it is important to have an approach when it comes to counseling patients. |
| The approach we’re going to talk about today is the five A’s approach: ask, assess, advise, assist and arrange. Studies have shown that implementing all of the five A’s is associated with a higher quit rate, compared to consultations that only involve general non targeted advice to quit smoking. So once you have opened the consultation and gone through the patient’s ideas, concerns and expectations, you can start with the first A. Ask your patient about features of their smoking history, along with other aspects of the traditional medical history. It is important to be nonjudgmental and empathetic. | |
| Areas of questions you might explore during this part of the consultation include: the patient’s history related to smoking, the past medical history, medications and allergies, family history and social history. As one of the connections between each area and smoking, for example, you might ask if the patient is currently or has ever been on any nicotine replacement. So now onto assess. So…[fade] |
| GP: | Uh, so, Mrs Jackson, you are here about having a contraceptive implant? |
| P: | Yes, that is correct. I just had my third a couple of months ago, and I want to make sure that there isn’t a fourth, at least for the time being. |
| GP: | I see. So I wanted to see what questions you heard about the process of inserting the implant. |
| P: | Yes, I do have a few questions, so I understand that I could have the implant fitted at any time during my period. But, what I’m not clear on is: How is it inserted? I mean, how do they get it under my skin? Is their surgery or? |
| GP: | So, a health care professional will use a needle and syringe to administer a small amount of local anesthetic to numb the relevant area of your arm. So the insertion of the implant itself should not hurt. |
| P: | Okay, on the next few days. |
| GP: | Well,…[fade] |
| N: | Dr Jacobs. I was just talking with the patient in bed seven and he mentioned something about an over-the-counter analgesic he often takes. It struck me as odd, because he is being treated for severe liver impairment. And when I checked, I didn’t see it in his medication history. |
| GP: | Thanks for telling me. Did he mention how often he was taking them before being admitted to the hospital? |
| N: | He said several times a day. So definitely enough to cause a serious adverse reaction. But just to be clear, I think he may still be taking them even while he has been here in the hospital. |
| GP: | Really? Why would he do that? |
| N: | I don’t think he wanted to ask for stronger pain medication from the team. So he has been having his wife bring him acetaminophen when she comes to see him. |
| GP: | OK, so that turns this into an emergency. I will talk to him immediately. Okay. Again. Thanks for…[fade] |
| A: | Hello, Dr Land. I’m calling about Mr Smith, the patient you sent the referral letter for this morning. I had a few questions about his condition. |
| B: | Yes, the patient. I referred with possible basal cell carcinoma. |
| A: | Yes, I see that you would like the diagnosis confirmed. And I also see that the patient was diagnosed with actinic keratosis seven years prior. So I’m wondering what treatment was carried out after that diagnosis was made. Also, do you know if a biopsy was done at the time to confirm the diagnosis? |
| B: | Uh, I’m not sure about those particular details of this patient’s history, as I have only recently become his GP. |
| A: | Okay. Do you think it would be possible to talk to the GP listed on the referral letter? Or do you think you could help me get that information. |
| B: | Well, His GP retired from this practice last month, so she is no longer coming into the office. But I’m sure something could be arranged. I’ll reach out to her…[fade] |
| A: | Just had my annual budget meeting with Jane from the finance team. |
| B: | How did it go? I have mine tomorrow, also with Jane. I’m quite nervous about my budget getting cut. I mean, I’m dreading and bringing up the variances in the budget statement. I mean, my staff’s costs, particularly over time, went through the roof during this year’s crazy flu season. |
| A: | I had a bit of that myself, but surprisingly, she didn’t make too much of a deal about that. She did focus more than usual on non stuff costs like drugs. Apparently, there is an idea going around that we are prescribing too many opioids. |
| B: | Thanks for the heads up. I was so focused on my staff costs, that I haven’t really taken a detailed look at non staff costs. What is a few more hours away from actually taking care of patients? |
| A: | I know. I mean, we know this job will include some administrative duties, but it seems like every year there are more and more things put on us…[fade] |
| Jessica: | Hello, everyone, and welcome to this year’s Dietitians Summit. My name is Jessica Stokes, and I am a researcher working with the team based in Cambridgeshire. It’s great to have this opportunity to share our research so that we can better advise the patients and other health care professionals that we work with, especially as many of us move into roles in primary care on hospital settings and become integral members of teams. |
| So the research that I want to talk to you about today is about coconut oil and blood lipids. This is an important area as coconut oil, an oil high in saturated for approximately 90% has gained popularity as a dietary ingredient throughout the UK. You may have noticed television cookery programmes, recipe books, as well as social media posts making claims of health benefits associated with the consumption of coconut oil. | |
| So naturally, researchers have started to conduct intervention studies. And two recent reviews of such studies on the effects of coconut oil on cardiovascular risk markers provide no suggestion that consumption of coconut oil, rather than unsaturated burnt oils would benefit cardiovascular health. Rather, these reviews suggested that compared to unsaturated oils, such as safflower, soybean or olive oil, consumption of coconut will raise total cholesterol, low density lipoprotein cholesterol as well as high density lipoprotein cholesterol. | |
| However, both reviews highlighted the limited number of intervention studies to date and that those available often had a small number of subjects, or were conducted in populations not largely representative of the UK, such as Sri Lankans and Malaysians. | |
| For this reason, a new randomised study was carried out. The aim of this study was to investigate the effect of daily consumption of 50 grammes of either extra virgin coconut oil, extra virgin olive oil or butter for one month on blood lipids and metabolic measures in free living UK subjects. The finding from this round of my study were recently published. | |
| So before getting into what you are also eager to hear the results, I will talk a bit about the study design. So in this trial, middle aged men and women living in the general community were randomly allocated to consume 50 grammes of extra virgin coconut oil, or 50 grammes of butter, or 50 grammes of extra virgin olive oil over four weeks. Subjects who did not have a known medical history of heart disease, stroke, cancer or diabetes and without gallbladder or bowel problems, not taking cholesterol lowering medication and living near a particular town were recruited through advertising over two months in 2017. | |
| In all, 96 subjects were included in the study. 2/3 of the subjects were women. On the mean age was 60 years of age. Another important factor, the mean BMI for the three groups, ranged from 24.8 to 25.5. Dietary intake, as assessed by a 24 hour dietary assessment questionnaire done before the study began, was similar across the intervention groups. Plasma lipids were found to be raised at baseline in all groups of study. Study fats were provided along with measuring cups and suggestions of how to include the fats in the diet, including recipes. Just to make sure we’re all on the same page as to the study fats. Extra virgin coconut oil has a saturated fat wanton of 94% followed by butter with 66% and finally extra virgin olive oil with 19%. | |
| So now to the big reveal. The first warning was that coconut oil did not significantly raise LDLC concentrations compared with olive oil, while butter significantly raised LDLC concentrations compared with both coconut oil and olive oil. On the other hand, coconut oil significantly raised HDLC concentrations compared with both butter and olive oil. As to body weight, BMI, central adiposity, blood glucose, systolic or diastolic blood pressure. There were no significant changes in any of the groups over the period of the study. | |
| The conclusion that the author drew from the results is that two different dietary fats, butter and coconut oil, which are predominantly saturated fats, appear to have different effects on blood lipids compared with olive oil, a predominantly monounsaturated fat, with coconut oil, more comparable to olive oil with respects to its effect on LDLC | |
| As with any study, there are a number of limitations to point out. First of all, the study was short term in nature. In addition, the study did not include a running period. According to the EFSA, blood lipids tend to stabilise after about four weeks in response to fix nutritional interventions. So future study should be longer in duration to collect evidence on the sustainability of this effect with continuous consumption of the food or, in this case, fat. Another factor is that there was no attempt to control other aspects of the usual diet. In particular, total energy intake. Related to this is…[fade] |
| DR: | So, today we’re going to go over the sputum sample collection, which is a procedure designed to collect samples of expectorated secretions from a patient’s lower respiratory tract. This procedure is normally used as a laboratory specimen for the isolation of microorganisms that might be causing infections of the respiratory tract. |
| So before getting into the procedure itself, it is important to know what patients are indicated for sputum collection. In general, this procedure is recommended for all patients with moderate or high risk, according to the CURB-85 pneumonia severity score, as well as those with suspected tuberculosis. | |
| Just as a reminder, the CURB 85 pneumonia severity score includes the following criteria: confusion, a respiratory rate less than 30 per minute, blood pressure with diastolic higher than 60 or systolic higher than 90, the age of patient being equal to or higher than 65 years, and the level of blood urea nitrogen being lower than 19 milligrammes per deciliter. A score of 2 or above indicates higher risk. | |
| On the other hand, sputum collection should not be performed in patients to whom severe coughing may be harmful. This may include patients with acute respiratory distress, unstable cardiovascular status, hypoxia and lung function impairment, among others. Another step to complete before carrying out the procedure is to gather all of the equipment. In order to obtain a sputum sample, you will need to gather the following equipment: to protect yourself, you will need appropriate personal protective equipment such as clean gloves, and an apron, and a mask or a gown and goggles if the patient is likely to have tuberculosis or another high risk infection, such as influenza or legionella. | |
| In order to carry out the procedure, you will need a sputum and specimen container, and label, a biohazard for delivery of the specimen to the laboratory, as well as an investigation request form. Last but not least, you will need tissue paper for the patient as the procedure produces severe coughing, as I mentioned previously. | |
| So once it has been determined that a patient is to undergo this procedure and do you have all of the required equipment, you can go about collecting the sputum sample. | |
| As with any similar procedure, you must explain the procedure to the patient. You might say something like, “Hello, Mrs Jones. My name is Dr Smith. We need to collect a sample from your lungs to be able to identify which bug is causing the infection in your chest. The procedure includes breathing in a doubt, coughing and collecting sputum in this pot. It might cause you to cough heavily straight after, but it shouldn’t be too uncomfortable.” Then you should check the patient’s understanding of the procedure and obtain a consent before washing your hands again. | |
| So the last step before collecting the sputum is to have the patient rinse their mouth before coughing. This is to remove any oral contaminants present in the patient’s saliva. After that, you need to instruct the patient to give a series of low, deep coughs, the race sputum from the lungs. The patient will need to keep breathing out until his or her lungs are completely empty. The test will be more accurate if the patient coughs up sputum from deep inside his or her lungs. | |
| For many patients, it is helpful for them to put one hand over their mouth with a tissue you will provide them and then put the other hand on their stomach. This will help them feel if they are coughing deeply as they should be able to feel it in their stomach. You may also find it helpful to pat the patient on the back. This should be done solidly up and down the back to help release the sputum. You then need to collect one or two teaspoons of sputum in the container before closing and sealing the lead. If your patient has a tracheostomy or is intubated and ventilated, you will need to vary the procedure as you will likely need to use suctioning device, such as a suction trap. Also for patients that find it very difficult to expect a rate, a 9% sodium chloride nebulizer might help to loosen secretions. Finally, you need to correctly label the specimen container and complete the request form before placing the specimen in a biohazard transport bag. You should…[fade] |