SOE Stations - Part II

‫ﻢ‬9‫ اﻟﺮﺣﻤﻦ اﻟﺮﺣ‬2 ‫ﺴﻢ‬/

B A ‫و;ﻪ =ﺴﺘﻌ‬
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Table of Contents
Legend of Abbreviations
Introduction
Case 1: Tertiary syphilis (with aortic regurgitation
Case 2: COVID 19 Pneumonia
Case 3: Stroke/Atrial Fibrillation
Case 4: Vitamin B12 deficiency
Case 5: Paracetamol toxicity
Case 6: Guillain-Barre syndrome
Case 7: Reactive Arthritis
Case 8: Polycythemia Vera
Case 9: Sarcoidosis
Case 10: Hemolytic Uremic Syndrome
Case 11: Spinal cord compression
Case 12: ARDS COVID
Case 13: Bisoprolol and CCB toxicity
Case 14: COPD
Case 15: Pericarditis
Case 16: Pleural effusion
Case 17: Diuretic abuse
Case 18: Meningitis
Case 19: HOCM
Case 20: Pancreatitis

Legend of Abbreviations
Abbreviation Meaning
PAM FOSS Past medical/surgical, allergies, medications, family history,
occupational, social (smoking, alcohol, IV drug use, travel), sexual
MOVIE Monitor, Oxygen, IV line and send STAT labs, ECG
ANERVES Admission, Nutrition, Education, Referral, Vaccination, Exercise,
Smoking Cessation/Screening

Hx History
Ix Investigation
Mx Management
SOCRATES Site, Onset, Character, Radiation, Alleviating, Time, Exacerbating,
Severity
Systematic Review Review of systems (CVS, Resp, GIT, Nephro, CNS, MSK)
Constitutional Fever, decreased oral intake, fatigue, night-sweats, weight loss
symptoms
Introduction
This work was made possible by the collaborative efforts of several colleagues who
attended the preparation course conducted in Faqeeh hospital during the period 29-31
October 2020. Efforts were made to reproduce the course content with the goal of
providing a means of preparation for Internal Medicine residents intending to enter the final
OSCE exam.
The case scenarios are the intellectual property of the organizers at Faqeeh hospital. This
work is not intended to generate profit or to plagiarize the work of the original organizers.

What is the SOE?

SOE stands for structured oral exam. You will be given a case scenario to read. You will be
assessed on approach which includes introduction, history taking and examination skills,
investigations, management and closure. The time allocated for each station is 10 minutes.
You will not be required to perform physical examination, instead, you will be assessed on
your ability to describe the examination findings you will look for. In addition, you will be
required to interpret investigation findings and outline lines of management (non-
pharmacological and pharmacological).
Our advice is to have a calm organized approach to gain the most points. Examiners will
differ in their marking strategies, some may provide helpful hints, while others may choose
to put on a mask face. Remember you will not lose marks if you say something extra, so try
your best to be exhaustive and practical with time. The best way to do that is to practice,
practice, practice!
Our final hope is that you are successful in the upcoming final OSCE exam and that you find
it in your hearts to make prayers for those who helped make this work possible!
Case 1
Place : OPD
45 year old male presented to OPD with SOB and palpitation
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
Analysis of Chief Complaint:
1-SOB: Onset, Duration, Character,Radiation, course, related to exertion, relieving/exacerbating
factor (Exertion/exercise, Pollen/chemicals)
Severity: Exercise tolerance>> Quantify how far the patient can walk before stopping due to
shortness of breath (e.g. number of stairs, distance on the flat)

Variability: Is the SOB continuous throughout the day, intermittent or progressively worse

2- Cardiac Symptoms: palpitation: • Duration of episode(s) • Frequency (if more than one
episode) • Precipitants and relieving factors • Asks about activities before onset • Asks about
intake of caffeine and alcohol • Rhythm of palpitations (regular, irregular)

Associated symptoms (look for DDx)

Respiratory: Wheeze or stridor, Cough: productive or dry, sputum, Hemoptysis, Chest pain

Cardiac Symptoms: palpitation: Onset, Duration, Chest pain, syncope, Hx of arrhythmia, Hx of CAD,
hx. Of cardiac disease

Associated GIT Symptoms: Nausea, Vomiting, dysphasia, Diarrhea, Jaundice, Hx of liver disease

Endocrinopathy: known thyroid, DM, Adrenal

symptoms of hyperthyroidism: weight loss, diarrhea, eye symptoms, agitation, sweating
Malignancy Hx: fever, weight loss, anorexia, family Hx of Malignancy

Elicits risk factors for PE/DVT: Calf pain/swelling, Recent travel, Recent surgery,
Family history of clotting disorders, Malignancy, Oral contraceptive pill (if female
patient), Pregnancy (if female patient)
Medication

GU: Hx of urinary infection, genital ulcer, discharge

Autoimmune disease symptoms: arthritis, skin rash, mouth ulcer

PMH: CAD Cardiac disease, arrythmia, thyroid disease/surgery • Anxiety disorders • Diabetes mellitus
 Social: Smoking, Alcohol, Occupation, sexual activity, IV drug use, travel hx, Stress levels, Exercise

Allergy/vaccinations/blood transfusion
Family hx: cardiac, lung disease, malignancy, hereditary disease, Thyroid disease, Sudden death,
Arrhythmias

EXAMINATION FINDINGS: diastolic murmur on the left 2nd intercostal space

What Physical Exam you would like to perform?

V/S: BP 120/80, HR 110, SO2 95% RA, temp 36, BMI

General: Pale Jaundiced, distress,

cyanosis, body habitus

Cardiac: inspection of pericardium: displaced apex, scar, central /peripheral cyanosis

Palpation: pulse, capillary refill, JVP, carotid, heave, thrill, LL edema, peripheral pulsation
Auscultate: heart sounds, valve area for any murmur, apex area, carotid, stigmata of IE
Resp: trachea tug, trachea deviation, percussion, auscultation for bronchial breathing. LN
Neurological: GCS, motor /sensory /reflexes, cranial nerves.
Abdominal: Soft lax +ve BS, organomegaly
Autoimmune: skin rash, arthritis, signs of joints inflammation, ulcers.
Endocrinology: thyroid, adrenal, DM

What is the diagnosis? Aortic regurgitation

What are the specific signs of this murmur?

• Water hammer pulse

• Wide pulse pressure
• Chest signs: displaced apex, diastolic murmur, soft S1 and S2
• Corrigan’s pulse: rapid and forceful distension of the arterial pulse with a quick collapse
• De Musset’s sign: bobbing of the head with each heartbeat (like a bird walking)
• Muller’s sign: visible pulsations of the uvula
• Quincke’s sign: capillary pulsations seen on light compression of the nail bed
• Traube’s sign: systolic and diastolic sounds heard over the femoral artery (“pistol shots”)

What are the signs of severe aortic regurgitation ?

-Collapsing pulse -Soft s1 - s3
-Left ventricular hypertrophy/failure
Mention 3 systemic disease associated with aortic regurgitation?
Syphilis
Rheumatic heart disease / IE
Marfan syndrome (male) / turner (female)
Vasculitis (aortitis, Takayasu)
Ankylosing spondylitis

Which Investigation you would like to order?

CBC: normal
ECG, Cardiac Enzyme

ECG: Left ventricular hypertrophy (deep S-waves in V1 and V2, tall R-waves in V5 and V6).
CXR: widened mediastinum
CRP, ESR, ANA, Electrolyte, Cr, BUN, LFT Blood glucose (normal)
Echo: aortic root dilatation, mainly ascending

What is your DDX:

-Rheumatic fever
-Syphilis (don’t forget ascending aortic dilatation specific for syphilis)
-Ankylosing spondylitis

Hx from examiner : patient had unprotected sex when he was 15. Other hx was negative.

What is your Diagnosis? Tertiary syphilis complicated by cardiovascular disease (aortic

regurgitation)

How to confirm your diagnosis?

-Screening for STD (HIV, chlamydia & gonorrhea by NAAT, HBsAG, HCVAB)
-RPR test, then FTA-ABS
Outline your management
Non-pharmacological (ANERVES)
Admission to ward
Nutrition
Education
Referral to ID, Cardiology, infection control/ MOH based on hospital protocol
Vaccination
Exercise
Screen partner for STD, Smoking cessation
Pharmacological
Penicillin 3 doses (1 dose/week)
DVT Prophylaxis
Surgery Referral for Aortic valve replacement if indicated

Q: What are the indications for LP in syphilis?

• Neurological symptoms
• Uveitis
• Ear symptoms (hearing loss, fluctuating hearing, or vestibular
imbalance/weakness (vertigo)
• Persistent high RPR

Q: What is the test you will send from CSF?

VDRL (specific, not sensitive)
Case 2

55 years old male patient presented to ER with shortness of breath and fever for 3 days

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1- Ensure patient is vitally stable; as suspicion of covid 19 infection is high, make sure
patient is isolated in airborne room and you wear PPE.

2- Analysis of Chief complaint:

Fever: onset, duration, course, the reading of temperature if measured, diurnal variation,
relieved by anti-pyretic. Exacerbating factors, alleviating factors (paracetamol),
rigors/shivers, lethargy, night sweats, weight loss, skin rash, Lumps/bumps.

SOB: onset, duration, course, relieving / aggravating factors, positional related,

cough, sputum, wheezing, sore throat, runny nose, chest pain,

Associated symptoms: Hx of contact with sick or covid 19 pt, hx. of contact with TB
patient, recent travel, recent hospital admission, recent chest infection, or use of
antibiotics

Systemic review:

Cardio: chest pain, palpitation, orthopnoea, PND, LL edema, syncope

GI: nausea, vomiting, abdominal pain, diarrhoea.

Neurology: syncope, dizziness, motor/ sensory deficit, vision, hearing

MSK: joint pain, muscle pain, skin rash, ulcers, back pain

Past medical hx, Past surgical hx

Social hx, travel hx, hx of IVDU, sexual hx, hx of ingestion of raw milk occupation hx,
contact with COVID, TB patient

Allergy hx, vaccinations hx

Family hx

Examiner hx: 55 years old male presented to ER with shortness of breath mainly on
exertion, associated with dry cough, pleuritic chest pain and fever for 3 days - continuous,
reached 39, improved with paracetamol. He also has fatigue and 3 people from his family
also had recent fever.

Examination

Vitals: temp: BP, O2 sat, HR: RR, Wt/ height, CBG, GCS

General: appearance, surrounding, respiratory distress, central/peripheral cyanosis, eyes

pallor/jaundice, throat exam, cervical /axillary LNs

Respiratory: inspection of shape of the chest, symmetry & movement of the chest wall,
use of accessory muscle
Palpation: tracheal tug / deviation, any tenderness, tactile vocal fremitus, chest expansion
Percussion all intercostal area (dullness/ stony dullness)
Auscultation looking for bronchial breathing, decrease air entry, crepitation, wheezing

Cardio: inspection of JVP, apex pulsation, stigmata of IE,

palpation of radial pulse regularity, character, BP both arms, orthostatic/ lying
carotid, apex pulse, heave/ thrill
auscultation: heart sounds, 4 valve areas
Lower limb pulsation/edema

Abdomen: tenderness, distention, organomegaly

MSK>> skin lesions, mouth ulcers, signs of joints inflammation joints, back examination

Neurological: cranial / motor/sensory / reflexes

Examiner examination: BP 120/70, no orthostatic hypotension, hr 110, o2 93% RA, 88%

after walking to bathroom, temp 38.9

No respiratory distress, no dullness on percussion, bilateral scattered expiratory crackles,

remaining examination is normal

Investigation

CBC-D, blood cultures, CRP, procalcitonin, ESR, RFT, LFT, electrolytes

Lactate, ABG, D-dimer, Coagulation profile, , cardiac enz.

Covid 19 nasal swab, influenza swab / mers-cov / H1N1 swab, sputum cultures/ sputum
PCR

ECG, Chest x ray

Examiner: wbc 3.2, plt 110, lymph: low 0.5, bun 24, AST/ ALT little high, LDH high, Ferritin
high, d-dimer 2, COVID 19 +ve

CXR: bilateral reticular–nodular opacities

What is your diagnosis?

Covid 19 pneumonia

Management?

Nonpharmacological: (ANERVES)

• Admit to medical ward, droplet contact / airborne contact isolation based on

hospital protocol

• ID /pulmonology consultation

• Immunization, respiratory physiotherapy, smoking cessation

Pharmacological:

• Supportive care: IVF, paracetamol, connect to oxygen to maintain saturation

>94%, cough

• Dexamethasone

• Antibiotics (Ceftriaxone/Azithromycin)

• DVT prophylaxis

Further Questions

Q1: After 3 days patient, patient deteriorated requiring 8 L O2 face mask, what is your
management?

ICU referral, CT chest with contrast, ABG, D- dimer

Examiner: CT chest showed Pulmonary Embolism

Q2: What is your management?

Referral to pulmonology/ hematology

Start therapeutic anticoagulation by LMWH (enoxaparin)

Q3: When to remove patient from isolation?

Symptoms free for 3 days, AND 10 days from First +ve swab (need both)

Or if repeated swab is –ve (not the MOH guideline now)

Q4: Dexamethasone showed mortality benefit in which group of patients?

Hypoxic patients only

Case 3
60-year-old male patient presented to ER with fainting and transient loss of consciousness
when he was working.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1- First make sure patient vitally stable, and order ECG (ABC, MOVIE)

2- Analysis of chief complaint

Syncope: First episode /recurrent

History from a witness or patient if he remember what happened when they were
unconscious?

- What was the patient doing prior to loss of consciousness? was the patient sitting,
standing or lying flat? Where was the patient?
-Symptoms before loss of consciousness: dizziness, aura: smell, vertigo, sick, visual
disturbances and ringing in the ears (tinnitus)
-During the time of LOC: ask for duration, frequency, color (pale, cyanosed), abnormal
movement, eyes rolling up, tongue biting, urinary incontinence. Could the patient see or
hear anything while unconscious?
-Symptoms after loss of consciousness: confusion, fatigue

-Trauma to head, fall

-Trigger (emotional/physical)

Asks about any recent illnesses

Previous episodes of loss of consciousness

Associated symptoms (search for the causes):

Neuro: headache, blurred vision, any weakness, sensation impairment, Visual

disturbance, Speech problems, Coordination/balance difficulties. Hx of trauma, hx. Of
epilepsy, or neurological disease.
Headache with features of raised intracranial pressure: Early morning headaches,
Vomiting, Worse on coughing/bending down/straining

Cardio: chest pain, palpitation, SOB, orthopnoea, PND, LL edema, carotid cause of
syncope (shaving, dissection, tight collar) hx. Of cardiac disease

Chest: cough, fever, pleuritic chest pain, WT loss, night sweats

ID: fever, neck pain

GIT: nausea/ vomiting, diarrhoea, abdominal pain, constipation

Endocrinology: Hypoglycaemia/ hyperglycaemia: sweating, anxiety, palpitations, insulin

use
Symptoms of hyper/hypothyroid (weight loss, hot intolerance, hx of adrenal insufficient
(hypotension, hypoglycaemia), Cushing symptoms, pheochromocytoma symptoms

Malignancy: (weight loss, loss of appetite, fever)

Vasovagal symptoms: crowded/warm environment, nausea immediately prior to loss of

consciousness, short duration (<5 minutes)

Carotid sinus hypersensitivity: after turning head, tight collar

Micturition syncope: during or immediately after urination

Past medical hx: of neuro/ cardio disease/ diabetes

Past medical hx: • Diabetes • Seizures/epilepsy • Febrile convulsions (during childhood) •

Cerebrovascular disease, strokes, transient ischaemic attacks •Cardiovascular problems: •
Aortic stenosis • Heart failure • Arrhythmias

Medications: (diuretics) /herbal hx/cardiac and diabetic medication

Past surgical hx

Social hx: travel hx, hx of IVDU, smoking alcohol hx sexual hx, occupation hx.

Allergy hx, vaccinations hx

Family hx: of arrhythmia, epilepsy, malignancy, congenital disease, sudden cardiac death

Examination

Vitals: temp: BP, O2 sat, HR: RR, weight/height, GCS

General appearance: respiratory distress, central /peripheral cyanosis, eyes for pallor/
jaundice

Neurological: GCS, cranial / motor (tone, power) /sensory / reflexes

Cardio: inspection of JVP, apex pulsation, stigmata of IE, stigmata of HF
palpation of radial pulse regularity, character, volume
BP both arms, orthostatic/ lying
Carotid, apex pulse, heave/ thrill
auscultation: heart sounds, 4 valve areas
Lower limb pulsation / edema
Respiratory: inspection of symmetry & movement of the chest wall, use of accessory
muscles
Palpation: tracheal tug
Percussion (dullness/ stony dullness)
Auscultation looking for bronchial breathing, decrease air entry, crepitation, wheezing

Abdomen: tenderness, distention, organomegaly

MSK>> skin lesions, mouth ulcers, signs of joints inflammation joints, back examination

LN examination, thyroid

Examiner:

Temp 36, saturation 94% on 2 L o2, BP 120/80, HR 80, RR 20

s1+s2+ systolic murmur and RT parasternal, JVP is normal
Normal breath sounds, minimal expiratory fine crackles
Power of left UL 3/5, left LL 4/5, normal cranial exam

Investigation:

CBC, RFT , LFT , Chemistry, electrolytes, BG, cardiac enzymes, ABG, pro-BNP, TFT, CXR,
ECG, ECHO, CT brain

Lab results from examiner:

ABG: metabolic alkalosis (from diuresis)

ECG: showed irregular rhythm, LVH picture

Echo report: severe aortic stenosis, EF 40%, CXR: cardiomegaly, pulmonary edema

CT brain: hypo density lesion

Q1: What is your diagnosis?

1- Stroke

2- Atrial fibrillation

3- Heart failure

4- Severe Aortic Stenosis

Management:
Nonpharmacological: (ANERVES)
-Admit the patient
-Secure airway / Aspiration precaution (NGT)
-Referral to neuro/ cardiology
-Safety assessment if vulnerable (e.g. lives alone, dangerous occupation, elderly)
-Physiotherapy
-Health/social education
-Vaccination
-Smoking cessation

Pharmacological:
1- Stroke:
Dual antiplatelet if no contraindication
High intensity statin
DVT prophylaxis if no contraindication
Control HTN to target
MRI brain

2- Atrial Fibrillation:
Rate control (BB or CCB)
CHADSVASC score: >2 anticoagulation if no contraindication after 2 weeks of repeating
brain image.

3- Heart Failure
ACE/ARBS, BB, with target HR 50-60 bpm
Lasix (use with caution if volume overload)

4- Severe aortic stenosis:

Cardiothoracic referral for replacement
Avoid strenuous exercise
Q1: What are Indications of aortic stenosis valve replacement?

- Asymptomatic sever AS + EF <50%

- Asymptomatic sever AS going for other cardiac surgery CABG
- Asymptomatic severe but there is exercise induced hypotension
- Symptomatic patient

Q2: What are the signs of severe aortic stenosis?

- late-peaking murmur
- paradoxically split S2
- small and delayed carotid pulse (“parvus et tardus”),
- LV heave
- S4 (occasionally palpable)

Q3: Rate or Rhythm control? no superiority, equal, rhythm control associated with more
side-effects.
Case 4

54-year-old female patient presented to OPD with CBC showing pancytopenia. Please approach
this patient.

PPE Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1- Analyze chief complaint:

Check symptoms:
Anemia: exertional dyspnea , palpitation , dizziness
Thrombocytopenia: easy bruising , gum bleeding , bleeding from any orifices
Neutropenia: fever, recurrent infection
Causes:
- Infection: raw milk ingestion, night sweats, contact with TB patient
- Hematological malignancy: gradual onset of fatigue, weight loss, lymphadenopathy, fever,
rigors, respiratory distress, abdominal distention
- Hematology: B12 and folic acid: peripheral neuropathy, LL weakness, history of
autoimmune disorders, vegan diet, total or partial gastrectomy, ileal resection, or celiac
disease
- GI Cirrhosis: jaundice, abdominal distention, hemoptysis
- Autoimmune (SLE): alopecia, skin rash, joint pian, Raynaud, recurrent abortion
- Endocrine: hypothyroidism: cold intolerance, tremor, weight gain
Risk factors and social: alcohol, blood transfusion, drug abuse, sexual Hx, recent travel, tattoo,
contact with tb, smoking
Drug Hx : Chemotherapy , radiotherapy, MTX
Past medical Hx : anemia, renal, liver, heart disease
Allergy
Family Hx: autoimmune, cirrhosis, brucellosis, TB, malignancy
Surgery : bariatric surgery

Examiner:
54-year-old female medically free seeking medical advice for 4 months for history of exertional
dyspnea and fatigue. Basic labs done showed pancytopenia. No history of infection or autoimmune
disease no, neuroglial syptoms, no raw milk ingestion, she is a social drinker, family history is
negative. She underwent bariatric surgery 1 year ago.

What’s you differential diagnosis ? give 4

1- Bone marrow infiltration (TB, leishmania, leukemia, myelofibrosis, MDS, metastasis)
2- Hypocellular bone marrow > aplastic anemia
3- B12 deficiency, pernicious anemia, anorexia nervosa
 4- Systemic disease > sepsis, Hypersplenism, cirrhosis, alcohol, toxic
5- Peripheral destruction: SLE
6- PNH

Based on history give 3 important physical signs?

- Splenomegaly
- Signs of cirrhosis
- Peripheral sensation and reflex

Examination:
Vital sign ,BMI
general examination> conscious, oriented , any pallor , jaundice, facial rash
glossitis and angular stomatitis, easy bruising or spontaneous bleeding
LAP, LL edema
CNS: peripheral sensory loss, balance and gait disturbance
Joint inspection and palpation, muscle inspection for any wasting
Chest auscultation
CVS: JVP, heart sounds
GIT: hepatosplenomegaly, signs of cirrhosis, abdominal pain, ascites, caput nodosa, spider navie
CNS: power, tone, reflexes

Investigation:
CBC with differential, blood film show hyperpigmented neutrophil with macrocytosis
RFT, electrolyte, TFT, Bone profile, LFT

B12: borderline low, folate:normal

Hemolytic workup (negative)

Auto-immune profile: ANA, RF

Serology: HIV, Hepatitis
Us abdomen: moderate hepatomegaly
Bone marrow biopsy

What is your next step ?

Order homocysteine and methylmalonic acid levels

What is your final diagnosis ?

B12 deficiency due to bariatric surgery

Management:
Referral to hematology
Educate the patient about the importance for vitamins, diet
Start b12 injections

Further Questions:
Q1: Mention 5 causes of macrocytic anemia?
- B12 deficiency
 - Folate
- Alcohol
- Hypothyroidism
- Liver cirrhosis
- Hydroxyurea

Q2: If patient had folate and vitamin 12 deficiency what you will correct first ?
B12 because if folate is corrected first it will lead to subacute combined degeneration of the spinal
cord.

Q3: What is pernicious anemia and how to confirm it?

B12 deficiency due to autoimmune antibodies include intrinsic factor and anti-parietal cell that
leads to decreased B12 absorption.
Case 5
A 26 year old male patient presented to ER with 1 day history of repeated nausea and
vomiting

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1- First make sure patient is vitally stable, and to do ECG for cardiac stability (ABC, Movie).

2- Analysis of chief complaint:

Vomiting: onset of vomiting, amount, Contents/ appearance of vomitus, Blood in vomit,
Regurgitation of undigested food
GIT: abdominal pain, association of abdominal pain with position (worse when supine), diarrhea,
yellowish discoloration eyes, hematemesis, melena, dysphagia, early satiety and postprandial
bloating, regurgitation of undigested food, hx of biliary stone, symptoms related to food intake,
Hx of CLD., Hx of PUD, Hx of Endoscopy.

ID: fever, contact with similar condition or sick patient, eating from outside, raw milk ingestion
Endocrine: Hx of DM? adrenal disease, thyroid symptoms (tremor, heat intolerance.), pituitary
disease? (diplopia, headache)
Cardiac: (Chest pain, SOB, palpitation, Hx of IHD)
Neurological: (confusion, headache, seizure),
Renal: Known CKD, NSAID
Constitutional symptoms (Fever, weight loss, anorexia, decrease appetite)
If female: pregnancy
Psychiatric illness: depression, anorexia nervosa, bulimia
Drug intake: medication, alcohol, drug abuse.
Past Medical: Hx of CLD., Hx of PUD, Hx of Endoscopy
Surgical Hx
Social hx: Travel, sexual contact, smoking. IVDU, Nutrition history
Family hx (GIT malignancy), psychiological disease

Examiner:
• 26-year-old male patient, previously medically free, presented to ER with
1-day history of nausea, associated with vomiting, 8 times, non-bloody,
associated with dull RUQ pain, and anorexia.
• There is No Hx of PUD or CLD, no previous Cardiac, endocrine or
neurological symptoms.
The patient has previous hx of anxiety, not on chronic medication, but he has hx of ingestion of 20
tablets of paracetamol (500 mg each) 20 hours ago, he is a smoker, not alcoholic, no drug abuse, no
contact with ill patient, no weight loss or fever, no recent travel or sexual activity, apart from anxiety
he is previously medically and surgically free, no Family hx of CLD.

Based on Mentioned history, any Further related history you would like to ask?
-Time of paracetamol overdose intake prior topresentation.
-Amount (how many tablets)
-Suicidal attempt
-Concomitant Intake of any other medication
-Hx of Chronic Liver disease, Family Hx of CLD.
-Hx of Fasting
-Hx of Alcohol abuse
Examiner:
Ingestion of 20 tablets of paracetamol (500 mg each) 20h ago, patient admites to previous suicidal
attempt, other hx is –ve
What are the signs you want to look for in your clinical examination?

1- V/S,
2- Abdominal Examination: RUQ Tenderness
3- Sign of Acute liver Failure: Jaundice, Encephalopathy, ecchymosis, bleeding, flapping tremor
4- Signs of underlying CLD: stigmata of CLD
5- Signs of increased ICP: Cushing effect, Triad (Brady, HTN, irregular resp.), cranial
nerve palsy, irregular breathing, papilledema
6- Systemic review: trauma, IV drug use marks, rash
Examiner:
RUQ tenderness, Jaundiced, Grade 1 Encephalopathy, no bleeding, no flapping tremor, no
stigmata of CLD or sign of increased ICP

What investigations will you order?

Investigation
-CBC-D, RFT, LFT, BS
-For Kings College Criteria: Lactic Acid, Cr, VBG (PH), INR, Paracetamol Level (and plot it on
Rumack-Mathew graft)
-Toxicology screen, Ethanol level, Amylase, lipase, LDH, ECG, Cardiac Enzymes.
-HBsAG, HCV Abx, HAV IgM, CMV IgM, EBV IgM, HSV IgM,
-Ceruloplasmin, Ferritin, Transferrin sat, ANA, ASMA, LKM Ab, IgG (the candidate allowed to go
back and ask for it after showing result of LFT)
-CXR, US abdomen with Doppler.
RESULTS:
-Random blood sugar 110 mg/dl, CBC: WBC 11, HB 13.4, Platelets 234,
-LFT
– AST 2130, ALT 2350, GGT 700, Alkaline phosphatase 440 T. Bilirubin 112, D. Bilirubin 98, INR 7.4
-Renal profile, Creatinine1.6, BUN 23, Na 138, K 4.3, Cl 112 Ca, po4 normal
•Arterial lactate (lactic acid): 4.3
ABG: PH 7.2, HCO3 17, CO2 29, PO2 94

• Paracetamol level 430

• Toxicology screen: Negative
• Ethanol level: Negative
• Amylase 40, lipase, 100, LDH normal
• HBsAG, HCV Abx, HAV IgM, CMV IgM, EBV IgM, HSV IgM, Ceruloplasmin, Ferritin,
Transferrin sat, ANA, ASMA, LKM Ab, IgG: all negative/ Normal.
• ECG: Normal, Cardiac Enzyme: Normal, CXR: Normal
• US: Normal liver, spleen and GB, normal Flow of PV and Hepatic veins.

Further Questions:

• Q1: What is your interpretation of LFT?

• Q2: What is your interpretation of VBG?
• Q3: What is your interpretation of Paracetamol Level?

Outline the management Lines?

- ICU admission
- Hepatologist referral, contact transplant center
- Psychiatry referral
-IV fluid
-monitor LFT, INR, Cr
-Liver support, monitor for Hypoglycemia, HypoPO4, AKI, Infection, Encephalopathy, GIT bleeding.
-N-acetylcysteine:
PO dose: Loading 140mg/kg, then 70mg/kg for 17 doses
IV dose: Loading 150 mg/kg over 1 h, then 50 mg /kg over 4 h, then 100 mg/kg over 16h.
Lactulose?
Abx broad spectrum
FFP if bleeding
PPI prophylaxis.
Any role of Activated Charcoal? No, because patient presented after 4 h on ingestion
What is the Indication for Liver Transplant in
Paracetamol Toxicity?

What is the etiology and initial work up for Acute

Liver Failure with AST-ALT >1000?
• Drug/Paracetamol toxicity
• Viral: HAV, HBV, HEV, HSV
• AI hepatitis
• Shock liver/ischemic
• Wilson crises
• AFLP
• Mushroom poisoning

The patient developed decrease LOC, and

Bradycardia What is your plan :
• ICU, elevate the bed
• Intubation, MV, ICP monitoring
• Mannitol
• Hypertonic saline, Hyperventilation.
• Provide Nutrition
• Avoid sedation
• EEG /Assess for Seizure
Case 6
35-year-old male medically free presented to ER with weakness/numbness of lower limbs
for 3 days preceded by diarrhea 1 weeks ago.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. First make sure patient is vitally stable, ABC, Movie

2. Analysis of chief complaint

Weakness : When first noticed, onset of sx, duration, progression, predisposing events (eg
trauma), aggravating/ relieving factors, character (ascending or descending)
Specific questions:
• sensory disruption - determine sensory level
• sphincter control - bladder & bowel
• weakness - partial or total
• flaccid or spastic?
• autonomic dysfunction

Associated symptoms:
• pain in muscle, bone, joint
• back pain
• deformity
• swelling
• stiffness
• loss of movement
• loss of function (impact on daily activities, walking distance)

Diarrhea: amount, frequency, blood or mucus, time, eating from outside, similar history
before,
Other GI sx : abdominal symptoms, nausea, vomiting,
Other neurological sx: seizure or decreased level of consciousness, hedache
Resp: shortness of breath, chest pain, fever, cough, nausea, back pain, recent vaccination
ID: fever , night sweats, contact with sick patient, TB risk factors
Endocrine: DM symptoms
Autoimmune sx : alopecia, rash, joint pain, mouth ulcer
Constitutional symptoms (fever, weight loss, anorexia, decrease appetite)
Past medical history of: tumours - 1* or 2* (breast, lung, prostate), infections,
neurological disease, skeletal deformities, disc prolapses, recent surgery (?haematoma),
epidural/spinal anesthesia, recent radiotherapy for malignancy?
Past surgical hx
Family hx
Drug Hx
Allergy
Social history: marital status, occupation, sexual activity, travel, animals/pets, drug use

Examiner:
35 years old male came with progressive symmetrical weakness started 3 days ago distally
and now he cannot walk or stand associated with numbness, moderate back pain, lower
limb pain, no upper limb symptoms, no headache no convulsion no decreased level of
consciousness.

Patient had gastroenteritis 3 weeks ago associated with vomiting and diarrhea 3 times
daily treated symptomatically with IV fluid and resolved, no shortness of breath, no fever,
no contacts sick patient, no drug use, no allergy to medication.

What are the signs you want to look for in your clinical examination?

Vitals, bedside vital capacity, neurological examination: motor exam, sensory level,
reflexes, cranial nerves

Investigation: CBC, RFT, LFT, INR/PTT,FVC,CXR, stool workup, EMG, PFT, LP, blood
glucose, spine MRI

Na 130, GQ1B antibody positive

All labs are normal

NCS/EMG: decreased conduction velocity

LP: cytology/albumin dissociation ratio

MRI: thickening of anterior spinal roots and cauda equina

Q1: What is your DDx?

• Guillain-Barre syndrome (GBS)

• Myasthenia gravis
 • Lambort Eaton Syndrome

• CIDP

Q2: What is your Dx?

GBS

Q3: What is your management?

Non-pharmacological: ICU admission,IVF, neurology referral, FVC f/o Q4H, NGT,

bladder/bowel care, PT, follow-up lytes

Education, screening, vaccination and nutrition

Pharmacological: pain control (gabapentin), IVIG or plasmapheresis

Q4: What are the indications for intubation?

• Unable to maintain airway

• Rule (20,30,40): FVC < 20, or MIP>-30, or MEP<40

Q5: Complications of GBS

• Respiratory failure

• Hyponatremia (SIADH)

• Autonomic dysfunction

• Aspiration pneumonia

• CVS (arrhythmia)

Q6: What is the triad for Miller Fisher? What is the antibody?

1. Ataxia

2. Areflexia

3. Ophthalmoplegia
Case 7

32-year-old male presented to ER with two-week history of asymmetrical joint swelling,

pain in both ankles and left knee, morning stiffness >30 min, history of genital ulcers and
rash in both knees, history of gastroenteritis before 1 week.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Make sure patient is stable.

2. Analysis of chief complaint:

Joint pain > site, Which joints specifically? small/large joints, symmetrical, proximal/distal,
onset, trauma, alleviating factors
(inflammatory >> worse in the morning , morning stiffness > 30 min , improve pain with
movement )
Redness, swelling, Fevers, Asks about any recent illnesses, previous episodes?

Rash: onset, painful, distribution, other associated rashes Likes Butterfly rash
Generalized: fever, weight loss, tiredness, myalgia
Autoimmune hx: Raynaud’s syndrome, Skin tightness, Dry mouth, Nails>> pitting,
onycholysis, eyes>> pain, dry eyes

GIT: diarrhea amount, frequency, blood or mucus, time, eating from outside, similar
history before, abdominal pain, nausea, vomiting,
ID: fever,night swaeting ,sexual, ingestion of raw milk, TB contact
CVS: chest pain, orthopnia , PND
Resp: cough, hemoptysis , shortness of breath, pleuritic pain
Renal: hematuria, ankle swelling (nephritis)
CNS: confusion, seizure, sensory disturbances, motor weakness, nerve palsies
Genitourinary: urethritis, ulcers, discharge, dysuria
Constitutional symptoms (Fever, weight loss, anorexia, decreased appetite)

Past medical hx : autoimmune disease, IBD

Past surgical hx
Medication
• Long-term steroids (osteoporosis)
• Thiazide diuretics (gout)
• NSAIDs (gout)
• Over-the-counter medication
Allergies
Family hx of autoimmune disease
Social hx: smoking , travel, sexual HX , occupation ,Drug abuse, Sports, exercise,
strenuous activity (osteoarthritis).
Effect on activities of daily living, loss of function, (dressing, writing, eating, stairs)
Exam:
Vitals Joints: for hotness, swelling, redness, deformity, limitation of movement
Rash: signs of infection, site, edges
Neurological exam: weakness, sensory, motor, reflexes
Ix:
CBC, RFT, LFT, APTT/INR, HIV,HEP B and C, syphilis, RF, ANTI CCP, ANA, ANTI DS,
HLA-B27
u/s and x ray of the joints

Arthrocentesis 3c (culture, cell count, crystals), TB, brucella, malignancy

Lab finding was normal except ESR:60, HLAB27:+VE, arthrocentesis :(wbc:17000,no

crystals,culture:-ve)

Skin finding: keratoderma blennorrhagica seen on the soles

Circinate balanitis: moist well-demarcated erosions with raised borders involving the
penis

Q1: What is your diagnosis?

Reactive arthritis

Q2: What is your treatment?

Non pharma: supportive, rheumatological referral

Pharma: NSAID/steroid/DMARD/Biological

Q3: What is the definition of inflammatory back pain?

• Morning stiffness > 30 min

• Improve with exercise

• Age younger than 40

• Alternating buttock pain

• Worsening during night

• Respond to NSAID

Q4: What are the different Spondylarthritis?

• Reactive
• IBD

• Psoriatic

• Ankylosing Spondylitis
Case 8

42-year-old male medically free presented to ER with RUQ pain for 5 days, progressive
not radiating, not associated with yellow sclera, history of headache on and off, respond
to analgesic, aquagenic pruritus for the last 6 months.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
1. Make sure patient is stable.

2. Analysis of chief complaint:

Right upper quadrant pain: onset, course, duration, aggravating factor or relieving factor

Jaundice discovered – did the patient notice it, or was it someone else?
• Onset (what brought it on, how it started) • Time: • Duration • Fevers • Pale stools •
Itching • Steatorrhoea • Dark urine
Symptoms of chronic liver disease: encephalopathy, ascites, lower limb edema, Bleeding,
bruising

Headache: site, onset course duration aggravating factor or relieving factor, severity

Ask DDx:
- GIT: (GB stone, liver disease, malignancy):nausea, vomiting, diarrhea, constipation,
weight loss, Symptoms of chronic liver disease, encephalopathy, ascites, lower limb
edema, Bleeding, bruising
- Autoimmune: Arthralgia, Skin rashes (systemic lupus erythematosus), oral genital
ulcer
- Hematological (hyperviscosity, PV): history of tinnitus, blurred vison, history of
thrombosis, bleeding
- ID (hepatitis): fever, asks about any recent illnesses, eating from outside, contacts
with sick patient, Contaminated needles: • Intravenous drug abuse • Blood
transfusions • Tattoos • Ear/body-piercing • Needlestick injuries • Foreign
travel/contacts • Sexual history
- Constitutional symptoms (Fever, weight loss, anorexia, decrease appetites)
Surgical hx
Allergy
Social hx
Family hx
Exam:
Vitals(BP:95/60)
GI: jaundice, pallor, lower limb edema, ascites, stigmata of liver disease, clubbing,
hepatosplenomegaly
Cardiac examination
CNS examination, fundoscopy
Erythromelalgia
Investigations:
CBC, hematocrit, erythropoietin, RFT, LFT, ECG, chest x-ray, ultrasound abdomen,
hepatitis, anti-smooth muscle antibody, antimitochondrial antibody, JAK 2,
bone marrow biopsy

>>The patient found to have WBC 14, hemoglobin 17, hematocrit high, erythropoietin
low normal, d-dimer high, ALT and AST high

U/S abdomen shows hepartic vein thrombosis (Budd-Chiari)

What’s your Differential diagnosis?
• Viral hepatitis
• Autoimmune disease
• Budd-Chiari
• Ascending cholangitis
• Cholecystitis
• Polycythemia rubra vera

Q1: What other investigation would you like to order?

• JAK-2 mutation
• BM Bx

Q2: How to diagnose Polycythemia Vera?

• Men: Hb >16.5 g/dL or HCT >49%, women: Hb >16 g/dL or HCT >48%, or ↑ red cell mass
• BM bx → hypercellularity for age, trilineage growth, pleomorphic mature
megakaryocytes
• JAK2 V617F mutation
• Epo
• ± ↑ WBC, platelets, basophils; ↑ uric acid, leukocyte alkaline phosphatase, vit B12
• Peripheral smear → no morphologic abnormalities

Q3: What is the treatment?

Phlebotomy to goal Hct <45%, consider <42% in women
• Low-dose ASA in all Pts
• Hydroxyurea if high risk of thrombosis (age ≥60, prior thrombosis) or symptomatic
thrombocytosis (plt >1.5 × 106/μL), or if inadequate Hct by phlebotomy alone
• Ruxolitinib (JAK1/2 inhibitor) if poor response, intolerant of hydroxyurea
• Supportive: allopurinol (gout), H2-blockers/antihistamines (pruritus)

This patient need ICU admission, hematology and gastro referral, stabilize with
anticoagulation especially IV heparin due to possible plan for using thrombolysis or
percutaneous intervention to open the hepatic vein.

Q4: What is the WHO criteria for diagnosis of polycythemia vera?

Major: Bone marrow biopsy, Jak 2, high hemoglobin
Minor: erythropoietin low
Need 3 majors or 2 majors and one minor

Q5: How would you differentiate between primary and secondary polycythemia?
Primary: splenomegaly and decreased EPO
Secondary: hypoxemia, malignancy, high EPO

Q6: If the patient came back with high platelets and bleeding after treatment?
This is due to acquired von Wilbrand dysfunction need to stop aspirin and order
plateletpheresis
Case 9

25-year-old female referred to you in OPD from ophthalmology clinic for evaluation of
uveitis (pain ,redness, photophobia) to rule out systemic cause. She has had uveitis for 5
months.

She has bilateral neck swelling, painful skin rash in the lower limbs, dry cough, previous
history of bell’s palsy, history is negative for TB and syphilis.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
Analysis of chief complaint:

Uveitis: onset, course, duration, unilateral or bilateral, pain, discharge

Autoimmune symptoms: (Behcet's syndrome, Reiter's syndrom, ankylosing spondylitis,

IBD) joint involvement, skin rash, mouth or genital ulcers, hair loss, fatigue, DVT,
abdominal sx: pain tenderness, diarrhea

ID: (TB , syphilis) fever, night sweats, weight loss, contact with TB patient, history of
sexual contact or genital ulcer, hx of syphilis

Chest: (sarcoid): SOB, cough and chest pain

CVS: chest pain, arrythmias

PMHx, PSHx

Social: history of travel or sick contact, sexual, IVDU, alcohol

Family hx: autoimmune disease

Allergy hx

Exam:

o VS
o Uveitis, other eye findings: conjunctival nodules, lacrimal gland enlargement,
cataracts, glaucoma, papilledema
o Salivary gland swelling
o Lymphadenopathy
o CNS: Cranial nerve palsies
o CVS: Arrhythmias
o GI: Hepatosplenomegaly
 o Polyarthritis
§ Rashes, Maculopapular of nares, eyelids, forehead, base of neck at hairline, and
previous trauma sites
§ Waxy nodular of face, trunk, and extensor surfaces of extremities
§ Plaques (lupus pernio) of nose, cheeks, chin, and ears
§ Erythema Nodosum (component of Löfgren syndrome)

Investigations:

CBC, RFT, Ca, 1,25 vitamin D, LFT

HIV, HEP B AND C

HLAB27,HLAB51

ECG, , CXR, ECHO, sacroiliac x ray

Lab showed:high ca, high 1.25 d, low hemoglobin

Further Questions:

Q1: What is your differential diagnosis?

• Autoimmune: Sarcoidosis, IBD, RA, Bechet, AS, Psoriatic arthritis

• Infection: herpes, syphilis, TB, HIV

Q2: What is your diagnosis?

Sarcoid

Q3: What is the indication for steroids in sarcoid?

Pulmonary Sarcoidosis:

§ Worsening respiratory symptoms

§ Deteriorating lung function (assessed by serial testing q 3-6 months), as indicated by
one or more of: decreased TLC by 10% or more, fall in FVC of 15% or more, decreased
DLCO of 20% or more, or worsened gas exchange at rest or with exercise
§ Progressive radiographic changes (e.g. worsening interstitial opacities, cavities,
fibrosis with honeycombing) or development of signs of PHTN

Extra-pulmonary Sarcoidosis:

§ Ocular, neurologic, cardiac, renal (hypercalcemia) involvement

Q4: List 3 causes of erythema nodosum?

• Autoimmune: IBD, Sarcoid

• Infection: Streptococcus/TB

• Lymphoma

• Medication: OCP, sulfonamide, phenytoin

Case 10

22 years old female patient pregnant referred to you from OB to your clinic due to
thrombocytopenia.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

History:
Previous comorbidity: HTN, DM, anemia, CKD, CLD, heart disease
Ask about her current pregnancy: how many weeks, complication, follow up, previous abortion,
fetal death

Check symptoms:
Thrombocytopenia: easy bruising, gum bleeding , bleeding from any orifices

Differential diagnosis :
Pregnancy-associated causes
-Gestational thrombocytopenia: does she has any previous thrombocytopenia before pregnancy,
or in her previous pregnancy
- HELLP syndrome: pre-eclampsia (severe): severe headaches. Blurred of vision, epigastric pain,
nausea or vomiting, increase in oedema, seizure
-Acute fatty liver of pregnancy: jaundice, RUQ pain, decrease level of conscious

Independent of pregnancy:
-SLE, APL: alopecia, skin rash, joint pian, raynaud, recurrent abortion, recurrent DVT or thrombosis
-TTP: fever, renal (oliguria, hematuria, ankle edema ), and neurologic (seizure, decrease level of
consciousness), thrombocytopenia, hemolytic anemia ( pentad )
- HUS: Fever, bloody diarrhea, renal (oliguria, hematuria, ankle edema) , irritability, lethargy,
seizures
-ITP: (dx of exclusion)
-Infectious disease (e.g., HIV, HCV, EBV): recent respiratory illness, IVDU, sexual contact
-Leukemia: gradual onset of fatigue, weight loss, lymphadenopathy, fever, rigors
-Poor nutrition: folate or vitamin B12 deficiency- if she is taking her folic acid medication
peripheral neuropathy, LL weakness, history of autoimmune disorders, vegan diet, total or partial
gastrectomy, ileal resection, or celiac disease
-Drug: penicillin , heparin, antihistamine ( cimetidine ), NSAID
-Social: alcohol, blood transfusion, drug abuse, sexual Hx, recent travel, smoking
-Allergy
-Family Hx: autoimmune, TB, malignancy
-Surgery : bariatric surgery
Examiner
22 years old female patient medically free, primigravida, c/o headache, never had
thrombocytopenia before, no abortions, thrombosis, bleeding, no B symptoms, no new drugs, no
viral infection, no autoimmune disease, no transfusion, no family history of thrombocytopenia,
eating regular diet, no surgery, single sexual partner

Examination:
Vital signs: BP: 160/100, HR: 95
BMI
General: conscious, oriented, appearance, pallor, jaundice, facial rash
Gum bleeding, epistaxis, glossitis and angular stomatitis, bruising
LAP, LL edema
Chest auscultation
CVS: JVP, heart sounds
GIT: hepatosplenomegaly, abdominal pain
Autoimmune: rash, joint inspection and palpation, oral ulcer, signs of DVT
CNS: power, tone, reflexes , peripheral sensory loss, balance and gait disturbance

Give 6 DDx ?

Pregnancy-associated causes
1-gestational thrombocytopenia
2-HELLP syndrome , pre-eclampsia
3-acute fatty liver of pregnancy

independent of pregnancy:
4-autoimmune : SLE, APL
5-TTP
6- HUS
7-viral infectious (e.g., HIV, HCV, EBV)
8- leukemia: gradual onset of fatigue, weight loss, lymphadenopathy, fever, rigors
9- folate or vitamin B12 deficiency
10-ITP
11-drugs

Investigation:
CBC with differential : hgb and plt low
Blood film show : schistocyte 1%
Hemolytic workup (evidence of hemolysis)
RFT : Cr: 1.8
Urine analysis : proteinuria
DIC workup: PT, PTT: mildly elevated
Electrolyte, LFT
B12, folate
Auto-immune profile ANA, DsDNA
Serology: HIV, Hepatitis
What’s your diagnosis :

-MAHA most likely secondary to severe pre-eclampsia

What is the triad?

Coombs negative hemolysis – schistocyte – thrombocytopenia

Management:

Referral to OBG for delivery

Stabilize the patient, IV fluid, Mg sulfate

Control BP using methyldopa or labetalol

Further Questions:

After 2 weeks of delivery she was feeling good but her lab worse: PLT: (70 > 40 ) , Cr: ( 1.8> 2.5 ) ,
proteinuria worse, NO CNS symptoms, no rash or purpura, blood film still show schistocyte

Q1: What your differential diagnosis : ( MAHA )

- HUS
- TTP
- DIC
- Malignant hypertension
- Valve related
- Scleroderma renal crisis

Q2: What are the types of HUS?

1- Typical HUS: (Shiga toxin mediated HUS) follows a gastrointestinal infection

2- Atypical HUS: (compliment mediated HUS) is associated primarily with mutations or
autoantibodies leading to dysregulated complement activation.

Q3: What is the treatment of HUS?

*Eculizumab for atypical HUS

Q4: What is the mechanism of action of HUS?

Monoclonal antibody targeted against complement C5, inhibits the cleavage of C5 into C5a and
C5b and hence inhibits deployment of the terminal complement system C9.
Case 11
65-year-old male presented to ER with acute LL weakness for one day + chronic back-pain for
two months. Patient has history of lymphoma 9 years ago since treated
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. First make sure patient is vitally stable

2. Analysis of chief complaint

Weakness: When first noticed, onset of Sx, duration, progression, onset , site, pattern,
symmetrical or not, involve upper limb)
Predisposing events (eg trauma), aggravating/relieving factors, charcter (ascending or
descending)
Specific questions:
• Sensory disruption - determine sensory level
• Sphincter control - bladder & bowel
• Weakness - partial or total
• Flaccid or spastic?
• Autonomic dysfunction
• Proceeded by URTI
Associated symptoms:
• Pain in muscles, bone, joints
• Deformity
• Swelling, stiffness
• Loss of movement, loss of function (impact on daily activity, walking distance)

Back pain: (onset, duration, relieving/aggravating factors, referred)

Constitutional symptoms: (weight loss, loss of appetite, fever, night sweats)

Systemic review
CNS: headache, seizures, ptosis, bulbar symptoms
Respiratory/CVS: SOB, productive cough, chest pain
Autoimmune: skin rash, oral ulcer, genital ulcer, arthritis/arthralgia
GIT: dysphagia, nausea, vomiting, abdominal pain, bowel movement
Renal: dysuria, frequency, hematuria
ID: fever, hx of contact with TB patient, raw milk ingestion

PMhx: Tumours - 1* or 2* (breast, lung, prostate), infections, neurological disease, skeletal

deformities, disc prolapse, recent surgery (?haematoma), epidural/spinal anesthesia, recent
radiotherapy for malignancy?, autoimmune, neurological diseases
Allergy
Surgical hx, medications
Family hx
Social hx: marital status, occupation, sexual activity, travel, animals/pets, drug abuse
Examiner
65 years old male came to ER complaining of progressive lower limb weakness, started 2 days
ago initially distally than progressing to involve proximal muscles, ascending pattern,
associated with numbness, constipation and urinary retention.

Now he cannot stand, no weakness in upper limbs, there is history of back pain which has
also been progressive, started 5 weeks ago, around the thoraco-lumbar area, radiating to the
lower limbs, increases with lying down, walking, standing and more severe at night. Patient is
also complaining of easy fatigability, exertional dyspnea, night sweats in the last 3 month, no
weight loss.

Patient has hx of lymphoma with treated 4 cycle of chemotherapy, he has lost follow up in
the last year. Systemic review unremarkable.
Examination:
VS
General: pallor, jaundice, rash, ecchymosis, bruising, cervical and axillary LN
Local back exam: tenderness in lumber area, swelling, atrophy, deformity
CNS: Power, tone , reflexes , sensation in the lower limb, anal sphincter tone, cranial nerve
exam
CVS, Chest, Abdomen

Examiner:
3/5 weakness of both lower limbs, reduced anal sphincter
Examiner: What is the DDx?
• Transverse myelitis
• Spinal cord compression
• GBS
• Potts disease
• Prostatic metastasis
Investigations
CBC, RFT, LFT, ESR, CRP, PSA
MRI of spinal cord

Picture showing MRI back report: compression of T12/L1

Examiner: What is the dx?
Spinal cord compression likely due to metastasis

What is your management?

Non-pharmacological:
• Admit to ICU
• Nutrition
• Education
• Referral to neurosurgery
• Physiotherapy as tolerated
• Bladder and Bowel care (foley catheter, laxatives as needed)
Pharmacological:
• Dexamethasone
• Analgesia
• IV fluids
• Laxatives
• Radiotherapy
Further Questions
Q1: What are the red flags of back pain in this patient?
• Age
• Urinary/Bowel symptoms
• Neurological symptoms
• Fever
• History of malignancy

Q2: What is the staging system for lymphoma?

Ann-arbor staging

Q3: What are the poor prognostic factors for lymphoma?

• Age > 45
• Lymphopenia < 600
• Hgb < 10.5
• Alb < 4
• Male
• Stage 4
• Extra-lymphatic infiltration
CASE 12
65 year old male presents to ER with hx of fever for 7 days and SOB for 2 days.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
STABLE OR NOT
BP 100/90 HR 110 RR 33 TEMP 39 SO2 80 RA
FEVER + SOB ---- ISOLATE PT THEN CHECK VS
ABC, O2, 2 LARGE IV CANNULA (MOVIE)
LAB WORK: BASIC > CBC, LDH, d-dimer, FERRITIN, cultures

Patient is now STABLE now what do you want to ask in hx:

Analysis of Chief Complaint:

Fever: Onset, duration, course, the reading of temperature if measured, diurnal variation,
relieved by anti-pyretic. Exacerbating factors, Alleviating factors (paracetamol),
Rigors/shivers, Lethargy Night sweats, Weight loss, skin rash, LN enlargement.

SOB: onset, duration, course, relieving/aggravating factors, positional related,

cough, sputum, wheezing, sore throat, runny nose, chest pain, loss of taste, URTI

Associated symptoms: Hx of contact with sick or COVID 19 patient recently, hx. Of contact
with TB patient, recent travel., recent hospital admission, recent chest infection, or use of
antibiotics

Systemic review:

Cardio: chest pain, palpitation, orthopnoea, PND, LL edema, syncope

GIT: nausea, vomiting, abdominal pain, diarrhea

Neurology: syncope, dizziness, motor/ sensory deficit, vision, hearing

MSK: joint pain, muscle pain, skin rash, ulcers, back pain

Past medical hx, Past surgical hx

Social hx: travel hx, hx of IVDU, sexual hx, hx of ingestion of raw milk occupation hx, contact
with COVID, TB patient

Allergy hx, Vaccinations hx, Family hx.

Examiner:
Fever for one week, intermittent, resolves with paracetamol, hx of geralized bodyache,
diarrhea, sore throat, loss of smell and taste. He wife recently tested positive for COVID-19.
EXAMINATION:
1- WEAR PROTECTION MEASURES , FACE SHIELD, GOWN, GLOVES, and N 95
2- ISOLATE PATIENT
3- VS TEMP 39
GENERAL: THROAT EXAM AND NASAL MUCOSA, SKIN RASH, LN, JVP
CHEST: FOR BILATERAL CREPITATIONS
CVS
ABD
INV:
CBC, RFT, LFT, INR/PTT, BG, LACTATE, CARDIAC ENZYMES D-DIMER, FERRITIN, LDH, CRP, IL6
SWAB for COVID-19, Influenza and MERS
ECG
CXR: BIL INFILTRATION (ARDS)
CT: SUBCUTANEOUS EMPHYSEMA
HOW YOU WILL MANAGE
A- ADMIT THE PATIENT TO ICU

B-NON PHARMACOLOGICAL
1- ISOLATE
2- O2
3- REFERRAL TO ID
4- PRONE POSITIONING

C- PHARMACOLOGICAL
1- Antibiotics
2- Dexamethasone
3- Hydration
4- Antiviral (Raltegravir)
5- Pain control
6- DVT Prophylaxis
7- Nebs
FURTHER QUESTIONS

Q1: HOW COVID CAN AFFECT LUNG

1- ARDS
2- EMPHYSEMA AND PNEUMOTHORAX
3- PULMONARY EMBOLISM
4- CYTOKINE STORM
5- CARDIOGENIC PULMONARY EDEMA
6- PLUERAL EFFUSION

Q2: HOW TO DIAGNOSE ARDS

BERLIN CRITERIA: NEW BIL INFILTRATION
NO CARDIAC CAUSE
PF RATIO < 300 (PaO2/FiO2)
Q3: CONTRAINDICATIONS TO PRONE POSITIONING
1- SPINAL INJURY
2- PREGNANCY
3- SHOCK
4- FRACTURE
5- HYPOTENSIVE
6- HAEMORRHAGE
Case 13

32 YEAR OLD MALE K/C OF MAJOR DEPREESION DISORDER PRESENTED TO ER WITH SOB.
HE INGESTED 20 TABlLETS OF BISOPROLOL AND 30 TABLETS OF VERAPAMIL.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

ASSESS IF PATIENT IS VITALLY STABLE

Hx by examiner : VS T.36 BP 80/40 HR 40 SO2 85, BILATERAL BASAL CREPITATIONS

What’s Next: (ABCDEFG)

Airway > secure airway
Breathing > place patient on oxygen
Circulation > BP monitor and ECG insert 2 large cannula and start IV fluid and draw labs
(CBC, RFT, LFT, LA, ABG, BNP and Toxicology screen)
Decontamination
Elimination > eg; charcoal (if within first 4 hours)
Focus therapy (give antidote if available)
Get Toxicology center help
Place patient on monitor (MOVIE)
Call for ICU help

-FOLLOW ACLS (BRADYCARDIA)

1. ATROPINE 3 TIMES
IF PATIENT’S BP AND HR DO NOT IMPROVE ->

2. TRANSCUTANEOUS PACING
IF REFRACTORY TO PACING ->

3. START EPINEPHRINE OR DOPAMINE

4. REFER TO CARDIOLOGIST IN CASE HE NEEDS PACEMAKER

History by examiner: PATIENT SATURATION STILL 80% ON 10 L O2 -NON REBREATHING
PATIENT NOW STABLE: ASK ABOUT HISTORY

For drug ingestion :

Hx FROM WITNESS, FAMILY MEMBER
-Time of drug intake prior to presentation
- Amount (how many tablets)
- Suicidal attempt
- Concomitant Intake of any other medication, HX OF OTHER TOXINS, ANY BOTTLES
AROUND HIM AT HOME
-ANALYSIS OF SOB: onset, duration, course, relieving /aggravating factors, positional
related
Cough, sputum, PND, orthopnea, SYNCOPE, CHEST PAIN, PALPITATION, HAEMOPTYSIS

Assess for end organ damage: fever

- Acute liver failure: jaundice, RUQ abdomen , Abdominal distention
- Encephalopathy symptoms: N/V, alter mental state, focal neurological symptoms,
weakness, sleepiness
- CNS: seizure . weakness , focal neurological defect , blurred vison , tinnitus
- Pulmonary edema: SOB , cough
- CVS: SOB ,orthopnia , chest pain , palpitation
- Renal: urine volume and color
- GIT: abdominal pain
- Hematological: bleeding from any orifices (hematemesis, epistaxis), bruises

Social history: smoking , Alcohol , Illicit drug use, previous suicidal attempt, occupation,
sexual hx, marital status
Family history, Allergy
Medical and surgical Hx: comorbidity and home medication

Review results as they become available (e.g. laboratory investigations)

Re-assess regularly and after every intervention to monitor patient’s response to
treatment.
EXAM
VS GENERAL
CONSCIOUSNESS, PUPIL EXAM
EXAMINE FOR FOCAL DEFICIT
CVS S1 S2, CHEST FOR CREPITATIONS
RAISED JVP
FURTHER MANAGEMENT
NONPHARMACOLOGICAL:
-ADMIT TO ICU
-REFERAL TO PSYCHIATRIST, CARDIOLOGIST
-FREQUENT MONITORING FOR BLOOD SUGAR AND ELECTROLYTES

PHARMACOLOGICAL:
-LAVAGE/CHARCOAL IF WITH IN 1-4 HRS
-LASIX " IF VOLUME OVERLOADED "
-CALCIUM CHLORIDE (antidote for CCB)
-GLUCAGON (antidote for BB)
-INSULIN

* IF NOT STABLE (CARDIOGENIC SHOCK):

1- ECMO
2- INTRA AORTIC BALLOON PUMP
FURTHER QUESTIONS:

Q1: WHAT MEDICATIONS CAN BE CLEARED BY ACTIVATED CHARCOAL?

• PARACETAMOL
• CCB
• SSRI

Q2: NAME 2 SUBSANCES THAT CAN NOT BE CLEARED BY ACTIVATED CHARCOAL:

• ALCOHOL
• CORROSIVE
• ANTIFREEZE
• METALS (LITHIUM/ZINC)

Q3: WHAT IS THE DIFFERENCE BETWEEN CCB AND BB REGARDING GLYCEMIC EFFECT?
CCB ---HYPERGLYCEMIA
BB ---- HYPOGLYCEMIA
REMEMBER IN TOXICOLOGY
ABC DEF
DECONTAMINATION
EXAMINATION
FIND ANTIDOTE
Case 14
65 year old male known case of COPD diagnosed 6 years ago on ipratropium and as
needed albuterol. He presented to OPD complaining of increasing SOB on exertion.
Required ER admission 2 months ago for COPDE.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
Analysis of Chief Complaint:
1-SOB: onset, duration, character, radiation, course, related to exertion,
relieving/exacerbating factors (exertion/exercise, pollen/chemicals)
Severity: Exercise tolerance>> Quantify how far the patient can walk before stopping due
to shortness of breath (e.g. number of stairs, distance on the flat)
Variability: Is the SOB continuous throughout the day, intermittent or progressively worse

Associated symptoms (trigger)

Respiratory: wheeze or stridor, cough: productive or dry, sputum, hemoptysis, chest pain
ask about post nasal drip, OSA symptoms
ID: fever , sinusitis , URTI ,
Cardiac: palpitation, chest pain, syncope, hx of arrhythmia, hx of CAD, hx. Of cardiac
disease
GIT: GERD, heart burn, nausea, vomiting, dyspepsia, diarrhea, jaundice, hx of liver disease
Malignancy Hx: Fever, weight loss, anorexia, family hx of malignancy
Elicits risk factors for PE/DVT: calf pain/swelling, recent travel, recent surgery, family
history of clotting disorders, malignancy, oral contraceptive pill (if female patient)
Pregnancy (if female patient)
Medication

PMHx:
Ask about COPD :
Increase sputum production, charcter, contact with sick patient
How has it affected activity (patient noticed that he has to stop walking after 100 meters)
Hx of acute exacerbation in the past
If acute exacerbation in the past ask if required hospitalization
Current medication and if increase in use of inhalers
Vaccination

Other disease: cardiac disease, arrhythmia, thyroid disease/surgery • Anxiety disorders •

Diabetes mellitus
Social: smoking, alcohol, ocupation, sexual activity, IV drug use, travel hx, stress levels,
exercise
Allergy/vaccinations/blood transfusion
Family hx: any cardiac, lung disease, malignancy, hereditary disease, thyroid disease,
sudden death, arrhythmias
What is your your DDx:
• Exacerbation of COPD
• Cardiac disease (MI/CHF)
• Vascular (PE)
• Malignancy (Lung Ca)
Examination:
General mental status, VS, conscious, alert, oriented
Assess if in respiratory distress, saturation on RA
Hand cyanosis, tar staining, flapping tremor
Volume exam: JVP and lower limb edema

Resp: air entry, breath sounds, percussion for dullness

CVS: Auscultation, evidence of right sided heart failure (left parasternal heave and
elevated P2)
Investigations:
CBC, RFT, CE, d-dimer, PBNP (2670)
ABG: ph 7.39 pco2 40 hco3 26 pao2 50 (type 1 respiratory failure)
Sputum cx
Chest x-ray: bilateral hyperinflation, flat diaphragm, narrow mediastinum
CT: emphasematous changes (thin wall) at upper lobes
ECHO: increase pulmonary pressure
PFT : interpretation ratio < 70% --- obstruction
FEV ( 31 ) (severe)
TLC 123 (high due to increased residual volume)
DLCO 48 (low due to emphysema)

Interpretation: severe obstructive pattern going with COPD with emphysema.

What is his GOLD classification?

Group 3 categary D
What is the long term management for a patient with COPD?
Nonpharmacological (ANERVES)
1. Smoking Cessation
2. Long term oxygen therapy
3. Inhaler education
4. Pulmonary rehabilitation
5. Vaccination
6. Nutrition support
Pharmacological:
Optimize bronchodilator (Add LABA/ICS to LAMA)

List the interventions that have been shown to decrease mortality in COPD:
• Smoking cessation
• Long term oxygen therapy
• Lung volume reduction surgery
• Pulmonary rehabilitation
Further Questions
Q1: What are the mechanisms of hypercapnia if patients with COPD receive oxygen and
saturation is higher than 92%?
1. V/Q mismatch
Perfusion is increased to areas where there is emphysema because of the higher oxygen
content, however as these areas have no functioning alveoli there is no gas exchange and
blood is effectively shunted.

2. Haldane effect
Increased oxygen concentration leads to hemoglobin leaving CO2 and attacheing O2. This
leads to hypercapnia.

3. Decreased breathing drive

Q2: What are the components that predict survival in patients with COPD?
BODE Index
1. Body mass index (B)
2. Degree of airflow obstruction (O)
3. Dyspnea (D)
4. Exercise capacity (E)

Q3: What is the strategy to help patient quit smoking?

5A: Ask Have you thought about quitting smoking?
Advise Discuss the harmful effects of smoking
Assess Willing to quit
Assist Provide a suitable action plan to help quit smoking
Arrange Follow up

*Nicotine gum, patch

Contraindication: cardiac disease
Side effects: nausea and vomiting
Case 15
36 year old male presents to ER with chest pain and fever.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
1. First make sure patient is vitally stable, ABC, MOVIE
Examiner shows ECG: pericarditis
And patient is vitally stable

2. Analysis of chief complaint:

Fever: onset, duration, course, the reading of temperature if measured, diurnal variation,
relieved by anti-pyretic. Exacerbating factors, alleviating factors (paracetamol),
rigors/shivers, lethargy, night sweats, weight loss, skin rash, lumps or bumps.

Chest pain: onset, duration, course, relieving/aggravating factors, positional related (if it
is decrease with sitting forward)
Any dyspnea, cough, sputum, wheezing, sore throat, runny nose,

Associated symptoms: Hx of recent cardiac surgery, contact with sick or Covid 19 patient,
hx. of contact with TB patient, recent hospital admission, recent chest infection, or use of
antibiotics

Systemic review:

Cardio: chest pain, palpitation, orthopnoea, PND, LL edema, syncope

GIT: nausea, vomiting, abdominal pain, diarrhea.

Neurology: syncope, dizziness, motor/ sensory deficit, vision, hearing

MSK: joint pain, muscle pain, skin rash, ulcers, back pain

Past medical hx, Past surgical hx

Social hx: travel, IVDU, sexual hx, hx of ingestion of raw milk, Occupation

Allergy, Vaccinations
Family hx.

Examination :
VS, General

Focus on CVS
Pericardial rub, signs of tamponade (hypotension, distant heart sounds and raised JVP)
Investigations
CBC, RFT, cardiac enzymes (raised troponin)
ESR, CRP, Full septic screen (covid –mers –h1n1)
Chest x-ray
Echo: pericardial effusion, EF normal and NWM
What is the Dx?
Myocarditis
Management :
Nonpharmacological: (ANERVES)
• Admit patient
• Nutrition (low salt diet)
• Educate about disease
• Referral to Cardiology
• Vaccination appropriate
• Physiotherapy as tolerated
• Smoking cessation, age-appropriate cancer screening

Pharmacological
• NSAID
• Colchicine (improves symptoms and decreases rate of recurrence)
• Heart failure treatment
• Treat if tamponade (pericardiocentesis)
Further Questions
Q1: Any role for sreroid: No

Q2: When to use steroid?

1. Refractory pericarditis
2. NSAID contraindication (advanced CKD)
3. If cause is autoimmune disease or TB
Case 16
39 year old male presents to the clinic with sob for 2 wks, CXR shows right pleural
effusion.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
History:
Chief complaint analysis:
SOB: onset, duration, alleviating factors, exacerbating factors: (exercise,
pollen/chemicals), severity (when walking upstairs or with minimal activity, or at rest)
Variability: Is the SOB continuous throughout the day
Ask about any recent illness, chest pain, cough

Differential diagnosis :
Infection: fever, cough, sputum, chest pain, sinusitis, recurrent infections, contact with TB
patient
CVS (HF): orthopnea, ankle edema, PND
GIT: symptoms of liver cirrhosis, abdominal pain (pancreatitis)
Malignancy: hemoptysis, weight loss, night sweats, hoarseness
PE/DVT risk factors: travel, malignancy, recent surgery, pregnancy
Autoimmune disease: arthritis, rash, Raynaud’s syndrome, skin tightness, dry mouth and
eye, oral, genital ulcer
Hematological (coagulopathy): bleeding from any orifice, bruises, diet
Drug history: nitrofurantoin, amiodarone
Family history: lung cancer, ischemic heart disease/myocardial infarction, pulmonary
embolism, autoimmune disease
Social history: smoking (active and passive): quantify pack years, alcohol, Illicit drug use
Exposure: occupational exposure > coal, dust, asbestos, fumes, molds (e.g. hay)
Animal exposure: Pets (especially birds), farming, any animals involved in hobbies
Tuberculosis exposure, sexual HX, recent travel
Activities of daily living/functional assessment and impairment due to SOB
Social hx, recent travel
Sexual HX
Surgical Hx
Examination
VS temp 37.5, saturation 97% room air
General: no tracheal shift
Resp:
Palpation: decrease right chest movement
Percussion stonny dullness on the right side
Auscultation: decreased right air entry
Investigations
CBC, RFT, LFT, CE, PBNP, LDH, Autoimmune Profile
Thoracocentesis: send for cytology, LDH , protein, BG, pH, RF and culture
Interpretation: exudative pleural effusion
Further Questions
Q1: List 3 DDx
1- TB
2- Malignancy
3- Rheumatoid

Q2: List 5 DDx of predominant lymphocytosis pleural effusion:

1- TB
2- Malignancy
3- Sarcoidosis
4- LAM
5- Medication
6- Chylothorax

Q3: What is the management of rheumatoid pleural effusion?

• Refer to Rheumatologist – NSAID ifsymptomatic
• If severe -> therapeutic thoracentesis
• Long term complication – lung entrapment (fibrosis)

Q3: List lung diseases associated with rheumatologic diseases:

• Pleurisy
• ILD
• Rheumatoid nodule
• Kaplan syndrome
• Pulmonary hypertension
• Vascular (PE)
Case 17
18 years old female referred from emergency department due to severe muscle
weakness and dizziness, ER doctor just received critical value of K: 2.7.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Assess if patient is stable, ABC, MOVIE

2. As he has severe hypokalemia, start management in ER: IV KCL before taking history

3. Analysis of chief complaint:

-Muscle weakness and dizziness (duration and onset)
-Episodic attack suggestive periodic paralysis
-Aggravating factors likes recent exercise
Associated symptoms: chest pain, SOB, cough
-Hx of nausea, vomiting or diarrhea
-Hx of any medical illness, history of previous attack of muscle weakness or dizziness,
-Family hx of similar condition, HTN, or hypokalemia
-Symptoms suggestive of hypothyroidism
-Symptoms suggestive of autoimmune disease
-Any history of drug abuse or drug used (especially diuretics, salbutamol)
-Prolonged fasting or large carbohydrate intake

4. Systematic Review, Constitutional symptoms

5. PAM FOSS (alcoholic, smoker, sexual history)

Examination
VS, BMI
Conscious level and GCS
General examination for dehydration, muscle wasting skin turgor
CNS: for CN
Upper and lower limb for weakness, power and reflexes
CVS: for S1+S
Abdomen: tenderness, masses , bowel sounds
Investigation
CBC with diff, RFT, LFT, ABG, Ca, PO4, Mg , urine electrolyte, INR, PTT urine AG, ECG,
Chest x ray , autoimmune profile, urine ca, urine screening for diuresis
TSH

Examiner: urine lytes showed high potassium and chloride (both >20)

Management:
Nonpharmacological: (ANERVES)

• Admission
• Nutrition (high K diet)
• Education
• Referral for psychiatric, Nephrology
• Vaccination
• Smoking Cessation, Screening, Stop the medication

Pharmacological:

• IVF
• Correct electrolytes (K and Mg)

Further Questions:

Q1: Indication for IV KCL replacement:

• Symptomatic
• Severe hypokalemia
• Not tolerating orally
• ECG finding

Q2: mention 2 finding in ECG for Hypokalemia

• Prolonged QT
• U waves
Case 18
18 years old female patient medically free presented to ER with fever and headache.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Make sure patient is stable, ABC, MOVIE.

2. Analysis of chief complaint:

Analyze the fever inform of onset, duration, diurnal variation responding to antipyretic
or not of there is any associated symptoms or aggravated or relieving factor
analyze the headache, site, onset, duration , aggravated or relieving factory association
of photopia or photonia

History of same episodes before, history of travel, history of vaccination , history of raw
milk ingestion, contact of sick patient , history of neck swelling suggested
lymphadenopathy

Any rashes, history of medication, history of orbital sinusitis

Previous history of meningitis

3. Systematic Review, Constitutional symptoms

4. PAM FOSS (alcohol, smoking history)

Examination

Vital signs including orthostatic hypotension, conscious level, orientation

GCS level

Neck: for Nuchal rigidity

Neurological examination For cranial nerves, cerebellar examination, gait

Upper and lower limb for power, reflexes

Kernig’s sign,Brudzinski’s sign

Skin finding: petechial rash, genital or oral ulcer for (HSV)

Investigation
CBC with diff, RFT, LFT, ESR, CRP, INR, PTT, Septic workup

CT brain, LP for gram stain and culture, cells , glucose, total protein, pressure

Management:
Nonpharmacological: (ANERVES)

• Admission (droplet isolation)

• Nutrition
• Education about the prophylaxis for contact
• Referral for ID& Neurology
• Vaccination
• Smoking Cessation, Screening

Pharmacological:

• Ceftriaxone 2G Iv q12 hr. + vancomycin 15-20 mg/kg IV q12 hr.

• Acyclovir
• Dexamethasone 10mg Iv q6hr for 4days (before or at time of First Ab dose)
• DVT prophylaxis

Further Questions:
Q1: When to do CT brain before LP?

• Immunosuppression

• Hx of CNS disease

• New-onset seizure

• Focal neuro finding

• Papilledema

Q2: If patient allergic to penicillin what are your choice for AB?

Ciprofloxacin 400mg q8hr or Aztreonam 2g q6h

Q3: What you will do as prophylactic for contact with this patient?

Rifampin 600 mg po bid for 2 days or Ciprofloxacin 500 mg po once or ceftriaxone 250
mg IM once
Q4: WHEN YOU WILL DO Vancomycin Trough level?

Before the forth dose by 30 minutes.

Q5: What is your Target for Vancomycin Trough level?

Between 15-20

Q6: When you will stop isolation:

24- 48 hour after the First Abx dose

Case 19
25 years old male patient free medically presented to ER with transient loss of
consciousness for 10 seconds.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Assess if patient is vitally stable, ABC, MOVIE

2. Analyze chief complaint:

Transient loss of consciousness for how long, history of similar episodes before,
witnessed or unwitnessed, any aura before or prodromal symptoms, any loss of
sphincter control, any abnormal movement, what he was doing during or before LOC,
any known trigger, any symptoms post-attack, any associated symptoms likes
palpitation, chest pain, or orthopnea

3. Systematic Review

Starting by cardiac symptoms likes chest pain, dyspnea, or PND

Any palpitation, or lower limb swelling

Any neurological symptoms like headache, numbness, seizure before or weakness

Any medication

Any family history of similar attack

4. PAM FOSS (alcohol history, smoker history, sexual history)

Examination

General appearance for body build, cyanosis, pallor or jaundice including GCS

Vital signs: including pulse character and regularity, BP in both arms, RR, Spo2,
orthostatic vitals

NECK for JVP

Cardiac sounds for any abnormal visual pulses, scar, any abnormal sounds or murmurs
with maneuver

CNS examination: motor, sensory, reflexes, CN

Chest: for pulmonary overload

Abdomen: for tenderness, organomegally and bowel sounds

FINDING: systolic murmur at left third intercostal space that increases with valsalva
maneuver and decreases with lying flat.

Investigation:

CBC, RFT, LFT, proBNP, INR, PTT, ECG

Chest x ray

Echocardiogram: septal thickening, systolic anterior motion (SAM) of mitral valve

Management:

Nonpharmacological: (ANERVES)

• Admission (he is stable no need for admission)

• Nutrition (avoid dehydration)
• Education (avoid any strength exercise, family counseling and screening)
• Referral to Cardiology
• Vaccination
• Smoking Cessation, Screening

Pharmacological
1. If symptomatic, use beta-blockers. May cautiously add diuretic if persistent Sx of
CHF. If progresses to end-stage disease with systolic dysfunction – treat as your
usual CHF pt. If asymptomatic, do not need to use meds (except BB in young pts w
severe LVH).
2. Interventions – septal myomectomy, alcohol septal ablation, dual-chamber pacing.
ICD to prevent SCD.
3. Family genetic screening – echo.
Risk Factors for Sudden Cardiac Death
1. Sustained or non-sustained VT
2. Family hx of sudden cardiac death
3. Unexplained syncope
4. Failure of BP to increase with exercise
5. LV wall/ septal width > 30mm

Further Questions:
Q1: What is the characteristic murmur of HOCM?

Systolic murmur : crescendo-decrescendo at left lower sternal border increasing with

valsalva maneuver and standing +- mild to late or holosystolic murmur of MR at apex

Q2: What are the indications for ICD in HOCM?

• Previous episode of VT/VF, NSVT

• Family history of sudden cardiac death

• Unexplained syncope

• LV wall > 30mm

• Failure of systolic blood pressure to increase from peak >20mmHg with exercise
Case 20
65 years old male patient presented to ER with severe abdominal pain associated with
nausea and vomiting.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Assess if patient is vitally stable, ABC, MOVIE

2. Analyze chief complaint: abdominal pain, site, character, severity duration and onset
associated with diarrhea or constipation related to food

Nausea and vomiting: onset, duration bloody or only food in content

Any history of jaundice, coffee ground vomitus, hematemesis, or melena

Any history suggestive cardiac cause like chest pain, palpitation, orthopnea or PND
any chronic illness before , any history of gall stones before

3. Systematic Review, Constitutional symptoms

4. PAM FOSS (alcohol use, smoker, sexual)

Examination

Vital signs and BMI

General appearance: for jaundice, pallor, or cyanosis

HEENT: sign of dehydration, or stigmata of liver disease

Abdomen: any tenderness, masses or organomegally

Chest: air entry

CVS: abnormal sounds

Investigations:

CBC, RFT, LFT, Amylase, Lipase, Ca, Mg, Po4, ESR, CRP, INR, PTT, ABG, ECG

Chest and abdominal x ray

US abdomen

Interpretation: cholestatic picture with evidence of GB stones on U/S abdomen, CBD is

not dilated

Management:

Nonpharmacological: (ANERVES)

• Admission
• Nutrition (keep NPO)
• Education
• Referral to Gastro, GS for cholecystectomy
• Vaccination
• Smoking Cessation, Screening

Pharmacological:

• Hydration
• Analgesia

Further Questions:
Q1: List five complications of acute pancreatitis:

• Systemic: ARDS, abdominal compartment syndrome, AKI, DIC

• Metabolic: hypocalcemia, hyperglycemia, hypertriglyceridemia

• Fluid collection (ACUTE FLUID collection, or pseudo cyst)

• Pancreatic necrosis

Q2: How would you assess severity?

Use one of the following scores: BiSAP, Ranson’s, APACHE II

Q3: What are strong predictors for choledolithiasis?

CBD stones on imaging, bilirubin >4

Q4: What drugs can cause pancreatitis?

• ACEI, Azathioprine, pentamidine, statins, thiazides, dapson, estrogen,

furosemide, Isoniazid, valproate

Q5: After discharge by 4 weeks patient had road trffic accident. CT abdomen was done
and he was found have a pancreatic cyst 7.5 cm in size. What will you do?

• No need for treatment if asymptomatic

Special Thanks:
*Fakeeh OSCE course organizers
*The authors of this work