KANAAN AL SHAMMARI, R4 EXAMINER FORM HISTORY STATION {A 25-year-old Saudi business man presents to your clinic complaining of weight loss, vague dull right upper ‘quadrant abdominal pain and jaundice for the last one month Please fill the table below: (8 minutes for this station) ‘COMMUNICATION MANNERS: 1. Introduces him-herself/ Explains task for the patient 0 0.25 2. Attentive to patient's answers [Acknowledging of patient 0 0.25 HISTORY RELATED QUESTIONS 3. Associated symptome(abdominal swelling, other swellings, ° @O generalised fatigability, lethargy, tremor) Gi aympioms(stool colour change, loss of appetite, ematemasis) | 9 | CD . Jaundice ( intermittent, persistent) 08 Biliary obstruction: pale stools, dark urine, and pruritis 0 Hypercoaguable state( leg swelling, Chest pain, and SOB) © 1 ° 0 0 0 ‘Symptoms suggestive of chronic infection( fever, sweating, cough) @. Viral hepatitis: blood transfusion, food exposure, sick contact, travel history 10. Social history( smoking, alcohol intake) 11. HIV risk: drug abuse, sexual exposure ‘THE 2 MOST LIKELY DIAGNOSIS 42. Hepatic carcinoma, and Cholangiocarcinoma, 0 05 THE 2 MOST IMPORTANT CONFIRMATORY INVESTIGATIONS, 13. Abdominal ultrasound, or CT abdomen, and ERCP o oF Over all approach to the task PLEASE DO NOT WRITE ON THIS SPACE: GR iageerie7 -| 88 eSEXAMINER FORM EXAMINER'S NAME: var? SORTOREATION WANTERS anna — acon] War done ia a OTT ETT 7 a} | ZAtientive fo plient’s anewers “Acknowledging of patient o 025 ee TABTORY RECATED QUESTIONS RE i eating od i ak tania? : oe a aT ET 7 a 7 i pete ooo 7 3 ; aya op RaT FL Wa F a os — | ¥. Any Fisiory of ong standing reflux symptoms? 0 OF “Oy a oo, oP, aT SET 7 a5 5 Ra ikany at pant ewang COAT pT? 7 @ 7 To WaT 7 ee Fa a TRS ae ea, ET : att 2, PHI (EGD, asitwna, oi bees) o & ¥ 2 eta: NSA, ipo eras, TeRGRS 7 Cy = Ta Rleigy BIO. BopY, SaaTONAT ATO, MIMDCOTUCTTTS ove: IW 7 (6) FORT RG eoroniial Diagnoses ‘What would bo the next stop in ihe workup of his pationt? TEGD and Esophageal biopey (rom Tid and lower exophague Neod> 76 Eosinophil! HPF) { ESsmophc ophaGis O | 2 0 1 | 2 Gero wan, peptig stcture FMontion 2 (two) possible next management slops for Wis patent? Refer to alergist ana clean 3. Aels suppression wih PPL 2 Topical swatowod contcosterics ° 1 @ 4. Sarmetal iti f03 etinaon et 5. Etophagealdiation “Over air approach tothe task ° 7 | PLEASE DO NOT WRITE ON THIS SPACE:KANAAN AL SHAMMARI, R4 EXAMINER FORM EXAMINER'S NAME: 25 year-old lady who presented with decrease vision in right eye for 3 days duration Please fill the table below: (8 minutes for this station) ‘COMMUNICATION MANNERS 7. Introduces him-hersel Explains task for the patient 0 0.25 05 2, Aitentive to patient's answers /Acknowledging of patient o 0s sy HISTORY RELATED QUESTIONS 15. Onset and progression change in vision, 0 1 ev “Severity of visual aculy by changes especially color o w z 5, Assodaied symplom of per-orbtal pain with eye movement o @ z . Any similar past hx of disturbed vision & improvement, triggered by factors including exercise, infection, fever, ° oO 7 ‘exposure to high ambient temperatures, and psychological stress ( uthoffs phenomena) [7 CNS and others complaints, such as Imb weakness, = | numbness, neck pain on flexion, vertigo, Diplopia, Gait o 1 aK @ disturbance, Biadder problem 8, Systemic inquiries: fever, joint pain, skin rashes, viral ° ees Cc Ss) 2 infection, head trauma, Vitamin B12 deficiency 8. Medications and medical history 0 7 THE MOST LIKELY DIAGNOSIS: o 70 Mulliple Sclerosis with Optic Neurtis a os oO _ Oo © ‘THE 2(two) MOST IMPORTANT CONFIRMATORY INVESTIGATIONS 11, MRI ~ Brain/orbit & visual evoked response o 05 42, Lumber Puncture 0 0 Over all approach to PLEASE DO NOT WRITE ON THIS SPACE:EXAMINER FORM PHYSICAL EXAMINATION STATION 3: MITRAL REGURGITATION KANAAN AL SHAMMARL R4 PLEASE FILL THE TABLE BELOW: 8 MINUTES FOR THIS STATION T ‘Physical examination manners 7 [Introduces sel &@ explains task to the patient 0 | 025 | 5 2 | Kind to the patient & covers the patient o | 025 (6s Physical examination technique t 3 | Postion the patient at 45 degrees ot ey | Tnspection of the precordium Tor scars, deformifies.and pulsations oy Tt Te 3 _| Palpation of the precordium for apex beat, parastemal heave and thls o | 4 & | Auscultation ofthe diferent cardiac areas ov] 4 6 t “Turing the patient to the eft lateral position & Nistening fo milal area using the doa a ee) ‘Siting the patient forward & listening t the le 3""& 4 intercostal spac eae P11 Radiation of the murmur to the axl carotids 0 7 | ‘Description of the auscultatory Hndings ‘Most ikely diagnosis 72_| Mitral regurgitation o | 65 CS) Signs of severe disease i | 13 | Pulmonary hypertension (loud P2), left ventricular failure (S3), sok ST 0 (oy 7 | ‘Over all approach to the task C z S PLEASE DO NOT WRITE ON THIS SPACE:EXAMINER FORM PHYSICAL EXAMINATION STATION. 3: QRGANOMEGALY. KANAAN AL SHAMMARI, Rt PLEASE FILL THE TABLE BELOW: 8 MINUTES FOR THIS STATION Physieal examination manners | T [introduces sof & explains task o the patent 0) 028 Z| Kind'te the patent & covers the patient o | 025 | O55 Physical examination techoique 3 | ingpection of the abdomen Tor distension, scars, sae, Brusing, veins, hernia a ©) 7 _| Asking for location of abdominal pain, Superficial palpation, Eye contact 0 1 ay ‘S| Balpation for hepatomegaly, relation to breathing, percussion forliver span ot | ay | Paipation & percussion for splenomegaly, paliont on he right side positon o> 4 7 | Bimanval palpation for renal enlargement, percussion over renal mass 77> t |] @y] _| Percussion for ascites by shifting dullness 0 4 GY 9 | Auscullation for bowel sounds, hepatic bruit, renal bruit, sp 0 7 5 ‘Abdominal ndings 70 | Repatesplenomegaly oo | C87 | 2 differential diagnosis 77” | Chronic iver disease with poral hypertension o | 026 | Gay 72 | Myeloprolieratve disorders & ymphoprolferatve cisarders: CMI, lymphoma oo Teystemic signs to support each diagnosis 19 | ae, IBDG, patra ners Wephaderapehy, paler of os [4d L [Peer atTaperoacnto me pproach to the ta TD PLEASE DO NOT WRITE ON THIS SPACE:io the pate itary, vasculitis, paraneoplasti> [TContinmatorytest 73 | Nerve conduction studiesDe Yowsu EXAMINER FORM mena) tet | | CONSULTATION EXAMINER'S NAME: KANAAN AL SHAMMARI, R4 Please fill the table below: ©. (8 minutes for this station) HISTORY POINTS: DIAGNOSTIC EVALUATION; 7, Patient Ago: malignant nodules more frequently in patients 50 7, Smoking history in pack years: 0 0s Oo 2. Symptoms of cough/SOB/ Hemoptysis Fever 0 05 ww 3 Symptoms of weight loss/anorexia 0 ow Symptoms of Bleeding per rectum, altered bowel habits 0 eee 5. Family hlo malignancies o a 6. Occupation history( e.g. asbestos exposure) a 08 ® © years of age or older Risk Factors: (Hisiory of smoking, asbestos exposure, [amily history, previously diagnosed with malignancy) @. Radiographic features: (size, border, calcification, attenuation, } growth, location) MANAGEMENT: 10. Determine probability of malignancy ( High, intermediate, or low) ,and surgical risk TT, Nodute size: <3 om: Serial CT chest ° Ae = 3 cm: PET scan or sampling procedures, and if: 72, Malignancy suspected in low surgical risk: Surgical excision T Malignancy suspected in high surgicat risk: Serial CT chest No malignancy suspected: serial CT chest ‘Over all approach to the task 7) PLEASE DO NOT WRITE ON THIS SPACE: SKANAAN AL. SHAMMARI, R4 Please fill the table below: (Sittinutés for this station) Communication Manners Not ] incomplete | Complete Done | 7 | Greel patient appropriately 0 025 | 2 | Explains the reason forthe visit Eee 0 025 | 3°] Explores how much the paint krows about his agnosis (eg since when | : j ® ‘he knows, what could be the risk factors, his opinion about this disease) 4 | Uses eye contact and voice tone to show care, and concer 0 05 qa 5 | Explores patient's fears and stigmas 0 0s Gy) | © | Emmpiiasizes the patients right to Keep his diagnosis sticly confdental (with exception of his wife) but asks ifhe would lke one of his close 0 os © relatives to know his diagnosis in case of emergency situation 7 Discuss the need to test is wie & the impact efthaton her ow heal and | i oO her current pregnancy. Discuss the need to test his three year old daughter. 8 | Avoid medical language, uses simple language 0 6 | @ | 9 | its risky behaviors and encourages complete abstinence from any ‘i 7 O possible high-risk behavior to reduce transmission 10 | Discusses how HIV affects patients’ Ife but emphasizes, that tis 0 ; @ considered at present as a chronic but treatable disease ike diabetes 71 | Explores pattents readiness to receive treatment needed and the importance of his compliance to therapy and followup (treatmentimproves | 0 1 survival & quality of life) , 72 | Invites patient io ask questions 0 05 | 13 | Provides summary of what has been said “To 1 | 14 | Describes treatment plan and follow-up 0 1 (©) ‘Over all approach to the task o] 7 z PLEASE DO NOT WRITE ON THIS SPACE:Examiner Name: KANAAN AL SHAMMARI, R4 A 23 year old male presefited’ fo Emergency room with Headache A- Examiner: What further information you would ike to know? MARKS score( $) 3) | will take a dotaled history regarding the headache + Nature of headache. ~~ ‘+ Associated symptoms: fever, neck pain, photophobia, nausea, vomiting, seizures, weakness, blurring of vision, ++ Risk factors such as immunosuppression, alcoholism, neurosurgery, CSF leak ..ete 8. Examiner: the was associated with fever in, What is your most like diagnosis? (Acute meningitis) ‘2 MARKS score ( ‘2s 2) C+ Examiner: what are the causes of acute meni MARKS ScoRE(}/ 3) ‘+ Infectious (the commonest) Ut Bacteria Sreptococeus pneumoniae gneumocacis), + Neisseria meningitidis (meningococeus). 2 Haemophilus influenzee (haemophilus). + Listeria monocytogenes (listeria)... -~ 1B Viral: enteroviruses Protozoal = Fungal Non-infectous: drug induced (e.g NSAIDS), SLE , neoplasms ((Streptococcus pneumoniae, Neisseria meningitidis, and, less often, Haemophilus influenzae and {group 8 streptococcus are the most likely causes of community-acquired bacterial meningitis in otherwise healthy adults up to the age of 60)) DB z itive sian you will check on physis score( 2/2) © Vitals, skin rash = + Meningea! signs: Nuchal Rigidity, Kerrig’s Sign and Brudinsk?s Sign ‘= CNS examination & fundoscopic exam &—~ E. Examiner: What important investigations you would like fo order?__ 4 MARKS score( YI 4) ‘= Basic blood test: CBC, eects <= Blood cutture,. L - CCT brain prio to LP if age >60, seizures, focal deficit, immunocompromised CSF analysis (minimal tests includes :) = Cell count, differential = Protein--- Glucose = Grem stain ,C/S and Z-N stain Le POR ‘Others tests depends on the possible risk: (in immunocompromised patie special tests for fugal steria and amebic etc.. F. Examiner: will show the CSF analysis of acute bacterial meningitis and ask the candidate if this is what helshe expects to see and how to di ri ibercualus? SCORE( Y/ 3) eee Normal This Viral Bacterial Tuberculosis patients Cellcount | 60% of | 20 mg/dl Normal tow Low blood glucose Protei To 4.5 g/l Sail Normal Elevated | Elevated Gram stain | negative positive = Positive = G- Examiner: H score ( $/ 3) IV antibiotics ‘+ Must be immediately after CSF is obtained or when lumbar puncture is delayed + The choice is directed against the most ikely pathogen based on patient age and host factors + For commonest organism in heathy adults (3 generation cephalosporin vancomycin) Use of dexamethasone 10 mg IV q 6 hx 4 days prior to or with antiotcs in cases of ‘Streptococcus pneumoniae s confmed orf he organism is unknown Fluid management (Careful management of fuid and electrolyte balance is important, since both cover. and under-nydration are associated with adverse outcomes TOTAL SCORE: 120This patients [Viral | Bacterial | Tuberculosis Cell count 1760 + Way 14 Cell type Polymorphs | 1. Pe,| 7 ay “1 OO | Glucose 20 mg/dl A, tL Ly Protein ‘Sg/ N-FlT MD Gram stain positiveAFIX LABEL Nan AL | Sharrow , EXAMINER FORM EXAMINER'S NAME: Procedure Station- Intubation 1 Please ask the candidate to describe 2 of the demonstrated items. 2, Please ask the eandidate to list and demonstrate the steps in the management a patient with Respiratory Arrest and has a Pulse on a manikin. 5. Please evaluate the candidate individual task according (othe following scoring system: © Mark 0: not performed / mentioned (© Mark I: performed / mentioned incompletely Mark 2: performed / mentioned completely & competently 4. Please evaluate the eandidate for the overall approach to the task according to the following scoring system: @ Mark 1: Poor © Mark2: Merginal © Mark 3: Good © Mark 4: Very Good 5, Please oliserve the candidate and do not inte pt him during the procedure. Piease fill the table below: (8 minutes for this station! Perfor Performed b Competantly | fully competent incompetent ‘Sep 1: Ava eefitiatos breathing) __ Veavate eneal ani Conthu.” rescue tL iveath every Wot performed orKANAAN AL SHAMMARI, R4 Examiner Name: 60 year old lady presented to emergency department with generalized weakness, and found to have serum Sodium 115 mmol/L ‘A-Examiner: What further information you would like to know? 3 MARKS, ‘Score ( = Respirator 13) + twillta take a detailed history: @ The candidate needs to ask in the history about medication especially diuretic and anti- psychiatric medication ‘eardiac ,Gastro, Hypothyroid, and CNS symptoms = | will do detailed physical exam to assess pationt volume status A- Examiner: Patient's volume status is dry What fu Score F investigations you need to order? 2 Marks: 12) Serum and Urine Osmolality, Urine electrolytes Renal function test, RBS, TSH, Usie seid, and Chest x-ray B- Examiner: His laboratory investigation revealed: {Please handle lst to candidate) Serum Osmolality 250 mmol Urine Osmolity 150 mmolit Urine Sodium 100 mmol Urine Chloride 80 aid Urine Potassium 75 mmov! Renal function test, Sevum uri acid, RBS, lipid profile, TSH, and Chest- x-ray All normal __ What is the possible explanation for this feature mention 4 causes? 4 Marks Score (3 14) C- Examiner: Suppose this Salt lose nephropathy, Cerebral salt wasting, Osmotic diuresis Mineralocortioid deficiency patient was euvolemic and Serum Osmolality 250 mmol , and Urine Osmolality 200 mmoV, and Urine sodium 100 mmol, Urine K 13 mmot/, and Urine Cholride 12 mmol (Please handle list to candidate) ‘What is your diagnosis? 2 Marks Seore ( 12) ‘Syndrome of inappropriate ADH secretion (SIADH)E- Examiner: What are the major criteria of STAD! 2-Marks Score( 12) ~ Diagnosis by exclusion patient should had normal adrenal, thyroid, pituitary, renal apd aN use = Serum osmolality fess than 280 ~ Urine osmolality more than 150 Urine sodium more than 40 D- Examiner: Your patient presented with drowsiness and generalize weakness how you manage hier? 2Marks Soore( 12) ~ Hypertonic saline at rate 0.5 mmol /L/ Hour correction, not more than 12 mmo L per 24 hours in addition to furosemide in order to enhance free water excretion. ‘What is the main concern for rapid correction of the sodium to normal level? 2.Marks Score( 12) = Main concer not to induce (central pontine myelinolysis) E- Mention 3 (three) risk factors to developed central pontine myelinolysis? 3 Marks Score( 13) Liver transpfant ‘Alcoholics Malnoutished patient Hypokalomic patients Bum Elderly women Hypoxemia ‘TOTAL SCORE: f 120KANAAN AL SHAMMARI, R4 Examiner Name: A 50-year-old male presented to ER with 3 hours history of severe retrosternal chest pain ‘A; Examiner: What further information you would like to know? 3 MARKS B. Score (3 13) | will take a detailed history regarding the chest pain: ‘+ Confirm chest pain: OPORST ‘+ Associated symptoms: SOB, presyncope/syncope, nausea, vomiting, diaphoresis, fever, chills, URTI ‘+ PMHx and cardiac risk factors: DM, HTN, Lipid, smoking - Examiner: The chest pain was pleuritie, improves with sitting. What is your most likely diagnosis? MARKS Score (“} 13} (Acute Pericardtis) D- Examiner: what are the causes of Acute Pericarditis? LIST 3 MARKS Score(3 13} 0 Idiopathic Infectious: Viral: coxsackie, HIV, adenovirus, Bacterial: strep, pneumococcal, staph, legionella, TB, Fungal, syphilis © PostMipercardetony, © Inlammatry. connective tissue symptoms (LE, hheumatc fever, RA, FM) © Metabolic: renal disease (uremic), thyroid symptoms (myxedema) 2 Malignancy: B symptoms, history of malignancy (breast/lung, lymphoma) 8 Druge: procainamide, NF, hydralazine, dtantin 8 Radaton E- Examiner: what are the important positive signs you will check on physical exam? = MARKS Score (2/2) + Vials + CVS: pericardial sub and evidence of pericardial effusion (distant heart sound, dullness over the left posterior lung field “Ewart's sign” F- Examiner: What important investigations you would like to order? 3 MARKS. score (3 13) a Investigations to confirm the diagnosis: = ECG: Diffuse ST elevation with PR depression, concave up (T wave inv after resolution of ST elevation) + Cardiac enzymes to r/o ACS ( + in 20% in myopericarditis) bb: Investigations to look for the etiology: Creatinine, ANA, RF, CXR, HIV, TSH, viral cultures (low yield) © Also echo to rlo tamponadeG- Examiner: will show the typical ECG of Acute Pericarditis and ask the candidate if this is what he/she expects to see and how to differentiate from MI? 3 MARKS Score (3 13) ST segments in pericarditis = diffuse elevation = concave up = <5mm = no reciprocal changes — ST segment and T wave inversions do not occur together in Pericarditis ~ No Qwave evolution in Pericarcitis STEMI ST Elevation is concave down with Q waves and T wave wersions. PR usually norm. H Examiner: how you will manage the patient? 3 MARKS Score(.2 3) ‘Treat underlying etiology Aspirin 650 gah or NSAIDS like ibuprofen 600 mg tid or Indomethacin 25-50mg QID ‘HE colehicines 0.5 mg bid Close follow-up ie. 1 week Atypical patients may require pericardiocentesis Glucocorticoids if autoimmune, uremia or refractory ‘Avold anticoagulants Consider pericardiocentesis for tamponade, purulent effusion, persistent effusion > 1 wk Pericardiectomy in refractory cases TOTAL SCORE: 2.0/20