Professional Documents
Culture Documents
Part II
Part II
Part II
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.
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)
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
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
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
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
Hx from examiner : patient had unprotected sex when he was 15. Other hx was negative.
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.
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.
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:
MSK: joint pain, muscle pain, skin rash, ulcers, back pain
Social hx, travel hx, hx of IVDU, sexual hx, hx of ingestion of raw milk occupation hx,
contact with COVID, TB patient
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
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
MSK>> skin lesions, mouth ulcers, signs of joints inflammation joints, back examination
Investigation
Covid 19 nasal swab, influenza swab / mers-cov / H1N1 swab, sputum cultures/ sputum
PCR
Covid 19 pneumonia
Management?
Nonpharmacological: (ANERVES)
• ID /pulmonology consultation
Pharmacological:
• 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?
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
1- First make sure patient vitally stable, and order ECG (ABC, MOVIE)
- 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
Cardio: chest pain, palpitation, SOB, orthopnoea, PND, LL edema, carotid cause of
syncope (shaving, dissection, tight collar) hx. Of cardiac disease
Past surgical hx
Social hx: travel hx, hx of IVDU, smoking alcohol hx sexual hx, occupation hx.
Examination
General appearance: respiratory distress, central /peripheral cyanosis, eyes for pallor/
jaundice
MSK>> skin lesions, mouth ulcers, signs of joints inflammation joints, back examination
LN examination, thyroid
Examiner:
Investigation:
CBC, RFT , LFT , Chemistry, electrolytes, BG, cardiac enzymes, ABG, pro-BNP, TFT, CXR,
ECG, ECHO, CT brain
Echo report: severe aortic stenosis, EF 40%, CXR: cardiomegaly, pulmonary edema
1- Stroke
2- Atrial fibrillation
3- Heart failure
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)
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
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.
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
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.
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).
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
Further Questions:
- 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?
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
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
• Myasthenia gravis
• Lambort Eaton Syndrome
• CIDP
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
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
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)
Circinate balanitis: moist well-demarcated erosions with raised borders involving the
penis
Reactive arthritis
Pharma: NSAID/steroid/DMARD/Biological
• Respond to NSAID
• 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.
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
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.
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:
ID: (TB , syphilis) fever, night sweats, weight loss, contact with TB patient, history of
sexual contact or genital ulcer, hx of syphilis
PMHx, PSHx
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:
HLAB27,HLAB51
Further Questions:
Sarcoid
Pulmonary Sarcoidosis:
Extra-pulmonary Sarcoidosis:
• Infection: Streptococcus/TB
• Lymphoma
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 :
Management:
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
- HUS
- TTP
- DIC
- Malignant hypertension
- Valve related
- Scleroderma renal crisis
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
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
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.
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:
MSK: joint pain, muscle pain, skin rash, ulcers, back pain
Social hx: travel hx, hx of IVDU, sexual hx, hx of ingestion of raw milk occupation hx, contact
with COVID, TB patient
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
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
2. TRANSCUTANEOUS PACING
IF REFRACTORY TO PACING ->
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
PHARMACOLOGICAL:
-LAVAGE/CHARCOAL IF WITH IN 1-4 HRS
-LASIX " IF VOLUME OVERLOADED "
-CALCIUM CHLORIDE (antidote for CCB)
-GLUCAGON (antidote for BB)
-INSULIN
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
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
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.
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)
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:
MSK: joint pain, muscle pain, skin rash, ulcers, back pain
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
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
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
2. As he has severe hypokalemia, start management in ER: IV KCL before taking 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:
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
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
Examination
GCS level
CT brain, LP for gram stain and culture, cells , glucose, total protein, pressure
Management:
Nonpharmacological: (ANERVES)
Pharmacological:
Further Questions:
Q1: When to do CT brain before LP?
• Immunosuppression
• Hx of CNS disease
• New-onset seizure
• Papilledema
Q2: If patient allergic to penicillin what are your choice for AB?
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?
Between 15-20
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
3. Systematic Review
Any medication
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
FINDING: systolic murmur at left third intercostal space that increases with valsalva
maneuver and decreases with lying flat.
Investigation:
Chest x ray
Management:
Nonpharmacological: (ANERVES)
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?
• Unexplained syncope
• 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
2. Analyze chief complaint: abdominal pain, site, character, severity duration and onset
associated with diarrhea or constipation related to food
Any history suggestive cardiac cause like chest pain, palpitation, orthopnea or PND
any chronic illness before , any history of gall stones before
Examination
CBC, RFT, LFT, Amylase, Lipase, Ca, Mg, Po4, ESR, CRP, INR, PTT, ABG, ECG
US abdomen
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:
• Pancreatic necrosis
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?
Special Thanks:
*Fakeeh OSCE course organizers
*The authors of this work