Professional Documents
Culture Documents
Part 1
Part 1
Part 1
Table of Contents
Legend of Abbreviations
Introduction
Case 1. Adrenal Insufficiency
Case 2. SIBO
Case 3. Dermatomyositis
Case 4. Behjet
Case 5. Unstable hyponatremia
Case 6. Nephrotic Syndrome
Case 7. Febrile Neutropenia
Case 8. Acute Chest Syndrome
Case 9. Cerebral Malaria
Case 10. Ulcerative colitis flare
Case 11. MEN 1
Case 12. Amenorrhea
Case 13. Acute Kidney Injury
Case 14. Palpitation
Case 15. Myopericarditis
Case 16. Churg Straus
Case 17. Cystic Fibrosis
Case 18. Sepsis
Case 19. Myasthenia Gravis
Case 20. Esophageal Varices
Case 21. Guillain Barre Syndrome
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.
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
45-year-old female patient presented to ER with Hx of nausea, fatigue and generalized
weakness (Na = 119).
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
4. PAM FOSS
The patient was recently discharged 10 days ago from hospital after 2 weeks admission
for COVID pneumonia. The course of her disease was complicated by hypoxia and
required ICU admission and high flow nasal canula. She was started on therapeutic dose
enoxaparin and prednisolone 40, and was discharged on tapering dose, however she
stopped steroid by herself as she felt much better and was afraid from the side effects of
steroid. The patient has no symptoms suggesting of autoimmune, pituitary, TB, or
deposition disease. What examination findings would you look for?
Examination
VS (low BP) (low HR) (low BS)
Marked hypotension, Hyperpigmentation (1ry)
Look for signs of pituitary disease: (neuro, cranial nerve)
Investigation
CBC, Chemistry, ESR, CRP, serum cortisol, synactin test
Random serum cortisol: (less than 3 confirmed adrenal insufficiency, more than 18
exclude, 3-18 order à synactin test)
Management:
• Pharmacological:
-Hydrocortisone 100 mg IV TID (stress dose)
-Treat with 0.9% normal saline
-DVT prophylaxis
Further Questions:
Q1: What is your diagnosis?
Secondary adrenal insufficiency
Q2: Will you give hypertonic saline? No
Q3: ER doctor called you with incidental finding 2.7 cm incidentaloma for another
patient. What are the Features of benign disease?
Q4: What are the hormones you need to screen for in a patient with adrenal
incidentaloma?
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
3. PAM FOSS
Past Medical: irritable bowel disease, DM (detailed HX), celiac, IBD, lactose intolerance
Medications: PPI, SRI
Social: alcohol
Examiner: 53 year old k/c of DM type 1 on insulin therapy since childhood, the patient’s
diarrhea was intermittent for years, increased in the last 1 ½ year and become more
prominent in the last 8 months, not bloody, 4-5 times per day, sometimes increases with
meals, associated with abdominal cramps, nausea, bloating, fluctuating and early satiety,
weight loss 4kg.
Medications include insulin (Aspart and glargine), pantoprazole, and multivitamins
No laxative, NSAID
No Hx suggesting IBD, or chronic infection
He is a smoker, not using alcohol.
Investigation
-CBC, Chemistry, (LFT, Renal), ESR, CRP, serology, TFT
-Work up for celiac disease (Serum TTG), Anemia work up (B12, FA, Iron profile)
-Fecal calprotectin (less than 150 less likely IBD) Stool analysis and CX, stool osmolarity
-Hydrogen breath test
-Upper and lower scope + jejunal aspiration + Bx
Management:
What is the management for SIBO?
• Non-pharmacological: (ANERVES)
-Nutritional (high fat, low carbohydrate, low fiber)
Rule out fat and vitamin soluble malabsorption (sublimination)
-Education
-Nutritionist Referral
-Vaccination
-Exercise
-Smoking Cessation, Screening
• Pharmacological
ABX: Metronidazole for 14D
Control DM
Further Questions:
Q1: What is your DDx?
• Gastric bypass
• Scleroderma
• Atrophic gastritis
• DM
• Hypothyroidism
Q5: What is the difference between osmotic and secretory diarrhea? Give 2 examples
of each?
• Osmotic: osmolar gap > 100, improve with fasting, e.g. lactulose
intolerance/laxatives
• Secretory: osmolar gap < 50, e.g. IBD, malignancy
Case 3
40-year-old female presented to ER with lower limb weakness for two months.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
*Malignancy
*Stroke
5. PAM FOSS
Examiner: 40-year-old female medically free complaing of weakness of the thighs and
arms especially in the morning, difficulty to comb her hair, and to stand from her chair
for the last two months. She has skin rash on her trunk and joint pain in both hands and
the right knee and she lost 10 kg in the last 2 months.
Examination
-VS
-Skin exam
-Full Rheumatological exam
-Full CNS exam
-CVS, RESP, GIT
Investigation
-CBC, RFT, LFT, ESR, CRP, CK
-EMG, pan CT, mammogram for malignancy
-MRI lower limbs and muscle biopsy from site of inflammation
Management:
• Nonpharmacological (ANERVES)
-Admission
-Nutrition
-Education
-Rheumatological referral
-Vaccination
-Exercise
-Smoking cessation, age appropriate cancer screening
• Pharmacological
-Steroid 1mg / kg +- sparing agent
-Vit D, Ca++
-Sun block
-DVT prophylaxis
Further Questions:
Q1: What are 3 causes of myopathy?
• Dermatomyositis
• Polymyositis
• Steroid induced myopathy
• Rhabdomyolysis
• PMR: stiffness not weakness, dramatic rapid response to steroids, elevated ESR,
normal CK
• Dermatomyositis: weakness, gradual response to steroids, normal or slightly
elevated ESR, elevated CK
• Respiratory failure
• Dysphagia
• Refractory to immunosuppressive treatment
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
4. PAM FOSS
Family HX of thrombophilia, autoimmune disease or malignancy
Social: smoking, alcohol, unprotected sex
Examination
-VS
-General: Skin, LN, pathergy test
-Mouth: ulcers
-Genital exam: ulcers
-Lower limbs: Picture of erythema nodosum
-Eyes: Picture of hypopyon (indicate anterior uveitis)
-CVS, Resp, CNS
Investigation
-CBC, Chemistry, ESR, CRP, coagulation
-Urine analysis
-ANA, RF, ANCA, complement
-Spiral CT chest with contrast (to r/o pulmonary artery aneurysm before giving anti-
coagulation)
Management:
• Nonpharmacological (ANERVES)
-Admission
-Nutrition
-Education
-Refer to Rheumatology
-Vaccination
-Exercise
-Smoking Cessation
• Pharmacological
-Steroid, immunosuppressant
-Anticoagulant: before starting order spiral CT Chest to r/o pulmonary artery
aneurysm
Further Questions:
Q1: What is your DDX?
• Behjet
• IBD
• Vasculitis
• Antiphospholipid
• Behjet
• TB
• Sarcoid
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
Further Mx
• ICU/Neuro referral
• Admit to ICU
• Hypertonic saline (150 ml/q15 mins)
• Monitor lytes Q2-4 hours, target increase in Na (6-8 meq)
• DVT prophylaxis
----------------------------------------------0-------------------------0------------------------------------------
4. PAM FOSS
Examiner: 60-year-old male K/C of HTN on candesartan and thiazide, he had history of
generalized fatigability for 5 days with poor oral intake.
No Hx of other chronic disease or other drugs like steroid or antidepressant, no Hx
suggesting of hypothyroidism or adrenal insufficiency, no Hx of vomiting or diarrhea.
What examination findings will you look for?
Examination
-VS
-General Exam
-FULL CNS exam
-Chest
-CVS
-GIT
Investigation
-CBC, Renal, Liver, lactate, ABG, Cardiac enzyme
-Serum, urine osmolarity, urine Na
-ECG, CT Brain
Management:
• Nonpharmacological: (ANERVES)
-Admission to ICU
-Nutrition
-Education (Stop offending drugs (anti-HTN))
-Refer to Neurology
-Vaccination
-Exercise
-Smoking cessation, age appropriate cancer screening
-Frequent Na level measurement (Q2-4 H)
• Pharmacological:
-Hypertonic saline
-DVT prophylaxis
Further Questions:
Q 1: What is the definition of status epilepticus?
*DIMS*
• Drug (alcohol, sympathomimetic, antibiotic)
• Infection (encephalitis, meningitis)
• Metabolic (hypo Mg-Na, uremia, hyper Ca, hepatic encephalopathy)
• Structural (epilepsy, hemorrhage, tumor)
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
3. PAM FOSS
-Sexual history, PMHX, medication use like NSAID, gold, penicelliamine, heroin
-Social history
Examiner: 25 years old female referred to you because labs showed significant
proteinuria, she noted frothy urine, no Hx of hematuria, dyuria,fever, frequency, there is
history of lower limb edema, no abdominal swelling or SOB, no history of headache or
blurred vision, no nausea, vomiting, pleuritic chest pain, neuropathic pain, no Hx of URTI,
no history of constitutional symptoms or jaundice.
There is history of joint pain, alopecia and malar rash, no seizure or abortion.
PMHX was –ve , no history of medication , smoker, alcoholic, no history of ilicit drug
abuse, she is single , works as secretary, +ve fmHx of breast cancer, no family history of
autoimmune disease or allergy. No blood transfusion, tattoo or sexual contact.
Further Questions
Q1: Mention 4 DDX of nephrotic syndrome?
• Primary: MC, membranous, FSGF
• Secondary: systemic disease (DM, amyloidosis)
-Infectious (hepatitis, malaria, syphilis, HIV)
-Malignancy as solid and hematological
-Drug as NSAID
-Autoimmune: SLE, RA, Sjogren syndrome
• Pharmacological:
-ACEI, statin, diuretic
-Start HCQ
-Induction = pulse steroid + CYC or MMF
-Maintenance = steroid + MMZ OR AZA
-DVT prophylaxis
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
4. PAM FOSS
-PMHX: About AML when diagnosed, last time recived chemotherapy, Hx of previous
febrile neutropenia, ABX prophylaxis
-Travel, contact with sick patient
-Ingestion of raw milk ingestion, food intake
-Contact with animals, mosquito bite
-IV drug abuse, alcohol, smoking
-Vaccination, allergy, social, occupation
Examination
VS
Look for central line, mucositis, cellulitis, anal /perianal redness, rash.
Chest, CVS, Abdomen, CNS
Examiner: 30 years old male pt diagnosed AML 4 moth ago, received 3 cycles of
chemotherapy in remission, last chemotherapy 2 weeks ago, presented with fever one
day (39 documented at home) on 2 occasions. Associated with chills, decrease oral
intake, and nausea, SOB, dry cough, he is on fluconazole and acyclovir.
He is not on ABX or GCSF
Investigation
CBC-D, coagulation profile, full septic screen
chest x-ray: showed RT homogenous opacity
Management:
• Nonpharmacological: (ANERVES)
-Admission
-Nutrition
-Education
-Refer to Oncology/Pulmo/ID
-Vaccination
-Exercise
-Smoking cessation, age appropriate cancer screening
• Pharmacological:
-Start normal saline infusion
-Antibiotic (Tazo/Vanco)
-DVT prophylaxis
Further Questions:
Q1: Indication of vancomycin in febrile neutropenia?
• Hypotensive
• Pneumonia
• Mucositis
• MRSA colonization
• IV catheter related
• Soft tissue infection
• Cellulitis
• Patient on ABX prophylaxis
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
4. PAM FOSS
-PMHX: Ask about SCA (vaso occlusive crisis, ACS, blood transfusion /exchange, previous
admission, icu admission, visits to ER, hydroxuria, folic acid, pain control)
-Social history, occupational history
-History of travel, vaccination, allergy
Examiner: 26 years old male k/c of SCA presented with pleuritic central non-radiating
chest pain, started one day ago, progressive to severe, increases with cough, associated
with SOB with minimal exertion, productive cough and generalized body ache.
Other systemic review unremarkable
He is on hydroxyuria, folic acid and has had frequent ER visits due to painful crisis and
required multiple admissions -last admission was 4 months back, no icu admission. He
received simple blood transfusion in that admission.
Negative surgical history, negative family history
Non-smoker, no history of travel or allergy.
Further Questions
Q1: What is your DDx?
• Acute chest syndrome (ACS)
• Pneumonia
• PE
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
4. PAM FOSS
History of drugs, allergy, vaccination, occupation, social
History of alcohol, smoker, iv drug abuse.
Family Hx of autoimmune or malignancy
Examiner: 32 years old Saudi male solider, presented to ER with fever for 2 weeks, on
and off associated with chills, documented 39 responding to paracetamol.
He was referred to you because he did not respond to supportive care. Today he
developed generalized tonic colonic seizure, lasted 4 minutes, post ictal dark urine, no
focal deficit, no neck pain, no history of raw milk ingestion, no signs of infection of head,
chest, GIT, renal. No history of oral ulcer, no skin rash, photosensitivity, arthritis,
arthralgia, no family history of malignancy or rheumatological disease.
No history drug abuse, alcohol, no contact with sick or TB patient, married, no Hx of
extra-marital sexual contact.
Non-smoker, no history of travel or allergy.
Further Questions
Q1: What is your DDx?
• Cerebral Malaria
• Meningitis TB
• Neurobrucellosis
• Viral encephalitis
• Pharmacological:
-IVF
-IV dexamethasone
-IV artesunate
-DVT prophylaxis
Case 10
24-year-old male patient presented to ER with Hx of UC presented with Bloody diarrhea
- 10 times.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
4. PAM FOSS
-Use of antibiotics, NSAIDs
Examiner: 24 years old male pr k/c of UC diagnosed 2 years back on 5-ASA, c/o bloody
diarrhea with urgency for last 4 days around 10 times per day.
2-3 flare/ year, last flare 4 months ago managed by steroid, last colonoscopy upon
diagnosis (2 years ago). What examination findings will you look for?
Examination
-Vitals
-Abdomen: tenderness, distention
-Chest: crepitations
-MSK: hand look for arthritis, sacroiliac tenderness
-Rash: erythema nodosum, pyoderma gangrenosum
Investigation
-CBC-D, Anemia workup (Iron profile, Vit B12/Folate), Chemistry, Coagulation profile
-Stool analysis and CS, Stool for ova and parasite, C. Diff toxin PCR
-Fecal calprotectin
-PPD, hBsAg
-Chest x ray and Abdominal x ray
Management
• Nonpharmacological: (ANERVES)
-Admit to medical ward
-Nutrition (Keep NPO), Intake/output/stool chart
-Education
-Refer to Gastro for sigmoidoscopy, surgery consultation for possible toxic
megacolon
-Vaccination
-Exercise
-Smoking cessation, colon cancer screening
• Pharmacological:
-Start hydrocortisone or methyl-prednisone
-DVT prophylaxis (SCD)
Further Questions
Q1: After 3 days, still patient has bloody diarrhea, patient not responding to meds,
what is your further mx?
• CT abdomen
• Refer to GS
• Start anti-TNF/cyclosporine
Q2: Patient improved after 5 days post anti-TNF, what is your mx?
• Nonpharmacological:
-Nutrition
-Education
-Refer to Gastro f/o 2-4 weeks (TMP level to follow in clinic to start azathioprine)
-Vaccination
-Exercise
-Smoking cessation, screening for colon cancer and osteoporosis
• Pharmacological:
-Continue tapering steroids
-Ca & Vitamin D
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
History
1. Analyze chief complaint:
-Symptoms of hypercalcemia: polyuria, abdominal pain, constipation, n/v, weakness,
depression, psychosis
-Ask about causes:
*immobilization
*hyperthyroidism: weight loss, heat intolerance
*adrenal insufficiency: hypotension, hypoglycemia
*MEN
*Malignancy/lymphoma: weight loss, loss of appetite, cough)
*TB: night sweats, contact
*MM: bone pain or fracture, renal failure , symptoms of anemia
*Sarcoidosis: rash, sob, arthralgias
*Drugs: thiazide, vitamin D, Lithium
-Headache: onset, duration, relieving and aggravating factors, associated symptoms like
blurred vision, dizziness
3. PAM FOSS
Family Hx of malignancy, hypercalcemia
• Primary Hyperparathyroidism
• MEN1
• MM
Further Questions:
• Age<50
• Ca level >1 above upper limit
• Renal stones
• Elevated Cr
• Hypothyroidism
• Recurrent laryngeal nerve injury
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
History
1. Analyze chief complaint:
-Amenorrhea: duration, regularity of menses, frequency, amount
-Ask about causes:
- hypothyroidism or hyperthyroidism
- Prolactinoma: galactorrhea, headache, blurred vision, change in libido
-Infertility
- Hx of drugs: antipsychotic, metoclopramide
- Hx of diet or anxiety
- Hx of OCP
- Premature ovarian failure: dryness of vagina , hot flushes
- Polycystic ovarian syndrome: acne, hirsutism, weight gain
- Cushing: stria, weakness, buffalo hump
- Hx of chemotherapy or radiation
- Past Hx of chronic disease, depression
3. PAM FOSS
- Family Hx of amenorrhea
- Smoking
- Social: married, number of children
Examiner: 36 years old female referred to you with Hx of amenorrhea for 3 months.
Previously her period was regular, she is medically free, no change in appetite or weight,
no Hx of medications. She reports mild headache but no visual symptoms and mild
galactorrhea for the past 2 months.
What investigations do you want to order?
-Pregnancy test, CBC-D, Chemistry
-Hormones: TFT, LH, FSH, Cortisol, Prolactin was 800
-Brain MRI: revealed 1.2 cm adenoma
Further Questions
Q1: What is your diagnosis:
Macroadenoma
• Non-pharmacological: (ANERVES)
-No need for admission
-Nutrition
-Education
-Refer to endocrine, ophthalmology for visual field test
-Vaccination
-Exercise
-Smoking cessation, Screening: MRI after one year
• Pharmacological:
Dopamine agonist: cabergoline or bromocriptine
• Refractory to medical mx
• Co-secretion of GH (acromegaly)
• Persistent neurological symptoms
Q4: What is the management if failed both surgical and medical mx?
Radio-therapy
Q5: If after a few weeks, patient presented to ER with N/V, CN palsy and severe
headache what would be your Dx?
Pituitary Apoplexy
• Hydrocortisone
• Thyroid replacement if low free T4
• Urgent Surgical referral (Neurosurgery)
Case 13
63-year-old male k/c of DM, HTN, IHD admitted with acute limb ischemia s/p catheter
intervention with stenting and using contrast 2 days ago. Developed AKI. Referred to you
for your management
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
History
1. Analyze chief complaint:
-Pre-renal: nausea, vomiting, diarrhea, dehydration
-Renal: contrast, recent use of drugs: abx, ACE, anti-fungal, NSAID
-Post-renal: stone, BPH, urine retention
-Complications related to intervention: bleeding, hematoma
-Infection: Hx of flank pain, dysuria, frequency, change in urine color
-Autoimmune: joint pain or rash
3. PAM FOSS
-DM, HTN, IHD (control, medication and follow up)
-Hx of CKD
-Social Hx: alcohol, drug abuse, unprotected sex Hx of travel or contact with sick pt
-Family Hx of renal disease
-Allergy
Examination
-Vitals
- General: periorbital or LL edema, lymph node, rash, arthritis
-Examine site of surgery: hematoma or bleeding
-Abdomen: suprapubic tenderness, flank tenderness, renal bruit
-Chest: crepitations
Investigation
-CBC, Chemistry, Coagulation profile Serology, autoimmune profile, CK
-Urine analysis, Urine chemistry
-Renal us, Chest x ray, ECG
-Urine analysis shows hematuria with no RBC;
• CIN
• Rhabdomyolysis
• Cholesteol embolism
• Non-pharmacological: (ANERVES)
-Patient already admitted
-Nutrition, I/O chart
-Education (avoid nephrotoxic medication)
-Refer to Nephrology
-Vaccination
-Exercise
-Smoking cessation, age appropriate cancer screening
• Pharmacological:
-NS (target urine output > 200 ml/hr)
-Hyperkalemia mx
-DVT prophylaxis
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
- Carotid massage
- Adenosine (6 -> 12)
- Repeat ECG to check response
History
1. Analyze chief complaint:
-Palpitation: onset, duration, aggravation and relieving factors), associated with
dizziness, LOC, sweating, n/v
-Hyperthyroidism: heat intolerance , weight loss
-Pheochromocytoma: palpitation, headache
-Anemia: fatigue, bleeding
-PE: sob, hemoptysis, LL swelling
-Infection: fever, rash
-Autoimmune: alopecia, joint pain, skin rash, mouth ulcer
-Hypoglycemia: headache, fatigue
-CVS: chest pain, orthopnea, PND
-Resp: wheeze, cough
-Anxiety, caffeine
3. PAM FOSS
-MI, Asthma, A. fib, CHD
-Medications
-Family Hx of CVD, arrhythmia, SCD, congenital heart disease
-Social Hx: smoking, occupation
Examination
-Vitals
-General: pallor, lymph nodes, signs of DVT, Joint swelling, Rash
-Volume: JVP, LL edema
-Thyroid: Exophthalmos, Goiter
-CVS: pulse, heart sounds
-Chest: wheeze, crepitations
Investigation
-CBC, Chemistry, TFT, Cardiac enzyme, autoimmune profile
-Full septic screen
-Chest x ray, Echo
Examiner:
Patient has exophthalmos on examination
Labs: T4 high TSH normal
• Non-pharmacological: (ANERVES)
-Admission
-Nutrition, I/O chart
-Education
-Refer to Cardiology
-Vaccination
-Exercise
-Smoking cessation, age appropriate cancer screening
• Pharmacological:
-Propranolol
-Carbimazole
-DVT prophylaxis
Further Questions
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
History
1. Analyze chief complaint:
-Chest pain: SOCRATES
-Fever: subject or objective, onset, pattern, associated with chills or rigor, response to
antipyretic
-Associated symptoms: SOB, cough, palpations, N/V, joint pain, rash
-Hx of recent travel, contact with TB patient, Hx of TB
-Hx of autoimmune disease
-Hx of drugs
-Hx of URTI
-Hx of malignancy (weight loss , loss of appetite)
-Hx of radiation or chemotherapy
-Hx of trauma
3. PAM FOSS
-Hx of cardiac surgery
-Hx of CKD, MI
-Family Hx of autoimmune disease, malignancy
-Social: smoking, occupation
Examination:
-Vitals
-General: lymph nodes
-Volume: JVP, lower limb edema
-CVS: added sound s3, murmur, friction rub, distant heart sound
-Chest: crepitations
-Autoimmune: Arthritis, rash
Investigation
-CBC, chemistry, cardiac enzyme, ANA, RF
-Full septic screen
-ECG, Echo
Examiner: Elevated cardiac enzymes, ECHO: trace pericardial effusion, normal EF,
normal wall motion
• Non-pharmacological: (ANERVES)
-Admission
-Nutrition, I/O chart
-Education
-Refer to Cardiology
-Vaccination
-Exercise
-Smoking cessation, age appropriate cancer screening, PPD if at risk
• Pharmacological:
-NSAID and Colchicine for 3m
-DVT prophylaxis
Q3: What are the indications for steroids?
• Refractory
• TB pericarditis
Case 16
40-year-old male k/c of asthma on BD and montelukast, frequent exacerbations requiring
steroid medication. Presented to ER with worsening cough and SOB.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
History
1. SOB: onset, character time, relieving and exacerbating factors, wheezing
2. Cough: onset, character time, relieving and exacerbating factors, amount, consistency,
hemoptysis
4. PAM FOSS
-Asthma: control, medication and compliance, triggers and avoidance, emergency/ICU visits
-Vaccination
-Contact with animals, Travel
He has frequent exacerbations requiring steroid medication (2-3 times per year) with some
relief. He was started on montelukast one year ago and he feels his BA has worsened. He has
had dry cough with occasional hemoptysis. He used to go to his father’s farm and complains
of arthralgia, but no weakness. His mother has arthritis and is on medication, but he is unsure
what medication she was on or her diagnosis.
Investigation
-CBC-D, RFT, LFT, INR/PTT, BG
-Total IgE level, Total IgG, skin prick test for aspergillus
-ANA, ANCA/PANCA
-Elevated eosinophil count and elevated P-ANCA
-U/A (negative)
-Picture of chest x-ray: hyper-inflation
-HRCT: left sided infiltration
-BAL: inflammatory cells, predominant eosinophiles, gram stain and AFB were negative
-Lung Bx: features of chronic inflammatory cells with eosinophils, multiple granulomas,
immunofluorescence shows linear deposition highly suggestive of ANCA-associated vasculitis.
Management
Q3: What is the management?
• Non-pharmacological: (ANERVES)
-Admission
-Nutrition
-Education
-Refer to Pulmo/Rheuma,
-Vaccination
-Exercise
-Smoking cessation, age appropriate cancer screening, PPD if at risk
• Pharmacological:
-Pulse steroid
-Cyclophosphamide
-Azathioprine
-DVT prophylaxis
Further Questions
Q4: What are the indications for plasmapheresis?
• RPGN
• Alveolar HMG
• Concomitant anti-GBM disease
Q7: Apart from Churg-Strauss, what are the causes of pulmonary infiltrate + eosinophilia?
• Acute/Chronic eosinophilic pneumonia
• ABPA
• Parasitic infection
Case 17
22-year-old male with chronic cough for more than one year, presented to OPD. PFT showed
obstructive pattern.
PFT: ratio 47
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
History
1. Cough: onset, character, duration, sputum, amount, consistency
3. PAM FOSS
-Asthma, bronchiectasis, COPD, IG deficiency disease
-Family history of alpha-1 anti-trypsin
Examination
-Vitals
-Resp
-CVS
-Abdomen
-CNS
Examiner: 22-year-old male medically free, with chronic cough for more than one year,
presented to OPD. PFT showed obstructive pattern.
-Cough is productive with yellow sputum, no blood
-He is married and has no children.
-He has history of recurrent sinusitis and pulmonary infections
Examiner:
Q2: What is the Dx?
Bronchiectasis secondary to CF
Management
Q3: What is the management?
• Non-pharmacological: (ANERVES)
-Admission
-Nutrition, pancreatic enzymes, monitor for malabsorption: Vit B12/Vit D/Iron
-Education
-Refer to Pulmo
-Vaccination
-Exercise, Chest PT, Pulm Rehab
-Smoking cessation
• Pharmacological:
-BD
-Suppressive abx
-DNAse (CF bronchiectasis)
-7% NS, inhaled tobramycin
-CFTR potentiation
-Evaluate for lung transplant
-DVT prophylaxis
Further Questions
Q4: What are the complications of CF?
• Osteoporosis
• Pancreatitis
• DM
• Recurrent infections
• Malabsorption/weight loss
• Intestinal obstruction
• Infertility
Case 18
65-year-old male k/c of CVA with gastrostomy tube, presented to ER with fever for the past 3
days.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
IVF: 30 ml/kg
Send pan-cx, cbc, RFT, LFT, LA, pro-calcitonin
History
-Fever
-Screen for infection (Resp, GIT, Nephro, CNS)
-Gastrostomy tube indication and status
Examiner: 65-year-old male k/c of CVA with gastrostomy tube for 3 years, presented to ER
with fever for the past 3 days, partially responding to anti-pyretics. No other associated
symptoms. PEG tube functioning well. What do you want to examine for?
Examination
-Vitals
-General, volume status
-CNS
-Resp
-CVS
-GIT
-Skin rashes, joint swelling
-Pressure ulcers – examine the back
-Examine PEG tube for discharge
Examiner: patient is drowsy, no neck stiffness, no skin rashes, chest is clear, gastrostomy
tube appears clean. There is a stage 4 sacral bed sore with pus and necrotic tissue. Patient is
still hypotensive. What do you want to do?
Further Questions
Q1: What is your management?
• Non-pharmacological: (ANERVES)
-Admission to ICU
-Nutrition
-Education
-Refer to GS
-Vaccination
-Exercise, PT
-Smoking cessation, age appropriate cancer screening
• Pharmacological:
-IVF
-Meropenem/Vancomycin
-If still hypotensive: Inotropes (NE and vasopressin if needed),
-Stress hydrocortisone
-DVT prophylaxis
Q2: What are the indications for initial anti-fungal in septic patient?
• Neutropenic
• Intra-abdominal sepsis (perforated viscus)
• Multiple colonization by candida
• Invasive line
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
ER Management:
Stabilize: VS, ABC, MOVIE
History
-SOB: onset, duration, progression
-Resp/CVS: symptoms
-MG: Ptosis, proximal/distal weakness, dysphagia, ptosis
-Precipitating factors: infection, medications like abx, quinolones, CCB, recent surgery
3. PAM FOSS
History of thymectomy
Examiner: 45-year-old male k/c of MG for three years diagnosed in another hospital, he
complains of proximal weakness affecting daily work and ptosis. He started to have URTI 3
days back and then started to have SOB which is progressive and associated with dysphagia.
No history of new medication or surgery including thymectomy. His symptoms were
controlled on Pyridostigmine 30 mg Q6H. What examination you would like to do?
Examination
-Vitals, BMI, spirometry (or count 1-20)
-General exam, neck flexion test
-CNS: motor with repeated movement, sensory, reflexes, CN exam (7), ptosis (look upward
for 30 s)
-Resp
-CVS
-GIT
Examiner: patient is vitally stable, spirometry is not available, difficulty counting from 1-20,he
has choking episodes when trying to drink water, weakness flexion of neck, dysarthria,
cannot close his eye, weakness with repeated movement when he stands and sits down.
What do you want to do?
Management
Stabilize patient, ABC
• Non-pharmacological: (ANERVES)
-Admission to ICU for possible intubation
-Nutrition
-Education
-Refer to Neurology, surgery for thymectomy
-Vaccination upon discharge
-Exercise as tolerated
-Smoking cessation, age appropriate cancer screening
• Pharmacological:
-Plasmapheresis or immunoglobulin
-DVT prophylaxis
Further Questions
Q2: What is the chronic management for this patient?
Non-pharma: as above
Pharma: steroid, pyridostigmine
4. PAM FOSS
Examiner:
50-year-old male k/c of HBV liver cirrhosis presented to ER with hematemesis for one day
and Malena twice. Questionable NSAIDs use for back pain. Last scope was 2 years ago
showed esophageal varices and started on BB. What exam findings will you look for?
Examination
-Vital Signs – BP and orthostatic vitals
-General: joints, LN and rash
-Stigmata of CLD: pallor, jaundice, gynecomastia, spider navi, palmar erythema, clubbing,
Dupuytren's contracture, tremor
-Volume exam: JVP and LLE
Examiner:
What is the Dose of octreotide/ceftriaxone/PPI?
-Octreotide 50 mcg daily for 3-5 days
-Ceftriaxone 1 g daily for 5-7 days
-Pantoprazole 80 mg stat, followed by 40 BID
Further Questions
Q1: What is the benefit of antibiotics in esophageal varices?
-Decreases mortality
-Decrease SBP
Q3: Patient improved and was discharged. What is your OPD plan?
• Non-pharmacological: (ANERVES)
-Nutrition (low salt diet <2 g/day)
-Education
-Refer to Gastro, for liver transplant
-Vaccination
-Exercise
-Smoking cessation, Screening for HCC Q6H (US abdomen and aFP), Serial EGD to
eradicate varices
• Pharmacological:
-Propranolol secondary prophylaxis target heart rate 50-60
-Lactulose to avoid constipation
Case 21
35-year-old male medically free presented to ER with weakness/numbness for 3 days
preceded by diarrhea 3 weeks ago.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient
History
1. Weakness: onset, character (distal/proximal), unilateral/bilateral
-Associated with autonomic dysfunction
-Numbness: onset, location
-CNS: seizures, headache, double vision, hoarseness of voice, backpain
-Resp: SOB, cough
-GIT/Urinary: constipation/urinary retention
-History of vaccination
4. PAM FOSS
Examination
-Vitals, bed-side VC (spirometry)
-CNS: Mental status, motor, reflexes, sensory, cerebellar, CN
-Resp
-CVS
-Abdomen
Examiner:
-HR 105 BP 96/60 RR 16 SPO2 97 Temp 37.2
-Other examination normal
Management
• Non-pharmacological: (ANERVES)
-ICU admission, frequent FVC monitoring q4H
-Nutrition
-Education
-Refer to neurology
-Exercise, PT
-Smoking cessation, age appropriate cancer screeenig
-Bladder/bowel care
-Follow-up lytes
• Pharmacological:
-Pain control (gabapentin)
-IVIG or plasmapheresis
-DVT prophylaxis
Further Questions
Q1: What is your DDx?
• GBS
• MG
• LE
• CIDP
• Botulism
Q5: What is the triad for Miller Fisher? What is the antibody?
Ataxia, areflexia and ophthalmoplegia
GQ1B
Special Thanks:
*Fakeeh OSCE course organizers
*The authors of this work