Adrenaline (child,adult,IM,IV...

) ya Corticosteroids too asthma ya

croup o ...
 
Dengue fever JM 156/
ross river fever JM 283

1) A 43 y/o female secreter with pain in little joints(DIP & MCP) and
also feet. Arthritis JM 357/ Connective tissue disorder JM 310/
DDx: RA, SLE, OA, Viral arthritis
Investigation: anti CCP, ANA, dsDNA, X-ray, ESR + CRP (to
differentiate between RA and OA)
and management,explaining for the patient

2) A 47 y/o male building worker with acute chest pain

   DDx, Investigation and management,...

3) A 7 y/o boy with right hip pain- JM 712, see overview of hip pain in
childhood.PDF

 DDx with full details for each Diagnosis:

- septic arthritis, OM, transient synovitis (irritable hip), perthes disease, ,
slipped epiphysis, systemic arthritis, osteoid osteoma, malignancy,
,Investigatin and management,...
Septic arthritis — Septic bacterial arthritis is "the diagnosis not to
miss" in the evaluation of a child with hip pain, given the potential for
rapid joint destruction and long-term morbidity that can accompany
delay in diagnosis and treatment.

Children with septic arthritis of the hip typically are febrile and ill-
appearing, although occasionally the presentation is more subtle [15].
Neonates and infants may present with irritability and pseudoparalysis of
the affected limb, even without fever. Weight-bearing and motion of the
affected hip are quite painful and strongly resisted in all patients. M=F

Clinical and laboratory features predictive of septic arthritis of the hip

include fever >38.5ºC within the week before presentation; refusal to
bear weight; ESR >40 mm/h; WBC >12,000 cells/mm3; and CRP >2
mg/dL (20 mg/L) [15,18,19].

Diagnosis is confirmed by ultrasound-guided aspiration of inflammatory

hip fluid with identification of a causative organism by blood or synovial
fluid culture.

Therapy consists of urgent and, in some cases, repeated drainage to

avoid buildup of intraarticular pressure that may impede local blood
flow, and administration of parenteral antibiotics. JM → flucloxacillin

Septic arthritis of the sacroiliac joint also can present as pain in the
region of the hip. Careful examination reveals that gentle hip motion is
not painful, whereas maneuvers that torque the pelvis (eg, the FABERE
test) reproduce the patient's symptoms.

F→flexion of the hip

AB→abduction

ER→ external rotation

E→ extension of sacroiliac joint

Osteomyelitis — Osteomyelitis of the femur or pelvis can present with
hip pain. The diagnosis of osteomyelitis, like that of septic arthritis,
should be made as soon as possible, because delay in treatment increases
the likelihood of a poor outcome.

The proximal femur is the most common site of osteomyelitis in

children. Pelvic osteomyelitis, a rare condition, also typically presents
with hip pain and limp. However, children with pelvic osteomyelitis
often permit careful manipulation of the painful hip, a feature that
distinguishes it from osteomyelitis of the proximal femur and septic
arthritis of the hip.

The diagnosis of osteomyelitis may be strongly suggested by plain film,

bone scan, or MRI.

Transient synovitis — JM 713- Transient synovitis (TS) is a relatively

common disorder characterized by pain and limitation of motion in the
hip, arising without clear precipitant and resolving gradually with
conservative therapy. Fever typically is absent but may occur. TS
typically presents in patients between the ages of three and eight years,
with a mean age at presentation of six years and a male-to-female ratio
of slightly more than 2:1 M>F The prognosis usually is excellent.
Recurrence rates from 4 to 15 percent have been reported [2,25]. Most
children with recurrent TS have a benign course [2,26].

At clinical presentation, most children have had symptoms for less than
a week, although 12 percent in the largest series had discomfort dating
back at least one month [23]. Fever typically is absent or low-grade, and
children are nontoxic in appearance. Symptoms affect both hips in as
many as 5 percent of cases [23]. Even in symptomatically unilateral
disease, ultrasound can detect bilateral effusions in 25 percent of
children [12].

Etiology→ posttraumatic or allergic , viral infection

The management of TS is conservative, with the use of nonsteroidal

antiinflammatory drugs (NSAIDs) + bed rest and return to full activity
as tolerated + crutches [31]. Hip infection must be excluded. Patients
who are nontoxic with minimal fever and benign WBC and ESR often
can be followed clinically+ X-ray in 4-6m to R/O perthes. The prognosis
usually is excellent, with full recovery to be expected. A small
percentage (1 to 2 percent in most series) may go on to develop Perthes
disease with avascular necrosis of the ipsilateral femoral head. TS has a
recurrence rate of up to 15 percent [2]

Legg-Calvé-Perthes — Legg-Calvé-Perthes disease (LCP) is a

syndrome of idiopathic osteonecrosis (avascular necrosis) of the hip, It
typically presents as hip pain and/or limp of acute or insidious onset in
children between the ages of 3 and 12 years, with peak incidence at five
to seven years of age. It is bilateral in 10 to 20 percent of patients [34].
The male-to-female ratio is 4:1 or greater M>F. Avascular necrosis
secondary to an underlying disease (such as renal failure, steroid use, or
lupus, HIV) may present similarly.
Etiology→ thrombophilia as a contributor to avascular necrosis/
Structural abnormalities of epiphyseal cartilage/ prenatal or secondhand
smoke exposure/ material deprivation / birth weight less than 2.5 kg in
boys

Diagnosis of LCP demands a high index of suspicion, because initial

radiographs often are normal. At this phase, bone scan shows decreased
perfusion to the femoral head, and MRI reveals marrow changes highly
suggestive of the diagnosis.

Radiographs taken subsequently show fragmentation and then healing of

the femoral head, often with residual deformity
X-ray: ↑ joint space + head of femur too lateral

Current treatment focuses on maintaining containment of the femoral

head within the acetabulum, through the use of splints or occasionally
surgery, although the data for these interventions are limited [46].
Patients diagnosed with LCP should be made nonweight-bearing and
referred to an experienced pediatric orthopedist for management

Slipped epiphysis —  10-15y and obese child/ diagnosis: frog lat view
X-ray

In slipped capital femoral epiphysis (SCFE), the femoral epiphysis slips

posteriorly, resulting in a limp and impaired internal rotation. The
typical patient is an obese child in early adolescence who, if female, has
not yet reached menarche and, if male, has not yet reached the fourth
Tanner stage. The mean age of presentation is 12 years in girls and 13.5
years in boys, near the time of peak linear growth. The male-to-female
ratio is approximately 1.5:1. M>F. SCFE is bilateral in 20 to 40 percent
of cases. Patients may present with acute hip pain and inability to walk,
often after minor trauma, but more commonly they come to attention
after months of ill-defined hip or knee symptoms and limp with or
without an acute exacerbation. The absence of pain, or pain localized to
the knee or thigh instead of the hip, can lead clinicians to overlook the
diagnosis [58,59], a delay that may be associated with increased slip
severity [60]. Simultaneous external rotation and abduction of the hip
during hip flexion is a useful, though variably present finding

other cases which has been asked before in acrrm:

4) Pregnant aboriginal female with vaginal bleeding and abdominal pain

  DDx, Investigation and management,...

1st trimester:
Ectopic pregnancy
Miscarriage (threatened, inevitable, incomplete, complete)
note: bleeding before 24w→ treat as threatened abortion

Cervical, vaginal, or uterine pathology (eg, polyps,

inflammation/infection, trophoblastic disease)
Implantation of the pregnancy=vanishing twin

2nd & 3rd trimester: DO NOT examine the patient

Bloody show associated with cervical insufficiency or labor
Placenta previa JM 1061 → painless bleeding 28-30w
Abruptio placenta JM 1061
Uterine rupture
Vasa previa

5) Old man with acute unilateral headache 

  DDx, Investigation and management,...
6) A 65 y/o smoker man comes with COPD
Explain the condition for the patient in simple words and answer the
patients questions (does O2 help? does smoke      cessation help?...)

7) A child comes with breathing distress,harsh cough,cyanosis (finally

-----> croup)
  Management of croup JM 942
Cough JM 462

8) A man with a Hx of 6 month fatigue

DDx, Investigation and management,...

9) A man wants some advice before traveling to India→ tropical

medicine (vaccines,prophylaxis for malaria,...) JM 140
Most common diseases in traveling patients→ 1- diarrhea/ 2- malaria
the main treatment in diarrhea is rehydration (gastrolyte)
if fever/blood in the stool→use antibiotic→norfloxacin/cipro/azithro
use loperamide & diphenoxylate only in mild diarrhea

JM 142→ tell the traveler about: water, ice, salads and raw vegetables,
meat and seafood, dairy products, do not buy stuff from street vendors.

The golden rule is: If you can't peel it, boil it or cook it- don't eat it.
Prophylaxis against malaria:
1- prevent mosquito bite
2- medical prophylaxis :
for low risk regions→ chloroquine
for high risk regions→ mefloquine/atovaquone+proguanil

2 vaccines are compulsory: yellow fever/ meningococcus

10) Multipharmacy case

Verapamil, Hydrochlorthiazide, Furosemide, Dig, Aspirin, Atenolol,
Glibenclamide, Insulin

11) 14 y/o girl came with RLQ pain since 3w ago

 Hx taking,examination,investigation,DDx
JM 336 (abdominal pain)

12) 21 y/o female with vaginal bleeding who has passed a grape like
thing,Mx? High risk pregnancy p1031

13) 52 y/o male with diarrhea since 8w ago

 Hx taking,examination,investigation,DDx

14) 77 y/o woman came with her daughter with confusion

=4D Delirium/Dementia/Depression/Drugs JM 503

Acute delirium is a medical emergency.

I started the case by asking general condition of my patient and

haemodynamically stable or not
and also it is reliable to ask the history from the patient. If not, I would
like to ask the daughter
who is living together with her mum. I ask my history taking and
physical examination according
to my differential diagnosis of confusion. After that I explained the
patient and her daughter
about the possible diagnosis and management plan.
15) A boy with asthma came with his divorced mum.dad does not admit
his son disease and the child lives with his dad 3 days a week.Mx?

I assessed the respiratory distress first and how far the clinic and hospital
and also ambulance
service. I managed the child with nelbulized salbutamol and O2. After
that I asked the child is
my regular patient or new one. As he is my regular patient, I reviewed
his record. The child had
the recent viral infection.
Also talk about asthma action plan and give the copies to all the carers
of the child including
school. I would like to check the technique of inhaler and advise giving
inhaler by using spacer. I
would like to liaise with asthma educator although I didn’t know how, so
I will ask my
supervisor about the process. In addition, I would like to discuss with
dad who resisted on
asthma medication.

16) A 6 y/o child comes with lethargy and T=38.5/ (possible rash)
 DDx, Investigation and management,...

17) A 65 y/o with 8 years Hx of DM comes with blood test results:

     HbA1c : 9        FBS : 10
     Chol : 6            LDL : elevated      HDL : low
   Mx?

18- 26 w pregnant woman with abdominal pain= preterm labor

19- smoker woman on COC comes with leg swelling

20- woman 60y with low platelet and bruises? SLE

JM 422 → the most common cause is medication.

Spontaneous or immediate bleeding after trauma→ platelet dysfunction

Delayed bleeding→ factor deficiency→ check PT, PTT, TT, fibrinogen
Acquired bleeding→check for MILD: Malignancy, Infection, Liver
disease, Drugs
21- 50 y/o male with central abdominal pain with radiation to back
DDx?
then give you a picture showing periumbilical bruising (cullen's sign)
Investigations?
Management?

22- Worker falls while working, CT scan has been done, while
transferring to hospital----->decreased level of consciousness
they bring the patient to you for assessment
CT shows EDH (any kind of hematoma in brain)
Investigation?
Management?
23- a 4 y/o girl with cyanosis and retraction of intercostal muscles
Management?
(they have asked Adrenaline dosage in children here)

24- a 10 week pregnant woman comes with vaginal bleeding

DDx?
Investigation?
Management?

25- girl with elbow injury

26- man for follow-up with hypertension JM 1294, diabetes & ↑ lip

27- 50 year old man came to the clinic for flu needle. The practice
nurse told you that he
complaint of lack of energy and mild hypertention. The previous GP
did FBS and FBE. His
FBS is 11.1 mmol/L and FBE – normal. However, the GP hasn’t
done any action yet.
Do you see the patient now?
I asked the panel the previous GP is at the clinic or not. They replied the
GP was on holiday for a
week. So, as the patient has the symptom and FBS 11.1, I would like to
see the patient now.
Do you tell that patient has DM?
Yes, I must tell that he has DM2 because he has the symptom and FBS
11.1
How would you manage?
I told them that start from history, physical examinations to detect any
complications of DM.
Investigations I would like to do and why I want to do.
As a management, start from life style modification SNAP ( Smoking,
Nutrition, Alcohol,
Physical activity), refer to dietician, regular follow up and if blood
glucose is not well
controlled, start metformin. Depending on the investigation results, if
there are complications of
organ involvement, referred to the endocrinologist, podiatric,
ophthalmologist, renal physician,
diabetic educator, community nurse as a team care approach.

28- 20 year old female came to see you with the complaint of sore in
vagina for 2 days.
What are your D.Dx?
How would you approach?
I asked any blisters or ulcers in vagina. My D.DX are HSV, infected
Bartholin’s cyst JM 1036, Chancre.
Investigation viral culture for the HSV and STD screening
Treatment the onset is 2 days, I will give acyclovir 200mg qid for 5 days
Pain killer systemic and local
Safe Sex.

29- 45 yrs old woman with base of the thumb pain.

take history
examine and manage the case

Scaphoid fx JM 1396

de Quervain tenosynovitis JM 701

Rx→ rest+NSAID+local steroid

finkelstein test→ rotate the patient’s hand ulnarly

30- 10 yrs old boy , brought by parents, convulsing for 15 minutes

Manage the patient JM 945, 1292, 1341

31- 8w pregnant woman presents with hyperemesis gravidarum

JM 1046/ AMC clinical 730

If urine ketone +ve→ hospitalize the patient

32- carpal tunnel syndrome JM 698/ AMC clinical 701

Good luck!