Ammar Alani - AMC Clinical - 14.3.

2018 Cases - My Approach

***CONSENT and WASH Hands before any PE***

** Always ask if the patient was in pain and offer pain killers **

** Do not forget to ask about HR/BP/Temp/RR/SPO2/URNALYSIS/ECG/Blood Sugar **

Hx-History

PE Physical Examination

PEFE-Physical Examination From Examiner

IX Investigations

1-Common Peroneal Nerve Entrapment - PE then Counsel

Young lady with difficulty walking - introduced my self - consented for PE - asked her to walk -
there was obvious Rt foot drop - asked her to squat then did Trendlenberg Test. Then asked her
to lie down, inspected both LLs for wassting, skin, scars..etc – then told him I needed to measure
the length of the legs and the thigh circumference – examiner said we don’t have a tape
measure ! I was talking to examiner while performing PE - then palpation for tenderness -
temperature - masses - then did motor and sensory examination ( Power - Tone - Reflexes -
Touch - Pain Prick - Proprioception ) - was about to do vibration then examiner told me it was
normal - there was power and sensory issues - then talked to patient - told her that ONE of the
nerves in her Rt Leg is damaged - may be due to trauma-infection-pressure from LN - tumour - I
do not remember saying the work Peroneal Nerve- I was asking her general quick questions
while doing PE to exclude other central issues like headache/vision/unsteady gait..etc.

Bell rang!
2-Ear Pain for months with discharge- PE and Dx

There was a head model in the room with a table on which there were 2 tuning forks – Otoscope

There was a young pain – apparently in pain – not very cooperative – said he had pain with
discharge for months – then took brief history – asked him about loud noises/trauma/infection/
tonsillitis / said no – then he said he has been having this since childhood !

The consented for PE – inspected external ears on both sides – scars – discharge – trauma -
palpated for LN – wanted to examine throat then examiner said no tongue depressor – then
used the otoscope and examined the ear on the model – there was obvious TM rupture with
discharge and visible ossicles. – I told him that he had ruptured TM may be du to trauma –
infection-loud noises and I need to refer you to ENT for management – I told him about TM
grafting then examiner said no management then bell rang !

I DID NOT perform HEARING TESTS with TUNING FORK.

3-Liner Rash on Left Arm – Hx Ex Dx DDx

Young man with a red line from his left cubital fossa towards his shoulder – asked him whether
he was bitten/trauma/thorn/IVDU/clotting then general health/ SADMA/ then PE inspection

Then palpated for tenderness/pulses/ then Axillary LN then told him this might be
thrombophlebitis – DDx Thrombophlebitis/allergy/skin infection then bell rang

4-Father asking about his 4 yr old daughter with cough – no child in room only father.

Took history about the cough/nature/when/daily/fever/SOB/cyanosis/chest indrawing/general

health/immunization/birth history/family history ( NOW HE SAID THAT HE HAD ASTHMA ) – then
told him this was asthma as well but might be URTI/allergy/pneumonia – told him that I would
give him reading material about asthma and what to do in case of emergency - then bell rang
5-Mother asking about her 7months old with Inguinal Hernia – Umbilical Hernia – and
undescended testis – she said she was really worried - Counsel.

My first question was when did you know he had these issues – she said since birth – then I said
where have you been for 7 months !!? why did you come only now ? she did not know what to
say. Then explained to her about Umbilical hernia no need to worry but we need to follow up as
most of the get closed – then told her about inguinal hernia that needs to be fixed then arrived
at the most important think – the undescended testis and told her this is the most important
thing to be managed as it might lead to sinister tumours if left – then explained to her with a
drawing about how testes descend from the abdomen and that how sometimes the do not
descend completely and cause the hernia then told her that I was to refer her to a surgeon for
management then asked her if she had any questions – she said no Dr – Thank you then I told
her that I would give her reading material - then bell rang.

6- Amenorhoea in 47 years lady – with flushing – counsel and send investigations.

Started with history – 5 Ps – mood changes – regularity – medications..etc – it was an obvious

premenopausal symptoms – explained that to her and offered her HRT to minimize her
symptoms and told her that I would give her reading material ( was an easy straight forward
case ) . told her that we might need to send for FSH/LH/Prolactin/U/S.

7-Pregnant with headache – Hx and PEFE

Took history – 5 Ps – headache – tired – no visual symptoms – leg swelling – asked examiner
about PE – had HTN – protein in urine – told her that this is Pre Eclampsia – she asked about
cause – I told her unknown but some think it is related to some materials produced by placenta
– I told her that I need to send you to hospital then examiner said – NO MANAGEMENT in
tasks !! then told her that I would give her some reading material then I remained silent until
the bell rang after about a minute !

8-Primaegravida in 32 weeks – came for check up – examination given outside the room as
( LATEST FUNDAL HEIGHT 4 weeks ago was correspondent with 28 weeks )  TRICJK

Took history – 5Ps – previous US..etc ALL NORMAL then asked examiner about vitals normal –
asked for FUNDAL HEIGHT he said 36 now !! – then asked for LIE/Presentation/PV/Speculum .all
normal.then asked about urine/Blood sugar - Then told her this is mostly polyhydraminious –
then explained to her the meaning of that and complications of it and need for hospitalization to
know the cause and will give you reading material then bell rang.
9-You registrar asked you to chart ceftriaxone for a patient with pneumonia

There is an examiner and a table on which there was a medication chart and a pen.

CHECK FOR ALLERGIES FIRST

Write the medication name /dose / iv or im / your name / signature / timing.

( easy case if you have done this before / if you are working somewhere )

10-Post operative man with history of CHF – developed SOB

In the room there was a patient lying on the couch – looked tired and there was the fluid input
output chart – I started calculating the input and output – then examiner asked me to explain
the chart for him – there was an obvious FLUID OVERLOAD – I spoke to patient and told him that
he had extra fluid through the drip and with his weak heart , this caused some fluid to
accumulate in his lungs and that we need to give him some O2 and fluid tablets/injections – he
thanked me then bell rang.

11-MVA – Blurred vision – PE and DDx – the wrote Do not perform Corneal Reflex as it was
normal.

Young man –said had MVA 4 hrs ago – had blurred vision – now better- asked him quickly about
his general health/past medical/SADMA – all Normal.

Then inspection (was talking to examiner while performing PE ) – then palpation for tenderness
– then VA/VF/then Ocular movement/ Light reflex – grabbed the fundoscope then examiner
said no need then handed me a big photo showing normal retina/optic disc/macula told him
that the inside of the eye was normal ( then said some medical terms to examiner like normal
fundus/macula/disc/no flame hameorrhage..etc )

Then said ideally I need to do slit lamp to check anterior chamber – examiner said we do not
have one !

Then for DDx – told patient that everything is ok – nothing to worry about – might be due to
some concussion – need to refer you to specialist and follow up again – will give you reading
material then bell rang.
12-45F with left UL pain. Hx PEFE – Ix Counsel (easy case )

She had pain – from neck down – secretary – took brief history – it was obviously a neck issue as
she said in history she usually had neck pain – examination was normal – told her we need to do
cervical xray and MRI – DDx - might be OA/spondylosis/trauma/infection .

ManagementReading material / Physio therapy / specialist / follow up

13-Woman brought by police – Background of Schizophrenia – take history and TELL PATIENT
ABOUT MANAGEMENT !! PATIENT HAD NO INSIGHT BUT ACCPETED ADMISSION.

Patient was constantly talking to herself – looked unkempt – dirty clothes – I took history from
her as below
MSE
ASEPTIC
Appearance-behavior-proper dressing-agitation-smell-calm-dirty
Speech-low tone-monotonous-pressure
Emotions-Mood-angry-happy
Perception-hallucination-I hear them
Though-delusions—Im special-talking to angels
Insight-do you think you need help
Cognition-where are you now ( ORIENTATION)
DEPRESSION
S leep
I nterest
G uilt-Grief
E nergy
M ood
C oncentration
A ppetite
P sychomotor agitation-Do you remain on the edge all the time ?
S uicifdality – life is not worth living – thought of ending it all for once – plans-any notes left

Then wanted to talk to examiner about management – he said TALK TO YOUR PATIENT then I
spoke to patient that she needs admission as she had not taken her medications for 3 months.
14-Young woman with irregular menses then Secondary Amenorrheoa

Took history – hypothalamus ( eating disorder ) patient had eating disorder – bulimia

Pituitary ( visual disturbances ) – Thyroid symptoms – PCOS symptoms – Uterine issues

( previous D&C/Asherman/congenital )

then told her that the cause is her eating habit and that she needs to be referred to psychiatrist
for that. – reading material – she was happy to know the casue.

15-middle aged man wanted to know why his inpatient mother started to shout in the ward and
did not recognize him – she was a post operative.

Son was very angry – I calmed him and told him that I was there to help him – I asked him
quickly about his mother – he described the situation to me as she suddenly started to shout…
etc

I told him this is called Delirium / there is now specific cause for it – we need to do some blood
tests to check blood salts 9 electrolytes ) / CXR if pneumonia – have her relatives stay with her…
etc. he became very calm and happy and thanked me.

16-Young woman with chest pain – ECG shown outside room. Hx-no PE – Counsel

Young woman – hx of flu like illiness 2 weeks ago – chest pain – related to movement – better
when leans forward – radiates to left shoulder – ECG – T inversion in some leads only – told her
this is mostly Pericarditis – DDx ACS – MI – Trauma – Pneumonia. We need a CXR – FBC/CRP and
referral to ED for admission. Reading Material handed to patient – She thanked me.

Best of Luck Guys and All the Best for You All.