SOE Stations - Part I

‫ﻢ‬9‫ اﻟﺮﺣﻤﻦ اﻟﺮﺣ‬2 ‫ﺴﻢ‬/

@B A ‫و;ﻪ =ﺴﺘﻌ‬

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.

What is the SOE?

SOE stands for structured oral exam. You will be given a case scenario to read. You will be
assessed on approach which includes introduction, history taking and examination skills,
investigations, management and closure. The time allocated for each station is 10 minutes.

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

1. Make sure patient is stable.

2. Analyze chief complaint:

-Weakness and fatigue: (onset, duration, progression, relation to activity, course during
the day)
-Hyponatremia: CHF, CKD, CLD, medication
- DDX Hx:
-Adrenal insufficiency: (postural dizziness, syncope, skin pigmentation, fatigue,
weakness, anorexia, nausea, vomiting, diarrhea, weight loss, abdominal pain,
depression, sweating
- Adrenal insufficiency causes: autoimmune, infection (contact with TB patient, CMV,
immunosuppression) vascular (recent heparin exposure), trauma, infiltrative disease
(hemochromatosis: skin, arthritis, family Hx, dm) (sarcoidosis: cough and skin rash,
neurological symptoms), malignancy (b symptoms), drug Hx (antipsychotic, antiemetic,
steroid intake, anticonvulsant, antifungal
-Symptoms of pituitary disease: (galactorrhea, infertility)

3. Systematic Review, Constitutional symptoms

4. PAM FOSS

Examiner: 48-year-old female patient complaining of progressive fatigue, generalized

weakness, dizziness, nausea and vomiting. The symptoms started 3 days ago.

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:

• Mx of secondary adrenal insufficiency:

• Nonpharmacological: (ANERVES)
-Admission
-Nutrition
-Education on need to taper steroids
-Referral to Endocrine
-Vaccination
-Smoking Cessation, Screening

• Pharmacological:
-Hydrocortisone 100 mg IV TID (stress dose)
-Treat with 0.9% normal saline
-DVT prophylaxis

• Mx of primary adrenal insufficiency:

-Education, medi-bracelet
-(oral prednisolone 2/3 morning, 1/3 night), fludrocortisone
-Hydrocortisone IM prescription (for emergency home use)

Further Questions:
Q1: What is your diagnosis?
Secondary adrenal insufficiency
Q2: Will you give hypertonic saline? No

Q3: What is Waterhouse–Friderichsen syndrome? Causes?

Adrenal HMG
Caused by infections like meningococcal/malaria/staph/strept

Q3: ER doctor called you with incidental finding 2.7 cm incidentaloma for another
patient. What are the Features of benign disease?

-Size less 4 cm, smooth margin

-Homogenous and hypodense
-Unenhanced CT less than 10 Hounsfield
-CT contrast-medium washout more than 50%

Q4: What are the hormones you need to screen for in a patient with adrenal
incidentaloma?

-Serum/urine metanephrines and low dose dexamethasone suppression test

-Serum aldosterone and renin only if hypertensive
Case 2
53-year-old male patient presented to OPD with Hx of chronic diarrhea for 8 months.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Analyze chief complaint:

-Diarrhea: (onset, duration, progression, aggravating, reliving, constancy, tenesmus,
mucus, abdominal pain, bloating, indigestion, relation to meal, bloody)-DDX Hx:
-Dietary HX
-IBD: oral ulcer, Family HX, peri anal ulcer
-Celiac
-Pancreatitis
-Hyperthyroidism
-Addison
-Infectious: fever, travel, TB
-Malignancy: B symptoms

2. Systematic Review, Constitutional symptoms

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.

What examination findings would you look for?

Examination
-VS (postural hypotension), signs of dehydration
-BMI, rash, ulcer, LN, joints for tenderness
-DM: fundoscopy, peripheral neuropathy, skin, ulcer
-GI: tenderness, distention
-Chest: crepitations

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?

• Small Intestinal Bacterial Overgrowth (SIBO)

• Giardia
• Celiac
• Microscopic colitis
Q2: What does the fundoscopy exam show?
Picture showing non-proliferative DM retinopathy with hemorrhage and exudates

Q3: What are the investigations for SIBO?

Hydrogen breath test and jejunal aspirate

Q4: What is the etiology of SIBO?

• 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

1. Make sure that the patient is stable.

2. Analyze chief complaint:

Lower limb weakness: onset, duration, progression, course in the day, aggravating,
reliving, proximal or distal
CNS: loss of sensation, tingling, blurred vision, headache, backpain
Contact with sick patient, fever, skin rash

3. DDX Hx: (myopathy approach)

*Neuromuscular junction:
GB: preceded by URTI or diarrhea
MG: increase at night dysphagia, ptosis, recent use of aminoglycoside, quinolone
Lambert Eaton: improve with activity
Botulism: eating raw fish, descending weakness

*Congenital: family HX of myopathy

*Drugs: steroid, statin

*Electrolyte imbalance: Hx recurrent hypokalemia after exercise or heavy meal, family

Hx of periodic hypokalemic paralysis, hypocalcemia: perioral numbness

*Endocrine: adrenal, thyroid

*Malignancy

*Stroke

*Rheumatological: morning stiffness, joint pain, rash

4. Systematic Review, Constitutional symptoms

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

Q2: Difference between steroid induced myopathy and dermatomyositis?

• Steroid induced: normal CK, no skin rash

• Dermatomyositis: elevated CK, skin rash

Q3: Difference between PMR and dermatomyositis?

• 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

Q4: Indications for immunoglobulin?

• Respiratory failure
• Dysphagia
• Refractory to immunosuppressive treatment

Q5: What are these signs:

• Pictures for Gottron papules

• V sign (for dermatomyositis)
Case 4
22-year-old male presented to ER with acute right lower limb DVT for one day and
bilateral skin rash in the lower limbs.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Make sure that the patient is stable.

2. Analyze chief complaint:

-Right lower limb DVT: onset, duration aggravating, reliving, travel, immobilization Hx,
previous Hx DVT, PE
-Malignancy
-Autoimmune: aphthous ulcer, diarrhea, recurrent oral ulcer, recurrent genital ulcer,
rash, sob, chest pain, hemoptysis, red eyes, seizure, joint pain or swelling, hematuria,
face puffiness
-IBD: bloody diarrhea, abdominal pain

3. Systematic Review, Constitutional symptoms

4. PAM FOSS
Family HX of thrombophilia, autoimmune disease or malignancy
Social: smoking, alcohol, unprotected sex

Examiner: 22-year-old male 3 days Hx of right lower limb swelling

-No recent fracture or travel or new medication
-First time to have lower limb swelling, he also has lower limb painful rash on both shins
of the legs for the last 2 months. He reports recurrent oral and genital ulcers.
-No Hx of unprotected sex.

What examination findings will you look for?

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

Q 2: What is the DDx for pan-uveitis?

• Behjet
 • TB
• Sarcoid

Q3: What is the diagnostic criteria for behjet?

• Recurrent Oral/genital ulcer that is non-healing for 6 months

• Recurrent 3/year
• Uveitis
• Skin rash
• Pathergy test

Q4: What is this skin rash: picture of EN

Case 5
60-year-old male k/c of HTN on candesartan and thiazide, has decreased oral intake for 5
days, presented to ER with tonic clonic seizures for 10 mins

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Make sure that the patient is stable.

• VS, ABC, MOVIE

Basic labs (blood sugar, CBC, renal, liver, coagulation, ABG), ECG
• Anti-seizure medication- first line e.g. (Lorazepam) if no response à 2nd line e.g.
phenytoin if not controlled à anesthesia
• Labs: Na 119
• Imaging when patient is stable (CXR, CT brain)

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------------------------------------------

Patient now stable, what is your next step?

2. Analyze chief complaint:
-Seizure: (1st time, pre, post, description of seizure)
-Causes of seizure: DIMS: Drug, Infection, Metabolic, Structural

3. Systematic Review, Constitutional symptoms

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?

• ≥5 minutes of continuous seizures, or

• ≥2 discrete seizures between which there is incomplete recovery of
consciousness

Q2: List 4 causes for seizures:

*DIMS*
• Drug (alcohol, sympathomimetic, antibiotic)
• Infection (encephalitis, meningitis)
• Metabolic (hypo Mg-Na, uremia, hyper Ca, hepatic encephalopathy)
• Structural (epilepsy, hemorrhage, tumor)

Q3: List 4 causes of hypo-osmolar hyponatremic hyponatremia:

• Diarrhea/Vomiting/laxatives (GIT losses)

• Malnutrition
• Diuretics
• Adrenal insufficiency
Case 6
25 years old female patient to the clinic found to have proteinurea, protein/Cr
Ratio = 5.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Analyze chief complaint:

-Ask about urinary symptoms: hematuria, frothy urine, dysuria, frequency
-Associated symptoms: lower limb edema, sob, abdominal distention, wt. gain
- Autoimmune: (arthralgia, arthritis, alopecia, skin rash)
-Malignancy, constitutional symptoms (fever, night sweat ,wt loss)
- Infection: (sore throat, URTI, malaria , syphilis)
- Blood transfusion: (hepatitis)
- Uremia symptoms

2. Systematic Review, Constitutional symptoms

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

Q2: What investigations do you want to order?

-Serology, autoimmune profile, renal biopsy
-Renal biopsy showed focal prolifrative GN class 3

Q3: What is your Diagnosis?

Focal prolifrative GN secondary to class 3 lupus nephritis

Q4: What is your management?

• Nonpharmacological: (ANERVES)
-Admission
-Nutrition
-Education
-Referral to nephrology and Rheumatology
-Vaccination
-Exercise
-Smoking cessation

• Pharmacological:
-ACEI, statin, diuretic
-Start HCQ
-Induction = pulse steroid + CYC or MMF
-Maintenance = steroid + MMZ OR AZA
-DVT prophylaxis

Q5: What is the prognosis in thes case?

Class 3: excellent prognosis

Q6: What are the classes of lupus nephritis?

Class 1: minimal mesangial Class 5: membranous
Class 2: mesangial prolif Class 4: diffuse proliferative (worse prognosis)
Class 3: focal prolif Class 6: advanced sclerotic

Q7: What is the SLE course during pregnancy?

Flare up during pregnancy opposite RA which improved during pregnancy

Q8: What is the pregnancy precaution related to SLE?

Should be in remission at least 6 month before pregnancy
Avoid teratogenic medication like MMF, ACE inhibitors, statin
Check antiphspholipid antibody , Anti RO/ Anti LA
Case 7
30 years old pt K/C of AML, presented to ER with fever.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Make sure patient is stable:

VS, ABC, MOVIE
IVF, broad spectrum antibiotics and anti-pyretic
Take initial investigation as CBC-D, INR/PTT, full septic screen: blood, urine and sputum

1. Analyze chief complaint:

-Fever (onset, duration, pattern, response to paracetamol)
-CVS: sob, chest pain, palpitation
-Respiratory: productive cough, pleuritic pain
-Ear, nose, and throat
-GIT: abdominal pain, nausea, vomiting, diarrhea
-Urinary symptoms: dysuria, frequency
-Neurological: headache, rash, neck stiffness, altered conscious level

3. Systematic Review, Constitutional symptoms

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

Vital signs: BP stable, no orthostatic hypotension, T= 39, sop2=93 on RA

He has no central line, chest bilateral crackles
Abdomen soft and lax, no rash, no signs of mucositis, normal perineal skin

Investigation
CBC-D, coagulation profile, full septic screen
chest x-ray: showed RT homogenous opacity

CT chest showed halo sign (consolidation surrounded by ground glass)

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

What is the next step?

Bronchoscopy + BAL and send for (bacterial, fungal c/s, PCP stain, cytology), serum
galactomannan
Biopsy if no contraindication

After 3 days culture showed aspergillus. What is the next step?

Refer to ID to start voriconazole

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

Q2: What are the side effects of voriconazole?

• Drug –drug interaction
• Hepatitis
• Photosensivitiy
• Hallucinations
• Blurred vison
Case 8
26 years old male pt. K/C of SCA presented to ER with fever and chest pain.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Make sure patient is stable:

VS, ABC, MOVIE

1. Analyze chief complaint:

-Fever: onset, course, duration, pattern, response to paracetamol
-Chest pain: SOCRATES
-Respiratory symptoms: productive cough, sob, hemoptysis
-CVS: orthopnea, PND, lower limb edema, palpitation-
-Neurological symptoms: headache, neck stiffness, rash
-GIT: nausea, vomiting, abdominal pain, diaarhea
-Urinary symptoms: dysuria, frequency, hematuria
-Contact with sick patient, history of raw milk ingestion
-Contact with animals

3. Systematic Review, Constitutional symptoms

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.

Vital Signs : bp = 90/60 T = 38.5 RR =24 SPO2 = 90 on RA

Looks distress, not cyanosed
CVS: normal, chest bilateral crepitation
No signs of dvt or lower limb edema

Further Questions
Q1: What is your DDx?
• Acute chest syndrome (ACS)
• Pneumonia
• PE

Q2: What investigations do you want to order?

-CBC-D, coagulation, LFT, electrolytes, full septic scereen, CE, ECG, ABG
-Nasal swab for COVID 19, HINI, influenza, MERS COV
-Chest x ray showed bilateral infiltration

Q3: What is you Diagnosis?

ACS

Q4: What is your management?

• Nonpharmacological: (ANERVES)
-ICU admission, isolation
-Nutrition
-Education
-Referral to hematology
-Vaccination
-Exercise
-Smoking cessation
-oxygen, incentive spirometry
• Pharmacological:
-IVF
-ABX
-Pain control
-Bronchodilator
-Exchange transfusion
-DVT prophylaxis
Q5: What is the diagnostic criteria for ACS?
• New infiltration by chest x ray +
• Fever or desat , chest pain, cough , tachypnea.

Q6: How prevent ACS in SCA?

• Hydroxyuria
• Chronic blood transfusion
 • Bone marrow transplant

Q7: Whate are the long-term complications of SCA?

• Stroke
• Infection
• ACS
• Pulmonary hypertension
• Avascular necrosis
• Leg ulcer
• Sickle cell nephropathy
• Priapism

Q8: Pre-op clearance before cholecystectomy:

• Adequate hydration
• Oxygenation
• Make sure has no signs of infection
• Keep HB > 10
• HBS less than 30
• Resume hydroxyurea
Case 9
32-year-old male presented to ER with fever for two weeks, had one episode of seizure
in ER and stabilized.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Make sure patient is stable:

VS, ABC, MOVIE
Orthostatic hypotension, blood glucose, IVF, basic ix

1. Analyze chief complaint:

-Analysis of fever (onset, duration, pattern, response to paracetamol)
-Seizure: description, post ictal, episode, aura
-Associated symptoms: neck stiffness, headache weakness
-HEENT: nose and sore throat infection
-Constitutional: night sweats, wt. loss, loss of appetite
-Respiratory: SOB, productive cough, pleuritic chest pain
-CVS: history of palpitation, orthopnea, PND, lower limb edema
-GIT and urinary symptoms
-Autoimmune: arthralgia/arthritis, oral, genital ulcer, malar rash
-Contact with sick patient, animal, mosquito bite
-Raw milk ingestion, history of contact with TB patient

3. Systematic Review, Constitutional symptoms

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

Q2: What investigations do you want to order?

-CBC-D, chemistry, LFT, full septic screen, CT brain, LP
-HIV Ab, blood film for malaria
-Brucella serology and pan c/s.

Q3: What does the smear show?

Picture of Malaria falciparum

Q4: What is your management?

• Non-pharmacological: (ANERVES)
-Admit to ICU
-Nutrition
-Education
-Refer to ID
-Vaccination (upon discharge)
-Exercise
-Smoking cessation

• 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

1. Make sure patient is stable:

VS, ABC, MOVIE
Draw labs CBC, Chemistry, coagulation profile

2. Analyze chief complaint:

-Diarrhea: Onset, duration, course, amount of blood, frequency, urgency, consistency
-GIT: nausea , vomiting , hematemesis, melena, dysphagia
-Complication related to GIT bleeding : anemia (palpitation, dizziness)
-Ask about UC:
-When diagnosed, method of diagnosis, treatment, complication, frequency of flares, ER
admission, bowel surgery, steroid requirement, last colonoscopy
-Extra intestinal manifestations: red painful eye, back pain, rash, joint pain

3. Systematic Review, Constitutional symptoms

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

Q3: What is your recommendation for Colon ca screening?

After 8 years, interval 1-3 years colonoscopy

Q4: What would be your investigation if patient presented with jaundice?

LFT and MRCP

Q5: Mention 2 extra-intestinal symptoms that parallel disease activity?

EN, peripheral oligoarthritis

Q6: What are the parameters that indicate severe UC?

*True love score*

• Anemia
• Number of bowel motions
• HR
• Fever
• ESR
Case 11
58-year-old female patient presented to OPD with fatigue, headache, high serum Ca and
yellow discoloration of eyes.

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

-Jaundice: onset, duration, abdominal pain, stool/urine color, skin excoriation

2. Systematic Review, Constitutional symptoms

3. PAM FOSS
Family Hx of malignancy, hypercalcemia

What is your DDx?

• Primary Hyperparathyroidism
• MEN1
 • MM

What Investigations do you want to order?

-CBC, Chemistry, PTH, PTHrp, TFT, 1,25 vitamin D
-24 urine calcium

Further Questions:

Q1: What are the indications for parathyroidectomy?

• Age<50
• Ca level >1 above upper limit
• Renal stones
• Elevated Cr

Q2: Name 2 post-parathyroidectomy complications?

• Hypothyroidism
• Recurrent laryngeal nerve injury

Q3: What is your primary dx?

MEN 1 (hypercalcemia, h/a, jaundice)
Case 12
36-year-old female referred from OB-Gyne clinic with amenorrhea.

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

2. Systematic Review, Constitutional symptoms

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

Q2: What is your management?

• 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

Q3: What are the indications for surgical management?

• 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

Q6: What is the management of 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

2. Systematic Review, Constitutional symptoms

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;

Blood tests show High CK, P, K and Low ca

Q1: What is your DDX:

• CIN
• Rhabdomyolysis
• Cholesteol embolism

Q2: What is your management?

• 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

Q2: What is the role of sodium bicarbonate?

No role in treatment for treatment of rhabdomyolysis (even if metabolic acidosis)

Q3: What are the indications of Ca replacement in rhabdomyolysis?

• For hyperkalemia mx (Ca gluconate)

• Severe hypocalcemia <7.5
• Symptomatic hypocalcemia
Q4: What are the indications of HD in rhabdomyolysis?
Volume overload, Refractory hyperkalemia/acidosis, Uremic pericarditis, Uremic
encephalopathy.
Case 14
50-year-old male patient medically free, presented to ER with Hx of palpitation.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Make sure patient is stable:

VS, ABC, MOVIE

Examiner: HR 150, BP 110/70, he is able to communicate, there is no SOB or CP

ECG show SVT

What is your management?

- Carotid massage
- Adenosine (6 -> 12)
- Repeat ECG to check response

*Repeat it ECG show AF*

What is your management?

- Metoprolol and cardiology referral

Patient now stable, proceed with taking history

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

2. Systematic Review, Constitutional symptoms

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

What is your diagnosis?

Hyperthyroidism

What is your management?

• 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

Q1: Is there any indication CV?

No as patient is stable

Q2: What is the indication for anti-coagulation?

Depends on CHADS-Vasc score- 0

Q3: What is the SE of carbimazole?

Agranulocytosis, Fever, skin rash, upset stomach

Q4: Picture of homogenous uptake what is your diagnosis?

Graves disease

Q5: What is your next management?

Radioactive iodine ablation
Case 15
36-year-old male patient presented to ER with Hx of fever and chest pain.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

1. Make sure patient is stable:

VS, ABC, MOVIE
Draw CBC, Chemistry, coagulation profile, CE

ECG show diffuse ST elevation with PR depression >> pericarditis

Troponin: high

Examiner: patient is stable, proceed with history

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

2. Systematic Review, Constitutional symptoms

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

Q1: What is your dx?

Myopericarditis

Q2: What is your management?

• 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

3. Systematic Review, Constitutional symptoms

-CVS: Orthopnea, PND, palpitations, chest pain
-Autoimmune: arthralgia, rash, mouth-ulcer, alopecia
-Chronic Infections

4. PAM FOSS
-Asthma: control, medication and compliance, triggers and avoidance, emergency/ICU visits
-Vaccination
-Contact with animals, Travel

Examiner: 40-year-old male k/c of asthma on multiple inhalers, presented to ER with

worsening cough and SOB.

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.

Q1: Based on this history, give 2 DDx?

ABPA, Churg Straus

Q2: What investigations do you want to order?

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

Q5: List 6 causes of Pulmonary-renal syndrome.

• Wegner
• Churg Straus
• Microscopic polyangiitis
• Anti-GBM
• SLE
• PAN
• IE

Q6: Apart from Churg-Strauss, list 2 asthma plus conditions.

• Atopic asthma
 • Aspirin related asthma (SAMTER)
• ABPA

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

2. Systematic Review, Constitutional symptoms

-CVS: Orthopnea, PND, palpitations, chest pain
-Resp: SOB, orthopnea, PND
-GIT: steatorrhea, abdominal pain
-Autoimmune: arthralgia, rash, mouth-ulcer, alopecia
-Chronic Infections
-History of FB ingestion

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

Q1: What is your DDx?

• Kartagener
• CF
• Alpha-1 antitrypsin deficiency
Investigation
-CBC-D, RFT, LFT, INR/PTT, BG, ABG
-CRP, ESR
-IgG, alpha-1 anti-trypsin
-Sweat chloride 70 (high) and + for CFTR gene
-X-ray: hyperinflation, diffuse bilateral reticulonodular opacities
-HRCT: bilateral cystic changes, with thickening of alveoli consistent with bronchiectasis

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

1. Make sure that the patient is stable.

You find that the patient is hypotensive, tachycardic and febrile
ER Management:
Stabilize: VS, ABC, MOVIE

IVF: 30 ml/kg
Send pan-cx, cbc, RFT, LFT, LA, pro-calcitonin

What do you want to give?

Meropenem/Vancomycin

Examiner: After IVF, blood pressure improved

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

Q3: How to diagnose sepsis/septic shock?

*Sepsis -> sofa score (more than 2 criteria)
• Low platelets
• High bilirubin
• Change in LOC
• AKI
• Low PF ratio
• Hypotension

Septic shock ->

• persistent hypotension
• Despite IVF
• needs inotropes
• lactate > 2
Q4: What is the first hour bundle for septic shock?
• Pan Cx
• Lactate
• IVF (NS 30 ml/hr)
• Abx (broad coverage)
• Vasopressor (NE)
Case 19
45-year-old male k/c of MG presented to ER presented with SOB.

PPE
Introduction
Obtains Consent
Communicates effectively
Thanks the patient

ER Management:
Stabilize: VS, ABC, MOVIE

Examiner: patient is stable, proceed with history

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

2. Systematic Review, Constitutional symptoms

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

Q3: List 3 DDx for MG:

• Lambert Eaton
• GBS
• Botulism
• Aminoglycoside toxicity

Q4: List the differences between LE and MG?

1- Improve with exercise (LE)
2- LE associated with squamous cell ca, MG associated with thymoma
3- LE associated with autonomic dysfunction, MG associated with bulbar symptoms
Case 20
50-year-old male k/c of HBV liver cirrhosis presented to ER with hematemesis.
PPE
Introduction
Obtains Consent
Communicates effectively
Thanks
ER Management:
Stabilize: VS, ABC, MOVIE
Send blood for CBC-D, RFT, LFT, CE, blood cross match
History
1. Hematemesis – onset, amount, frequency
-Hx of CLD: previous diagnosis of CLD, previous bleeding, encephalopathy, ascites, jaundice
-Hx of gastritis: PUD, H. pylori, NSAIDS
-Medications: anti-platelets, anti-coagulants, steroids
-Precipitating causes of encephalopathy: Infection, metabolic derangement, constipation

2. Symptoms of anemia: fatigue, SOB, headache

3. Systematic Review, Constitutional symptoms

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

-GIT exam: assess for ascites, tenderness, splenomegaly, liver span

-CVS: auscultate for murmurs and apex beat
-Resp: auscultate for crepitations, wheezes and air entry
-CNS: motor, sensory and CN exams
Examiner:
BP 107/70, HR 90, pale, jaundiced and confused. What would be the next step in the work-up
for this patient?
Investigation
-CBC-D, INR/PTT, RFT, Ca/Mg, LFT
-CE and EKG
-US abdomen
Examiner:
Hgb 7.5, platelets 30, INR 1.3 Albumin 2
What is your management?
Management
-Admit to ICU for intubation (to protect airway), NPO, Gastro referral
-IVF/PPI/Octreotide/Abx/Lactulose
-Platelet transfusion (platelet less than 50), blood for cross match, blood and FFP standby
-Upper Endoscopy within 12 hours
-SCD

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

Q2: Endoscopy done showed esophageal varices. What is your dx?

-Esophageal varices bleeding secondary to HBV liver cirrhosis

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

2. Diarrhea: onset, amount, frequency, consistency, bloody diarrhea

3. Systematic Review, Constitutional symptoms

4. PAM FOSS

Examiner: 35-year-old male medically free presented to ER with weakness/numbness for 3

days preceded by diarrhea 3 weeks ago. The weakness of ascending, gradual, now patient
cannot stand, no previous history before. Associated with lower back pain. No headache or
decreases LOC. Other history negative.

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

What investigations do you want to order?

Investigation
-CBC-D, RFT, LFT, INR/PTT, BG, LP, MRI
-Na 130, GQ1B antibody positive
-Spirometry
-CT brain: normal
-NCS/EMG: decreased conduction velocity
-LP: cytology/albumin dissociation ratio
-MRI Spine: thickening of anterior spinal roots and cauda equina

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

Q2: What is your Dx?

GBS

Q3: What are the indications for intubation?

• Unable to maintain airway, FVC < 20
• FVC/MIP/MEP 20/30/40

Q4: What are the Complications of GBS

Respiratory failure, hyponatremia (SIADH), autonomic dysfunction

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