Medicine Handbook Cases

MED - Condition 006 Hair loss
Condition 006
Hair loss in a 38-year-old man
You are a Hospital MedicalOfficer working in a primary care clinic attached to a teaching hospital. This 38 year
old male newsagent has just consulted you about recent (2-3 weeks) hair loss from the scalp. One eyebrow is
also affected. He is otherwise well with no significant past or family history. The patient is very concerned
about possible future progression and wishes to ask you about the diagnosis and possible treatments. You
have completed an examination of the scalp. The findings are depicted below.
TASKS
Discuss the condition with the patient
Advise him about treatment
APPROACH
Good morning, I'm Dr. . I will be one of the doctors who will look after you today. How can I address you?
I can only imagine how difficult this must be for you, and I am here to help you get through this. But before I
continue with discussing your condition, is it alright if I ask you a few questions?
FOCUSED HISTORY
How did it start? Where did it start? Was it sudden in onset or gradual? Does a lot of hair fall or not? Is your
scalp itchy? Any discharge? Did you apply any creams or used any special hair products?
Did you have any fever, flu-like symptoms before this happened?
How is your general health?
PSYCHOSOCIAL+HEADSSS
How is your mood? Sleep? Appetite? (screening questions only)
Any particular stress at home? How about at work?
FH: any family history of baldness?
Based on the history you gave me and the findings, it seems that most likely you are having a condition called
alopecia areata. Have you heard about it? Let me explain the condition to you.
This is a disorder of the hair follicle that causes complete hair loss in patches leaving a smooth, clean, normal
scalp or other area normally covered in hair.The exact cause is unknown, but it
is usually said that this is anautoimmune condition,where the body's natural defenses tend to act against its
own normal tissues. In this case, the body's defenses then acts to your hair follicles causing it to fall. These
are also known to be triggered by a recent viral illness, or psychological stress.
A smaller localised patch will usually recover spontaneously within 12 months, though some may not. Alopecia
areata can cover an extensive area and rarely it may cover the whole scalp (alopecia totalis), even the eyelids or
eyebrows, when recovery is unlikely. There seems to be a different response to treatment per person.
Unfortunately if the hair loss persists for years, the prospect of hair regrowth is diminished, although the
potential for regrowth always remains because the hair follicle is not destroyed.
TREATMENT:
I will make a plan for you so that we can try to manage your condition the best way we can
You need to adapt lifestyle modifications. Please eat a healthy well balanced diet, engage in regular physical
exercise and avoid smoking and cut down your alcohol intake. Please try relaxation techniques such as
meditation and yoga as the stress you're experiencing tend to trigger this condition.
We can start with topical medications that aim to stimulate hair regrowth which we can use for 3-6 months.
Potent topical corticosteroid applied once or twice daily (betamethasone)
Or hydrocortisone cream application
I can also refer you to a dermatologist who can assess you further and manage your condition. He might
consider giving intralesional corticosteroid injections (triamcinolone acetonide) for small patches like that in
your eyebrows or resistant patches. However, multiple injections are usually required to achieve the
desired effect.
Oral corticosteroids may be considered if these topical treatments prove to be ineffective, with tapering
dosages over two months.
The dermatologist may also consider topical immunotherapy or ultraviolet phototherapy as adjunct to the
treatment of resistant cases.
As these medications tend to take a while to take effect, you may opt to wear a wig or a hair patch as well.
These steps may take a while and there are still possibilities that these treatments might not work, but do not
worry too much. It is good that you came here early, and we will arrange regular reviews with you to
monitor your condition
Here are reading materials to give you more insight about your condition
Are you happy with this plan?
KEY ISSUES
Effective communication skills are very important.
Appropriate language, verbal and non-verbal communication, and good interpersonal skills should be
displayed
Show empathy, sensitivity and perceptiveness, as well as being honest and generating trust and confidence are
particularly important in a chronically relapsing condition such as this which significantly affects the
patient's appearance
Place of topical and systemic treatment and prognosis
CRITICAL ERRORS
None defined
IMPORTANT POINTS FROM THE COMMENTARY

Alopecia: generic term for hair loss
Alopecia areata: one or more discrete circular areas of hair loss. It may occur anywhere in the body
Alopecia universalis: complete hair loss from the whole body. It is a variant of alopecia areata
Autoimmune disease
Patches in scalp may regrow, remain unaltered, or enlarge, or coalesce into alopecia totalis (whole scalp)
33% chance of complete regrowth within 6 months
50% chance of complete regrowth in one year
80% of patients eventually relapse
If hair loss persists for years, regrowth is diminished
Potential for hair regrowth always remains because the hair follicle is not destroyed
Unknown etiology
Family history present in 20% of cases
Link to organ-specific autoimmune disease
Triggered by a febrile illness, severe emotional stress,
MED - Condition 012 Thalassemia minor

Sunday, 21 May 2017 2:12 PM
Condition 012 Thalassemia minor in a 22 year old woman
You are working in a general practice. Your next patient is a 22 year old woman who recently had a self-limiting
febrile illness, which was suspected to be infectious mononucleosis (IM). She is now fully recovered. Blood tests
for IM were negative, but the full blood examination showed a hypochromic microcytic anemia of 108 g/L.
the mean corpuscular volume (MCV) was below normal (68 cubic microliters - normal 80-101). You followed
this up but there was no evidence of chronic blood loss (other than normal menstruation). Serum iron and
ferritin estimations were also normal. You suspected beta-thalassemia minor (Mediterranean anemia)
and this has been confirmed by electrophoresis which showed elevated Hb H2 level (4.3%).
You are aware of her Greek descent and that she has just become engaged to be married. Her fiance is also of
Greek descent . The family history is that her mother, father, and brother are all alive and well. Her
grandparents died in Greece and both were very old. One of her father's brothers was reported to have died
in childhood from an unknown cause. The patient is very worried about being told she is anemic, and as she is
to be married shortly, is worried about the effects on any of the children she hopes to have.
The patient has returned to discuss her results with you.
TASKS
Explain the nature of the condition to the patient
Answer the patient's questions
Advise the patient what should be done now.
APPROACH
Are you comfortable enough in this consultation room?
I understand that you are here to discuss the blood results that you have but before I continue, I would
like to know what have you been told about your medical condition so far? What is your understanding of the
reasons why reasons why we did the blood tests?
Your full blood examination is showing that you have low levels of hemoglobin, which is the protein in your
red blood cells that carry oxygen to different parts of your body. The size of the red blood cells are also seen
to be reduced. This sort of a picture can be seen in two conditions: one is in Iron Deficiency Anemia, but
the iron studies we have done for you has turned out to be normal. Another condition is thalassemia.
Thalassemias are a group of inherited blood disorders where there is defective production of hemoglobin.
This happens when the genes are mutated and they are permanently altered. We did another test called
hemoglobin electrophoresis to confirm presence of these genes, and results confirmed that you have
Thalassemia.
This is not usually uncommon, and is usually found in people with Mediterranean races, such as in your case, as
well as in Indians, Africans, and Southeast Asians.
However, the best part is, what you are having is a minor version of this disorder called a Thalassemia minor,
which carries no symptoms other than sometimes a mild anemia. It means that you are a "carrier" of this trait,
having the genes but do not fully manifest its effects in you.
Be assured that this condition is not serious to your own health, but since this is an inherited condition, it
might have implications which will depend on your fiance's genetic status as well.
Because of this, it is always better to get your partner tested as well, as that will decide if your future children
will be having Thalassemia or not.
If you alone has thalassemia minor, there is a 50% chance that your baby will be normal and also another 50%
chance of him developing thalassemia minor
If both of you are having thalassemia minor, there is a 50% chance that your baby will have thalassemia minor,
25% of him having thalassemia major, and 25% chance that he could be normal
I will refer you to a hematologist for further assessment of your condition. I can start you on folic acid tablets
that can somehow help with your mild anemia.
If you become pregnant, we can have tests to confirm if your baby will manifest with thalassemia as
well. You will be referred you to a high risk pregnancy clinic where a multidisciplinary team will look
after your entire pregnancy. If there is a chance of the baby getting affected, I genetic counselling will be
considered for you as well. But rest assured, it is still possible that you can still have a normal course of
pregnancy in the future.
Aside from your partner, I advise to have your relatives be screened for this thalassemia trait as well. Given
your blood test results, your Mediterranean race and your family history of unknown causes of death of
some of your relatives in childhood, it is possible that they can be carriers and it may have implications in
their future children as well.
I will give you reading materials that can give you more insight about your condition
I will regularly review you to monitor your condition.
Just in case you develop severe tiredness, shortnessof breath, easy exhaustion, or if you develop some
bleeding or develop a yellowish tinge in your skin, please come back to have a review immediately.
KEY ISSUES
Patient counselling regarding inheritance implications
Initial management plan
CRITICAL ERRORS
Failure to advise that the prospective spouse should be investigated for carrier state
Failure to understand principles of Mendelian recessive inheritance

Thalassemia is a common anemia in certain areas of the world including the Mediterranean region, India,
Southeast Asia, and Africa.
Pathology
Underproduction of either alpha or beta chains resulting in microcytic red blood cells
Hemolysis because of imbalance resulting in excess globin chains
Oxidized and result in premature RBC removal in the spleen
TYPES
Heterozygous alpha-thalassemia involving the alpha-chains is also compatible with survival
Homozygous state results in fetal hydrops and death in utero
B-thalassemia is a condition involving the beta chains with both homozygous and heterozygous states
being compatible with survival to term but with major differences in outlook
CHARACTERISTICS OF B-THALASSEMIA MINOR
Symptomless hypochromic microcytic anemia (rarely below 100g/L) with decreased mean corpuscular volume
(MCV) and usually normal red blood cell count
Diagnosis needs confirmation by serum electrophoresis (elevated HbA2)
Anemia does not respond to any form of iron therapy, unless the patient also happens to be iron-deficient
which is very rare
Initial management plan
Reassure the patient regarding effect on her health
Iron therapy is NOT indicated
Oral folic acid of 1mg per day will more than meet the requirements
of the mildly increased red cell turnover
Advise screening for partner and for relatives
Counsel the patient that it is a recessive inherited trait ("carrier state")
◊ Nature of the condition and possible consequences if conjugal partner also carries the trait
◊ Information about b-thalassemia major and risks of its occurrence in offspring and availability of
antenatal diagnosis and management of pregnancy if fetus is shown to have b- thalassemia major
B-thalassemia major is rare, but very serious congenital anemia requiring lifelong transfusional support
Need treatment to avoid complications of iron overload related to frequent transfusions
Important points of assessment (in this case)
Knowledge of mendelian inheritance (what is recessive inherited trait and what are its implications)
Meaning of
Heterozygous inheritance: results in B-thalassemia minor
Homozygous inheritance: results in B-thalassemia major
Advise that fiance be tested for B-thalassemia minor
MANAGEMENT
Hemoglobin test for B-thalassemia minor in the fiance is NEGATIVE
No further action required
Explanation of carrier state is required (can affect male or female children) -- each
offspring will have an equal chance of being a carrier or non-carrier
If fiance has a POSITIVE test
Need counselling about risks to fetus which are 1:4 for B-thalassemia MAJOR (25%) and
1:2 for B-thalassemia MINOR (50%--carrier status)
Diagnosis can be made by in-utero genetic sampling at 12-14 weeks.
If both partners are carriers, there is no cause for undue alarm because of increased
awareness, diagnostic certainty, known risks, and availability of antenatal diagnosis and
safe termination procedures
MED - Condition 019 Excessivealcohol consumption

Condition 019
Excessive alcohol consumption in a 45 year old man
You are working in a general practice. You are about to review a 45-year-old
businessman who consulted you two days ago about his drinking after seeing a TV
program about the harmful effects of alcohol.
At the previous consultation you established the following:
He is drinking excessively (at least five standard drinks every day)
This is of long standing--at home, at work and socially
He has problems at work
He has trouble with his close family relationships
His sexual performance is impaired
He has had two minor traffic accidents in the last year
He has a family history (grandfather) of alcoholism, and
On examination he is overweight (BMI 28kg/m2, hypertensive 180/90 mmHg, and has
hepatomegaly
Youtold him that his useof alcohol appears to be excessive and you ordered liver
function tests and a full blood examination. He is seeing you today for the results of
the tests which are as follows
LIVER FUNCTION TESTS

BILIRUBIN TOTAL 14umol/L (<20)
ALP (Alkaline phosphatase) 50 u/L (25-100)

AST (Aspartate transaminase) 45u/L* (<40)
GGT (Gamma glutamyl 65 u/L* (<50)

transaminase)
Serum albumin 32g/L (32-45)
Full blood examination: this showed a normal hemoglobin level (145 g/L) with
macrocytosis and elevated mean corpuscular volume (MCV) of 106 fL (normal range 10-
96) and some variations in red cell size and shape (Anisocytosis and poikilocytosis).
Other features were normal.
TASKS
Explain the results of the tests to the patient
Discuss the effects of the excessive alcohol consumption
Counsel him about his drinking
You do not need to take any further history, nor perform any examination.
APPROACH
Good morning, I'm Dr. . I'm one of the doctors who will look after you today. How can I
address you?
I understand that you are here to discuss your blood test results with me. But before I
fully discuss these with you, I would like to know if you are aware why we did these tests
to you?
I will now explain the results to you, and sorry for using some medical terms but I will
try to explain each one to you. Please feel free to stop me if you have any questions.
EXPLAIN THE RESULTS TO PATIENT
Given your history of alcohol intake, we tested factors in your blood which generally
check for your liver function, namely the Bilirubin, AST, ALP, GGT, and serum album, as
liver damage tend to be one of its worrying outcomes. We also tested for your full
blood exam and blood smear results as alcohol intake also tend to affect the
formation of blood cells in the body.
Your results show an elevated levels of GGT, and AST, suggesting that your liver tends to
overwork thereby developing damage already. In relation to that, we have seen that
your red blood cells which carry oxygen to different parts of the body to maintain its
function,were shown to be bigger than the usual, as shown by the increased MCV, and
some of your red blood cells also have different sizes and ages. This suggests that there
might be some problems in the formation of these red blood cells. Collectively, this
whole blood picture with your liver function test results suggests suspicion of liver
disease due to excessive harmful alcohol intake. Do you understand so far?
This excessive drinking can also be linked to you being overweight, thereby contributing
to development of your hypertension as well.
But do not be afraid, it is good that you came here for consult as we will do something
to ensure that these complications can be controlled.
DISCUSS EFFECTS OF EXCESSIVE DRINKING IN COUNSELLING AND EDUCATING THE PATIENT
Aside from the liver damage, weight gain, development of hypertension, alcohol also has
effects on our food passage, causing bleeding ulcers inside, as well as heart problems as
excess use can enlarge the heart and cause heart failure. It can also lead to problems in
the central nervous system or the brain, causing shakiness, imbalance, and memory
problems as well.
Aside from the physical signs, excessive alcohol intake can also affect mainly
relationships. As you tend to lose part of yourself because of its influence, this may
cause problems in your relationships with family members, your work performance,
sexual performance. Harmful intake may lead to trouble with law, and even accidents as
well, as was shown in your case.
But again,Iamgratefulthat you cameherenowas youare concernedaboutyour health.
That is already a big step for you, and I reassure you that we will do something about this.
From a scale of 1-10, how highly motivated are you to stop this habit?
COUNSEL ABOUT HIS DRINKING
I would just ask you some questions about your drinking. Is that okay?
CAGE
◊ Have you tried cutting down your alcohol intake?
◊ Have you ever been annoyed by criticisms of your drinking habits?
◊ Have you ever felt guilty about this?
◊ Do you require alcohol early in the morning?
Benefits of quitting
If you are motivated enough to quit, we can do this together. We can avoid all those
thingsthat I've mentionedearlier. We can also preventthe progress of your liver
damage. You can improve your social relationships, improve performance at work, sleep
better, and more money saved.
ASSIST
As of now I would like to advise you about the safe limits of drinking:
According to the NHRMC guidelines, the safe limit of alcohol is 2 SD per day. There will be
an equivalent for each drink you have, and you will be able to see it in the label of your
drink.
In your case, you have been drinking around 5 SD per day, and I am really concerned as
this level is quite high and related to its harmful effects.
However, if you decide for complete abstinence of alcohol, it is possible that you can get
withdrawal symptoms. This usually occurs if you have alcohol dependence.
It usually peaks in a day or two and improves in around 5 days' time. You will be able to
feel headache, nausea, vomiting, stomach cramps, sweating, racing of your heart, and
craving for alcohol.
However, this is what I am most concerned about: in some situations, fits,
hallucinations, delusions or problems in your perception can happen. This is a condition we call, Delirium
Tremens as an effect of alcohol withdrawal.
Just in case you'll feel any of these, please come to the ED immediately. But do not worry, we will
monitor you and give you medications in the hospital in case you develop these symptoms
If you agree, we can try a period of abstinence for you so that we can fully assess your level of physical
dependence with alcohol. Again, we will provide you all the support you need in order for you to overcome the
challenges of this habit
Ultimately, quitting alcohol is your decision. And whatever decision you make, we will be here to give you the
support you need to become better.
I can refer you to a support group called alcoholics anonymous.
Please adapt a healthy lifestyle by eating a well-balanced diet, doing regular physical exercise as well. I can
arrange a dietitian for you to help you with your diet as well.
I will arrange a review with you in three days to check on you, and if ever you decide to finally quit the habit,
please come back so that we can create a plan to help you quit.
Here are reading materials to give you more insight about your condition.
Do you have any questions?
KEY ISSUES
Interpretation of results of liver function tests (LFTs) and full blood examination (FBE)
Explanation of effects of hazardous and harmful drinking
Advising a period of abstinence to establish type and degree of dependency.
CRITICAL ERRORS
Taking a judgemental attitude and blaming patient for his condition

Patient is likely to have a true physical dependency
Next step in management: test this assumption by asking the patient to try abstinence and see what happens
Subsequent management: depend on result and willingness of the patient to accept and control the type and
degree of dependency on alcohol
MED - Condition 034 Headache in a 35 year old
Condition 034
Headache in a 35 year old woman
Your patient, a 35-year-old woman, is consulting you in the Emergency Department of the local hospital about
headaches. You have not seen the patient before.
TASKS
Take a focused history from the patient
Request from the examiner the essential features of the physical examination you would look for in this patient
as the next stage in the diagnosis. The examiner will inform you of the results.
Tell the patient what you consider to be the most likely diagnosis and what investigations, if any, should be
undertaken.
APPROACH
Good morning, I'm Dr. . I will be one of the doctors who will look after you today.
I'm sorry to hear that you are having headaches. But before we proceed further with this consultation, may I
ask if you have any pain right now? Can you point to me where exactly is the pain? From a scale of 1-10, 10
being the most painful, how bad is your pain right now? Do you have any allergies? I can give you some
painkillers to make you more comfortable, is that okay? I will talk to my examiner first, and get back to you, is
that alright?
I would like to offer some pain killers for my patient. And I would like to know what is her BP and is there a
postural drop, pulse and its rhythm, respiratory rate and oxygen saturation, and temperature?
If not stable, transfer to resuscitation room, insert IV lines and draw blood
HISTORY
Again I can see that you are very distressed about your headaches. It's good that you are here so that we can
have a look at you and help you with this. Can you tell me more about your headaches?
Where exactly is the pain?
When did it start? Is this the first time that this happened?
Is it always there, or does it come and go? Did it become worse recently?
During attacks, how long does it last?
Can you describe to me how the pain is like (character of the pain)? Is it sharp, throbbing, band-like?
Does the pain go anywhere else?
Any nausea, vomiting, visual disturbances, recent cough or colds, ear pain, dizziness? Do you become
extremely sensitive to light and sound? Any weakness, slurring of speech? Any numbness? Any recent head
injuries? Fever, Rash, Weight Loss, Night sweats, Loss of appetite? Been in contact with someone with a similar
problem or a flu-like illness?
Does it occur or worsens at particular times in the day? Have you noticed if it is related to yourperiods?
Is there anything that makes the pain worse? Go away? Did you take medicines for it?
From a scale of 1-10, 10 being the most painful, how bad is your pain during these attacks?
How did this condition affect your daily activities?
Is this the first time that you've consulted about this?
How is your general health? You regularly go to your doctor?
Any concerns about your period?
How are yourwaterworks?
SADMA
Do you smoke? Drink alcohol? Engage in illicit drug use? Coffee intake?
Do you engage in regular exercise? DO you have a regular balanced diet?
Any previous medical illnesses or surgeries? Do you have any allergies?
QUICK PSYCHOSOCIAL HX
How is your mood recently?
How is your sleep? You still enjoy the things you usually do?
Are you generally an anxious person?
How is everything at home? At work? Any stresses recently?
Have you felt your headaches became worse with these stresses you have at work recently?
Any family history of a similar problem?
PHYSICAL EXAMINATION
GENERAL APPEARANCE: BMI, PICCLED, RASH?
VS: BP with postural drop, HR with rhythm, RR with sats, Temperature
HEAD AND NECK EXAM: Inspection of head: Signs of head trauma: bruises, deformities?
EYE: PEARL, FUNDOSCOPY
EYE MOVEMENTS (CN 6 first affected by ICP, 3rd nerve affected by aneurysms)
HORNERS: Miosis, ptosis, anhidrosis
Watery eyes
ENT: check sinuses, runny nose, tenderness
Neck stiffness: rigidity
Carotid Bruit (if indicated--irregularly irregular pulse, stroke)
NEURO EXAM: F. A. S. T. (Motor and sensory loss in face, upper and lower limbs, weakness in limbs, fits, speech,
abnormality of gait)
GTPRCS: GAIT, TONE, POWER, REFLEXES, COORDINATION, SENSORY
Any hemiparesis orhemiplegia?
CVS: heart sounds and rhythm and murmurs
Chest: good airway, clear breath sounds?
Abdomen: distention, masses, tenderness?
OFFICE TESTS: UDS, BSL, PT?
EXPLANATION
From history and examination, most likely you have a condition called Tension Headache. Sorry for the
medical term, but have you heard about this? Let me explain the condition to you.
This headache is caused by an overactivity or contraction of the muscles of your scalp, forehead, and neck, which
causes a dull ache or tightness in these areas, causing you to feel a tight band around your head or having a
heavy weight on top of your head. This is a common condition among people your age. This is usually stressed
induced, both emotional and physical stress can trigger this, that is why you have been feeling it becoming
more frequent as you were becoming more stressed for the past few weeks.
I reassure you that we cannot fully consider a more sinister cause of headache as of this moment since you have
normal physical examination findings, plus you do not have alarming associated symptoms like a high blood
pressure, nausea, vomiting, visual disturbances, or slurring of speech. So no special investigations are
indicated at this stage. But for your comfort, I can refer you to a neurologist for assessment of your
headache.
What we can do for you now is this, I can give you pain relievers which you can take to address your
headache. But primary to addressing your condition is having a lifestyle change. First, you needto adapt a
healthier lifestyle.Try to engage in physical exercise and relaxation activities, with your friends and family if
you can. You also need to take a healthy diet, and at appropriate times of the day--do not skip a meal! I can
refer you to a physiotherapist to help you with relaxation techniques as well. You need to take it lightly and
please don't carry stresses at home. If possible, please take some time off and go for a holiday. I can give you a
letter for that.
I will review you regularly to monitor your progress.
However,if everyou feel any slurring of speech, weakness, nausea, vomiting, or if your headache worsens,
please come back to the ED immediately so that you can be assessed again.
Here are some reading materials which you can use to give you more insight to your condition.
KEY ISSUES
Use of communication skills to elicit the most relevant and important points in the history
Focused physical examination in a patient complaining of longstanding headache
Confidence in diagnosis of tension headache based on typical history, normal physical examination, patient
concern about a serious cause and lifestyle factors
Recourse to investigations (CT or MRI) unnecessary at this stage but allowable to diminish patient concern
Arrange follow-up to assess therapeutic effect of this initial assessment
CRITICAL ERRORS
Failure to request blood pressure and ophthalmoscopy findings
Failure to indicate the most likely cause is tension headache and that a serious cause is most unlikely

The candidate who takes immediate control over the interview by asking a series of direct questions about
site, duration, intensity, etc, may successfully reach the diagnosis of tension headache, but is likely to overlook
the patient's recent concern about a serious cause and miss the real cause (lifestyle factors) with two
consequences
Referral for unnecessary investigations which increases the patient's anxiety about a serious cause
Missing the opportunity to convert the diagnostic approach into the appropriate therapy by improving self-
understanding by the patient
Should then start history with an open-ended approach, listening, and encouraging the patient to tell the
whole story including concerns and life situation
MED - Condition 036 Syncope

Condition 036
Syncope in a 52 year old man
You are working in a general practice. Your next patient is a 52 year old technician who is consulting your about
recent transient loss of consciousness.
TASKS
Take history from the patient
Ask examiner for the findings of the focused physical examination you would perform
Tell the examiner your diagnosis and the reasons for this
Indicate to the patient how you would proceed in your further assessment of his condition
APPROACH
HEMODYNAMIC STABILITY
Good morning, I'm Dr. . I am one of the doctors who will look after you today. How may I address you?
I understand that you are here because you had a transient loss of consciousness earlier. Could you tell me
more about it?
HISTORY
Can you tell me exactly what happened?
PRE-SYNCOPE
What were you doing just before it happened? (r/o reflex mediated)
Sitting then stand up - postural hypotension
Standing for a long time, then I fell and fainted - vasovagal
Any nausea, vomiting, headache, vision problems, chest pain, shortness of breath, racing of the heart?
DURING SYNCOPE
Approximately how long were you unconscious for?
Did anyone witness the episode?
With your consent, I would like to ask him a few questions [CRITICAL ERROR IF YOU DON'T MENTION CONSENT]
Could you describe to me what happened?
Any jerky movements? Uprolling of the eyes? Did he wet or soil his pants?
AFTER SYNCOPE
Were you able to get up by yourself? Rule out focal neurologic causes, or rule out fractures/other injuries
Any tongue bites?
Any residual headache? Drowsiness?
Any confusion?
Do you know where you are? What day is it today? Do you know who I am?
Did you wet or soil your pants?
DDx questions
Any weakness, headache, nausea, vomiting, vision difficulties, difficulty walking, swallowing? - r/o TIA/Stroke
Any pins and needles anywhere? (stroke)
Did you have any jerky movements? Any fits? (epilepsy)
Any recent fever or flu-like illness, neck stiffness/pain (meningitis)
Any Shortness of breath, chest pain, racing of the heart (cardiac)?
Aortic stenosis triad: SYNCOPE + ANGINA + EXERTIONAL DYSPNEA
HOCM: is there any sudden cardiac death in the family?
Did you skip your meals by any chance? Have you been more thirsty than the usual? Have you been going
to the toilet more than the usual (hypogly/DM)
Any tummy pain, sudden episodes of fainting/dizziness, any darkening of the skin (addisons)?
Any recent head injuries? (trauma)
Any lumps or bumps? Any recent change in weight or appetite? Any night sweats? (malignancy)
Psychogenic: stress, anxiety, mood
Any stresses at work or home? How are the stress levels in your life?
Are you generally an anxious person? Do you worry a lot about trivial things?
How is your mood lately?
SAD + Coffee
Social (whenever a patient needs assistance)
Who do you live with? Who is there to take care of you? Any financial problems? Do you have good support?
PH: any past history of medical or surgical illnesses? How's your general health? When did you have your last
general check-up?
FH: any family history of medical or surgical illnesses?
GA: PICCLED + RASH
BMI
VS: BP with postural drop, HR, RR,O2 sat, Temp
CNS: I would like to do a full neurological examination of the upper and lower extremities, including all cranial
nerves, and cerebellar examination. level of consciousness, any focal neurologic deficits?
NECK: Carotid and thyroid bruits, NECK STIFFNESS, JVP
CVS: S1 and S2, murmurs?
RESPI: equal air entry, crackles?
ABDOMEN: distention, mass, tenderness, BRUITS (Aortic/renal)
OFFICE TESTS: BSL, UDS, ECG
PE FROM THE HANDBOOK

Cardiovascular examination
 PR 70
 BP 118/88 lying and standing
 JVP normal
 Systolic bruit over both carotid at the base of neck, loudest on right
 Prominent left ventricular impulse apex beat not displaced
 ESM 3/6 best heard over aortic area radiates to neck and apex
Neurological examination normal

There are no other abnormal physical findings.
DIAGNOSIS AND DIFFERENTIALS

The loss of consciousness was most likely due to an abnormality in one of the heart valves. In your case, most
likely you are having a condition we call as Aortic stenosis. Do you know what it is?
[ILLUSTRATE] This is your heart and it has 4 chambersand bloodflows through these chambers through the
valves allowing blood to flow in one direction. In your case, this is narrowed, causing less blood flow to the
heart and to the rest of the body including your brain, that is why you are feeling these symptoms, like arm
weakness and speaking difficulties. And also the same blood vessel supplies blood to the heart and when
you're playingtennis, due to the increased body demand and decreased blood supply you felt pain in the
chest and breathlessness.
But I would like to refer you to the hospital to confirm this and so that you will be seen by the specialist and to
rule out other conditions such as a mini-stroke or a problem with
the beating of the heart. In the hospital, they will do further investigations, most importantly an ECG and
an ECHOCARDIOGRAM, which will confirm the narrowing. The specialist might also consider doingthe CT of the
brain and Carotid doppler to rule out mini strokes. If it is negative, you'll be seen by a cardiologist and further
treatment will be given based on the severity of your condition/echo findings.
Most likely they might also consider surgical procedures like valvuloplasty / valve replacement or coronary
catheterization depending on the severity of your condition.
Once discharged from the hospital, I will be regularly reviewing you. Please avoid strenuous physical activities,
and please adapt healthy lifestyle modifications.
KEY ISSUES
History must elicit details of syncope, exertional dyspnea, and chest discomfort
Examination must request pulse, blood pressure, presence of carotid and cardiac murmurs
Choice of investigations must include ECG, and echocardiogram
Diagnosis must recognize that this patient's syncope has a serious underlying cause
CRITICAL ERRORS
Failure to ask about cardiovascular symptoms
Failure to request examination finding for both carotid and cardiac bruits

Syncopal episodes are common, accounting for 3-5% of attendances at Emergency Departments affecting 15-
25% over any 10 year period
Prevalence increases with age
An attack of sycope is associated with major morbidity such as fractures and motor vehicular accidents, and
minor injuries such as lacerations and bruising.
Essential to distinguish syncope from seizures and syncope caused by benign causes and from serious underlying
illnesses.
Middle aged + syncope + angina + exertional dyspnea
Causes
Neurally mediated syndromes (vasovagal/vasodepressor syncope, carotid sinus syncope)
Orthostatic syncope (volume depletion, drugs, autonomic failure)
Cardiac arrhythmias (bradycardias and tachycardias)
Structural heart disease
Cerebrovascular disease
History approach
Eye witness account is important
Must elicit that syncope comes on with exertion and against a background of cardiovascular symptoms of
chest pain and shortness of breath
Absence of palpitations: against arrhythmia but still a possibility
Exclude epilepsy and other neurological causes
Carotid sinus syncope and vasovagal syncope may be considered but other features are not apparent (head
turning relationship with the symptoms)
PE approach
Careful cardiovascular examination
Look for evidence of structural heart disease in particular for features of aortic stenosis
Systematic
Start from peripheral pulse and BP
Examination of carotis
Nature of cardiac apex beat
Request for details on heart sounds and murmur
Characteristics
Site
Radiation
Investigations
ECG and echocardigram
Referral to cardiologist would be an appropriate step to take
MED - Condition 041 An itchy rash on the hands

Condition 041
An itchy rash on the hands of a 19 year old woman
You are a Hospital Medical Officer in a general medical outpatient clinic. A 19 year old female computer
student presents with an itchy rash on her hands. The rash has been present for about one week and appears as
shown in the photograph. There are no abnormal examination findings apart from the rash.
TASKS
Take further focusedhistory
Explain the most likely diagnosis to the patient and how this can be confirmed
Advise the patient about treatment
APPROACH
Good morning, I'm Dr , I will be looking after you today. How may I address you?
I'm sorry to hear that you are having this itchy rash. I can only imagine how uncomfortable this must be for
you. But I will do my best to assess you and find out what's causing this. Could you tell me more about the
rash?
HOPC
When did it exactly start? Where/what part of the body did it start? Is it itchy or scaly? Is it oozing? What color
is the rash? Has the rash been spreading? Been worsening? Any aggravating or relieving factors? Isthe itchy
more severe at the night (yes)? Is there any trigger factors for the itch like a change in temperature (Wash
with hot water make the itching worse)?
Is this the first time you're having the rash?
Have you been in contact with anyone with a similar condition? Who is it?
Have you held or in contact with any irritants like chemicals or plants?
Associated symptoms: any fever, pain? How is your general health so far?
SOCIAL HISTORY-TRAVEL-SADMA
I will be asking you some personal and sensitive questions, but rest assured these will only be between the two
of us unless it will be harmful to you or to others. Will that be okay?
Who do you live with? How many are there in the house with you? Any stresses at
home? How about in work?
Are you sexually active? Do you live with your partner? Do you practice safe sex? Does he have the same rashes
as you have?
When was your last pap smear?
Have you traveled recently? Where?
Do you smoke, drink alcohol, engage in illicit drugs?
Any previous history of medical or surgical illnesses?
Any family history of a similar condition?
EXPLANATION
Based on history and examination, it seems that most likely you have a condition called, Scabies. Have you
heard about it? Let me explain this condition to you. This rash is caused by a mite called sarcoptes scabei.
The typical lesions from the infection are found on the feet, hands, and axilla, especially between the spaces
of your fingers. It is feels very itchy because the female mite burrows inside the skin and lays its eggs. The eggs
then hatch into mites, and these mites secrete factors which cause an allergic reaction (antigen) to the skin,
causing itchiness. To confirm the diagnosis, I would like to take the scrapings from your rashes and
examine it from the microscope.
It is very contagious and is spread by close contact, and even sexual contact. As you have shared that your
partner also have these similar lesions, please tell him to see me as well so that I could treat him of his
condition. It is also very important that I'll be able to see your close contacts--especially your family at home,
to avoid spread of this infection. But do not worry, although it can be contagious, it is not very serious, and
can be easily treated with the right medications.Compliance to the medications and advice that I will give you
is essential sothat we can control and fully treat this condition.
I will provide you a script for the cream that you will be using. Please apply (permethrin cream 5%--Lyclear),
this cream to the whole body from the jawline down to the feet, leave overnight, and then wash off
thoroughly. Please avoid hot baths or scrubbing before application.
Alternative: benzyl benzoate lotion 25% (Ascabiol), leave on for 24 hours, then wash off
Aside from that, please wash all your clothings and linens with hot water, and hang them in the sun to dry.
Please avoid sexual contact with your partner until he has also been properly treated of his condition.
I will review you after 3 days to check for progress of your condition and once lab results are available. It may
be necessary to repeat the treatment again in a week's time if infection is still present.
Here are reading materials which you can have to give you more insight about your condition.
KEY ISSUES
Approach to patient -- ability to establishsatisfactoryrelationship with patient to achieve compliance and
cooperation of patient to get boyfriend to seek treatment
History -- ability to take an appropriate history including site and severity of pruritus and sexual partner as
source of infection
Diagnosis -- should advise microscopy of skin or scrapings to facilitate diagnosis
Management -- provide adequate advice for proper treatment and advice the patient to avoid intimate
contact with boyfriend until he has been treated
CRITICAL ERRORS
Failure to suspect scabies or take action to confirm diagnosis

Scabies
Highly contagious
Spread through close contact, including sexual contact
Widespread inflammatory papules and severe pruritus and it can be endemic among school children and
institutionalized older patients
pathology
Female mite burrows beneath the skin to lay eggs and then dies
Eggs hatch into mites which spread throughout the skin and live for about 30 days
Mite antigen in the excreta induces a hypersensitivity rash
Clinical features
Intense itching, worseat night and when hands and body are warm (after a shower)
Erythematous papular rash usually on hands and wrists
Rash in webspaces, on male genitalia, on elbows, axillae, feet, ankles, nipples of females
Diagnosis confirmed by microscopy of skin scrapings
MED - Condition 043 Swelling of both ankles
Condition 043
Swelling of both ankles in a 53 year old woman
You are working in a general practice. The patient you are about to see is a 53 year old clerical worker who is
consulting you about bilateral swollen ankles as illustrated below.
TASKS
Take a relevant history from the patient (you have five minutes to do this)
Tell the patient your working diagnosis as to why the ankles are swollen after concluding the history
Describe to the examiner the essential features you would look for in physical examination to confirm your
provisional diagnosis
Differentials of ankle edema:

Cardiac failure
Renal failure Liver failure
DVT/Thromboembolism Anaphylaxis
APPROACH
I'm sorry to hear that you are having this swelling on your ankles. I can only imagine how
uncomfortable this must be for you. But I will do my best to assess you and find out what's causing this. Could
you tell me more about this?
HISTORY
When did it start? Was it sudden or slowly progressing?
Is it present in one or both ankles?
Is it just in the ankles, or does it involve other parts of your body as well?
Is there anything that makes it better or worse?
Is it becoming worse while walking and improves at rest?
Is this the first time that this happened?
Is there any pain on your legs? Any difficulty walking?
Do you have any shortness of breath? When do you notice it? Does anything make it better or worse (r/o
exertional dyspnea in CHF)
Do you unusually feel exhausted when doing your usual activities? Or do you easily get exhausted when
exerting effort in your usual activities?
Do you have any chest pain or discomfort? Does it come at rest or only duringactivities? When did it start? (if
positive for any history of chest pain, ask further about that episode--angina at rest/only with activity,
any meds taken, hospitalizations, consultations done?)
Do you have any difficulty lying flat on the bed at night because of shortness of breath? Do you need to prop
up your head with pillows to be more comfortable?
Do you snore?
Do you have any racing of the heart? Can you tap it out for me? When does it usually occur? Or is it constantly
there all the time?
Other DDx
Do you ever felt dizzy or had black outs recently?
Any cough, colds, fever, chills, shakes, tummy pain?
Any weight loss or lumps in the body?
Do you have any skin color changes? Any itchiness noted? Changes in the color of stools and urine? Any issues
with your water works and bowel motions? (r/o renal and hepatic disorders)
Any weather preferences?
Any recent travel? (r/o DVT)
How can you describe your general health? Do you undergo regular checkups? Were you ever treated for any
medical or surgical illness?
Do you smoke, drink alcohol, engage in illicit drugs?
Do you have any particular diet? Do you engage in regular exercise?
What is your occupation? Any stresses at home and at work? How does your condition affect your usual
activities?
Do you have any family history of heart, kidney, liver conditions? Any cancers in the family?
PROBABLE DIAGNOSIS TO THE PATIENT

It seems that most likely you have a condition called congestive heart failure. Have you heard about this?
[illustrate] This is the heart, and it is situated immediately beside the lungs. It has 4 chambers, and the right
side of the heart pumps blood from the rest of the body to the lungs, and the left side of the heart pumping
blood from the lungs to the rest of the body. Normally the heart functions to pump all of the blood in the
body to be able to optimize bodily functions. In your case, the heart is failing to do that. Now, there can be
many causes of heart failure--it may be due to a particular condition that is in the heart and its valves, or they
might be an obstruction in the blood flow. In your case, given your history of having a racing of the heart with
irregular heartbeats, and also a history of chest pain--which may be a sign that the heart is not receiving
enough blood or oxygen to it before, it seems most likely that your heart became weaker due to the effects
of these irregular heartbeats and causing build-up of fluids immediately in your lungs, causing you feel easily
exhausted and short of breath, and also causing the fluid to accumulate to dependent parts of your body--
causing your leg swelling during prolonged standing, which tend to improve when you lie down. However,
the leg
swelling can also be due to multiple causes, such as a problem in your thyroid (but I ruled this out because you
didn't have any weather preferences), or a problem in your kidneys (but I ruled this out since you didn't have
issues with your waterworks plus your urine test results are clear), or problems in your liver (but I ruled this
out because your liver is not enlarged and you didn't have any changes in the color of your skin), or clotting
problems. But to be sure, it is best that we do full investigations to rule these conditions out. I will also let you
undergo an echo of the heart--which is like a video of your heart, to confirm the diagnosis. I will refer you to a
specialist as well to further assess you.
EXAMINATION FINDINGS FROM EXAMINER TO CONFIRM DIAGNOSIS
General appearance: pallor, icterus (r/o hepatic cause), cyanosis & clubbing (r/o cardiac), lymphadenopathy
(r/o malignancy)
Edema: where is it confined? Bilateral/unilateral? Pitting or non-pitting?
VS: HR and rhythm, BP, Temp, RR, O2 sat
JVP elevation? Neck distention? Carotid bruits?
Cardiac examination
Any visible pulsations and dilated veins, any thrill or parasternal heave, Apex beat displaced or not? s1 or s2
normally heard or not? any murmurs or any added sounds?
Respiratory examination
Accessory muscle use? Equal air entry? Any adventitious sounds?
Abdomen
Any visible mass or distention?
Palpable masses and tenderness? -- tender hepatomegaly?
Extremities: symmetry of edema, discoloration of the legs, erythema, tenderness, elevation of temperature of
the limbs
Office tests: Urine Dipstick (r/o proteinuria in nephrotic syndrome), Blood Sugar Levels, ECG
KEY ISSUES
Ability to take an appropriate history
Ability to explain to the patient why she has swollen ankles and shortness of breath
Ability to provide a sensible differential diagnosis
Ability to state precisely what would be sought on physical examination and why
CRITICAL ERRORS
None mentioned

Congestive heart failure can present in a subtle way with symptoms of right heart failure, such as bilateral leg
edema, worse on prolonged standing and reduces with supine rest. Other symptoms include exertional
dyspnea
Heart failure is difficult to define. Various definitions include the following
Abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate
commensurate with the requirements of the metabolising tissues
Clinical syndrome caused by an abnormality of the heart and recognized by a characteristic of hemodynamic,
renal, neural, and hormonal responses
Biochemical definition is that the failing heart exhibits a reduction of power such that it cannot maintain a
normal cardiac output without abnormal elevation of systemic and/or pulmonary venous pressures.
Causes of heart failure
Primary myocardial disease (ischemic heart disease, cardiomyopathy)
Pressure overload (hypertension, aortic stenosis)
Volume overload (aortic regurgitation, mitral regurgitation, ventricular septal defect, high output states)
Obstruction to ventricular filling (mitral stenosis)
Restriction of ventricular filling (hypertrophic cardiomyopathy, constrictive pericarditis)
Onset of atrial fibrillation is often a precipitant of heart failure, and this is particularly true in patients who
are older, have hypertension and/or diabetes, or underlying mitral valve disease.
Stiff (noncompliant hearts) - due to age, ventricular hypertrophy, hypertension, diabetes, ischemic heart
disease, or a combination: first presentation may be due to cardiac diastolic dysfunction
Where heart failure is caused by an increased resistance to filling of one or both ventricularfilling with lossof
the atrial systoleand an increased ventricular rate.
Diastolic dysfunction of the left ventricle
Presentation is usually with breathlessness on exertion and episodes of acute pulmonary edema.
In this case, the presentation with leg edema is an indication of right heart failure, which in the great majority
of patients is secondary to a longstanding problem with the left heart, the so-called "backward failure"
MED - Condition 046 A painful rash on the trunk

Did my partner give it to me?

Herpes: it is possible, but we cannot be 100% sure, as it can spontaneously happen even in a stable relationship.
***
Condition 046
A painful rash on the trunk of a 45 year old child care worker
You are a medicalofficer in a hospital primary care clinic. A 45 yearold child care worker presents with a painful
rash on the trunk, as illustrated below.
TASKS
Take a history about the presenting problem
Explain your diagnosis and the nature of the condition to the patient
Advise the patient about management.
APPROACH
I'm sorry to hear that you are having this painful rash. Are you in any pain now? From a scale of 1-10, 10 being
the most painful, how bad is your pain now? Do you want me to give you some painkillers? Do you have any
allergies?
I can only imagine how uncomfortable this must be for you. But I will do my best to assess you and find out
what's causing this. Could you tell me more about the rash?
HOPC
When did it exactly start? Where/what part of the body did it start?
How did it spread?
Can you describe the appearance of the rash? Is it itchy or scaly? Is it oozing?
Is there anything that makes it better or worse?
Anyone in the family with the same problem?
Anyone in the childcare or at work with a similar problem?
Did you take any medications prior to this episode?
Were you able to apply any medications to it?
Any recent change of soap/detergents/cosmetics?
Any recent travel?
Pain Is it only on the rash? Or does it also involve other parts of your body? Is it constantly
there or is it only on or off? Does the pain go anywhere else? Is there anything that
makes it better or worse?
Any recent flu-like illnesses? Cough, colds, joint pains?

Any fever associated with this rash?
When did it start? How high was the temperature?
Any chills/shakes?
Is it always there or does it come and go?
Any medications taken?
R/O other causes

How has your health been in general?
Any headache, unable to tolerate light, neck stiffness?
Any recent changes in weight? Tiredness? Lumps or bumps in the body? Night sweats?
(immunosuppression signs)
Any vomiting, diarrhea, tummy pain? How are your waterworks?
SADMA
Sexual History [CONFIDENTIALITY]
Are you sexually active?
Are you in a stable relationship?
Do you practice safe sex?
I'm sorry to ask you this, but is there any chance that you engage in intercourse with other people aside from
your current partner?
Past Medical history: any previous history of chicken pox or a similar rash?
Have you had any immunisations with varicella?
History of asthma, hay fever, or any other medical or surgical illnesses?
Family history: history of allergies, asthma in the family?
EXPLAIN DIAGNOSIS AND NATURE OF THE CONDITION

From your history and the appearance of the rash, it seems that most likely you have a condition called herpes
zoster or commonly called shingles. It is an infection which is caused by the chicken pox bug, that may have
reactivated in your body causing this distinct appearance of the rash. This condition is mildly contagious, in a
sense that chickenpox can be acquired by those persons in close contact with you who still has not developed
chickenpox/those without vaccines. Therefore as of now, it is important that you stay at home first to avoid
spread of infection within the community. I can give you a medical certificate for that.
However, I am just concerned about your recent weight loss and tiredness as it has also been significant and may
possibly suggest another underlying condition that decreased your immune system--or your bodily defenses
that made you prone to develop this type of infection. That is why I would like to also do further investigations
just to be sure that you are in good health, and to identify the possible causes of your weight loss and
tiredness, and then we'll go on from there.
Meanwhile, we can do this for your current condition
We can apply calamine or cold compress and a drying lotion over your rashes
I can give you a script for pain killers (with or without codeine)
We will observe your pain further. And in case the pain becomesworse or tends to cause numbness or
significantly affects your activities, we might consider starting you with other medications that act on the
nerves itself (monitor for development of postherpetic neuralgia)
TREAT with antivirals (aciclovir, famciclovir, valaciclovir) if he presents WITHIN THE FIRST 72 HOURS OF THE
RASH APPEARANCE.
I will arrange another review with you once your lab results are available.
Just in case your pain worsens, or the rash spreads further, or you develop any nausea, vomiting, headache,
please don't hesitate to come back
Here are reading materials for you to give you more insight about your problem.
KEY ISSUES
History taking must elicit weight loss and tiredness
Diagnose herpes zoster/shingles
Management must consider use of aciclovir or other related antiviral drugs
Must advise further assessment regarding weight loss and tiredness and discuss implications of infectivity
CRITICAL ERRORS
Failure to diagnose herpes zoster
Failure to consider the possibility of an additional underlying cause in this patient
Failure to assess the implications for contacts in community and work settings

Herpes zoster (shingles) is caused by reactivation of varicella zoster virus
More common in people over 50 years of age
Virus is found in the dorsal root ganglion
Reason for activation is unknown
Occasionally can be related to an underlying MALIGNANCY, such as a LYMPHOMA, LEUKEMIA, OR
IMMUNOSUPPRESSION including HIV INFECTION
May get rare complications including meningoencephalitis
Post-herpetic neuralgia is an important sequel
Incidence increases with age
30-50% of adults aged 70-79 years
MED - Condition 054 Assessment of hearing loss

Condition 054
Assessment of hearing loss, first noted during pregnancy, in a 35 year old woman.
You are working in a general practice and your next patient is a young woman who gave birth to her first child
one month ago. She is complaining of loss of hearing, which she first noted about midway through her
pregnancy. It has become progressively worse since and affects both ears.
She is otherwise well and her infant (breastfed) is thriving
TASKS
Take a further focused history concerning her hearing loss (limit this to one minute)
Examine the patient and test her hearing, telling the examiner what you are doing, including your findings
Tell the examiner the type of hearing loss present
Inform the patient of the most likely cause of her hearing loss
Suggest to the patient what further action is indicated for her hearing loss, including a prognosis
APPROACH
Congratulations on your pregnancy!
HISTORY
I'm sorry to hear that you are having progressive hearing loss since you were pregnant. Could you tell me more
about it?
Initially Bilateral/ unilateral?
Hear better during loud noise or not? Do you hear any buzzing sounds?
Ear pain? Ear discharge? Dizziness, Fever, headache, Colds, Flu-like illness before/after this happened?
First time? Previous episode?
Anyone in the family with a similar problem?
WASH HANDS
Today I’m going to do a physical examinationof your hearing, this will involve me going to have a look, feel, and
I’ll ask you to do some movements. I will guide you throughout the examination. Is that alright with you?. I will
also have to say running commentaries to my examiner while I check you, so I'm sorry for all the medical
terms that I'll mention along the way. Will that be alright?
Before I start. Are you in pain? Where exactly is the pain? Do you need any painkillers? During the examination
if I hurt you or you feel uncomfortable, just let me know so that I could stop.
CN8
Inspection of the ear:
REPORT: Comparing both ears, on inspection, there are no erythema, scars, skin tags and ear discharge.
Whisper test: 60cmaway
I will whisper in your right ear while I’ll distract your left ear, can you please
repeat what I will say. Ninety nine. Thirty Three.
REPORT: The whisper test is normal.
Examine external auditory canals and eardrums
I would like to do an otoscopic examination of both ears to check the auditory canal and ear drums.
REPORT: the auditory canal is patent without any presence of ear wax, discharge. The tympanic membrane is
non-erythematous, non-bulging, and
intact.
Rinne’s test (512Hz or 256Hz)
This is a vibration fork, I will put this behind your ear. Please, let me know if you can hear it and tell me when it
stops. Then I will put it behind your ear and tell me if you can still hear it.
REPORT: The bone conduction on both ears is greater than the air conduction.
Weber’s test
Now, I will put this vibration fork in your forehead. Let me know if you can hear it more on the right side, left
side or in the middle?
REPORT: The sound is heard at the midline.
TYPE OF HEARING LOSS TO THE EXAMINER
Based on the history and examination, it seems that most likely the patient is having a Conductive Hearing
Loss on both ears
DIAGNOSIS TO THE PATIENT
Based on history and examination findings, it seems that most likely you are having a conductive hearing loss.
Sorry for the medical terms but let me explain this condition to you.
[ILLUSTRATE] This is your outer ear, composed of the ear canal, and ear drum. In the middle ear, you have 3
small bones, In the inner ear, you have an apparatus or balancing and a nerve. Normally, when we hear, the
sound waves passes to the ear canal, causing vibration of the ear drum causing the 3 bones moving, stimulating
the nerve in the inner ear and this is transmitted to the brain, causing us to hear.
In your case, there must be a problem in this part of your ear (OUTER & MIDDLE EAR). It can be due a number of
reasons, but in your case, it is due to a condition called, OTOSCLEROSIS, or that there is hardening or fusion
of one or more of the small bones present in your middle ear, causing it to be stiff to vibrate, therefore
affecting the transmission of sound. I can say this because you don't have obvious blockage here in yourear
canal, which canbe of any wax, foreign body, and that you don't have any signs of infection that will cause
inflammation of the ear canal, or hole formation in the ear drum, or when sometimes there is an abnormal
growth of skin inside the middle ear because of longstanding infection.
It is quite a common condition especially in pregnant women, and it is usually related to a genetic inheritance.
What we can do for you now is this, I need to arrange investigations to further confirm mydiagnosis. This will
involve serial audiogramsto formally check yourhearing. I will also refer you to an ENT specialist who will
consider assessing you further and might consider either a hearing aid or a surgical procedure to address
your hearing loss. Usually they do a painless procedure called, stapedectomy with prosthesis and vein
grafting, which is an effective treatmentfor otosclerosis. It is generally done while you are asleep under
anesthetic care. Complications like bleeding, pain, ear discharge may occur, but these risks are very rare
especially under experienced hands.
I will arrange a review with you again once results are back.
For now here are reading materials that you can use to give you more insight about your condition.
DO you have any questions?
KEY ISSUES
Skill in useof tuning forktests to define types of hearing loss -- conductive versus sensorineural
Ability to explain to the patient the problem and its management
CRITICAL ERRORS
Failure to correctly use tuning fork in assessing hearing loss
Failure to advise a referral for audiometry and/or ENT opinion
Predominantly a test of skill in clinical assessment of hearing loss
Conductive deafness - due to wax occlusion or other causes MUST BE EXCLUDED!
In this case, she has conductive deafness due to OTOSCLEROSIS
Deafness is common
Bilateral deafness in a young woman during pregnancy == UNCOMMON!
Positive family history of a mother requiring surgery for her hearing loss points towards an inherited cause =
OTOSCLEROSIS
Onset is generally in early adulthood and may progress rapidly in pregnancy
Stapes footplate becomes ankylosed in the oval window
Hear more clearly in noisy surroundings
Treated by PROSTHETIC STAPEDECTOMY and VEIN GRAFTING
CN 8
2 functional parts
Cochlear: subserves hearing
Afferent cochlear fibers from inner ear pass through the internal auditory meatus and enter the upper
medulla at the level of the inferior cerebellar peduncle to reach the dorsal and ventral cochlear nuclei.
Fibers cross to other side and end in the inferior colliculus.
Fibers then go to the medial geniculate body and the auditory radiation to the temporal cortex. There are
bilateral connections in the cochlear nucleus and above
Vestibular: balance
Deafness may be due to impaired conduction of sound through a muffled middle ear (conductive or middle ear
deafness) or to a lesion of auditory nerve/cochlear/brain (perceptive or sensorineural)
SENSORINEURAL DEAFNESS -- damage to the cochlear nerve fibers anywhere from the inner ear to the cochlear
nuclei
Most common: degenerative changes in the elderly
OTHERS: fracture of the petrous temporal bone, acoustic neuroma
CONDUCTIVE DEAFNESS -- blockage of the ear canal and by damage or disease of the tympanic membrane or
ossicular chain, fluid in the inner ear
TESTING FOR TYPE OF DEAFNESS
HEARING first tested clinically for each ear with examiner's finger occluding the other ear.
Examiner stands to the patient's other side and whispers numbers, which are repeated by the patient
Otoscopy: retract ear upwards and backwards
Excludes causes of conductive HL (wax, osteoma, otitis externa, chronic otitis media)
Tuning fork for high pitch (256Hz or greater) used to compare hearing by bone versus air conduction
Normally, AC>BC
NERVE DEAFNESS: AC>BC in the AFFECTED EAR
CONDUCTION DEAFNESS: BC > AC in the AFFECTED EAR
RINNE TEST
Tuning fork placed on the mastoid, then at the auditory meatus, and patient isasked which is louder
BC > AC: conductive deafness
Alternatively, put the fork on the mastoid until no longer audible, then put it outside the meatus. Sound in
normal individuals will be heard again in normal individuals and in nerve deafness, BUT NOT in conductive
deafness
WEBER test
Very useful in unilateral deafness.
Fork placed on the center of the forehead in the midline, ask whether this is louder in one ear or equal.
Normal test: EQUAL ON BOTH EARS

Nerve deafness: sound heard better on NORMAL ear
Unilateral conduction deafness: weber test localizes to the affected side.
Bilateral conductive or bilateral nerve deafness, the sound will be the same
Unilateral nerve deafness-- due to a lesion of the nerve itself, as cortical radiations are bilaterally and diffusely
represented in the temporal cerebral cortices
Common causes of conductive HL: wax, otitis media, otosclerosis, and paget disease
Common causes of nerve HL: cochlear degeneration, acoustic nerve tumor, drug ototoxicity, or trauma
(fracture of petrous temporal bone)
OTOSCLEROSIS
Bilateral symmetrical hearing loss
Stapes footplate is ankylosed in the oval window.
Autosomal dominant
F > M, worsens with pregnancy
Hear more clearly in noisy surroundings
Perceptive hearing loss background noise worsens hearing
INVESTIGATION: AUDIOMETRY will be diagnostic
Treatment: prosthetic stapedectomy and vein grafting
Hearing aid less effective
MED - Condition 058 Hepatitis C positive

Condition 058
Positive test for hepatitis C in a 26 year old woman
You are working in a general practice. Your next patient is a 26 year oldwomanwhohas been sent to see you
because she was tested for hepatitis B and C and for HIV when she attended the Red Cross blood bank as a
blood donor one week previously and was found to be hepatitis C positive.
She has just been notified that she was found to behepatitis C positive, and advised to see her local doctor for
further assessment. Other blood tests were negative for both hepatitis B and HIV.
She had never given blood before, and had not been tested for any of these infections previously.
TASKS
Take relevant history from the woman
Advise her about subsequent management and likely prognosis
APPROACH
Good morning, I'm Dr. . I'm one of the doctors who will look after you today. How may I address you?
Could you tell me exactly what happened?
Is it alright if I can ask you a few questions about it?
Hepatitis symptoms
Any nausea? Vomiting? Abdominal pain?
Any loss of appetite (anorexia)?
Any yellowish discoloration of your skin?
Any changes in the color of your urine or stools?
Any rash anywhere in your body?
Noticed any joint pains?
Any itchiness?
Mode of transmission
Any recent travel? (r/o co-infections--anything that affects the liver)
Any possibility of eating contaminated food or water? - hep A
Any recent or past history of blood transfusions? (before 1990s)
Any tattoos orpiercings?
Any IV drug use?
I will be asking you some sensitive questions, rest assured, Everything will be confidential unless there's any
harm involved. Will that be okay?
Are you sexually active?
Are you in a stable relationship?
Did you have any other partner/s before this happened?
What are your sexual preferences?
What type of sexual activity do you normally engage in?
Do you practice safe sex?
Any recent exposure to sick persons or known hepatitis cases?
PMH+MA: Any past history of any liver problems? Any other medical conditions? Are you taking any other
medications, either over the counter or prescription medications (blood thinners)? Do you have any
allergies?
Any conditions in the family especially affecting the liver?
SAD: do you smoke, drink alcohol, engage in recreational drugs--share needles?
ADVISE
The results show that unfortunately you are infected with a virus called Hepatitis C.
Hepatitis C is a blood-borne virus that infects the liver. It is the most common virus causing chronic hepatitis,
or swelling and eventual deterioration of the liver in the long- run.
Usually this infection maybe acquired through blood contact, and in your case, it is most likely that you got the
infection from your use of shared needles a few years ago.
I want you to be awareof certain serious complications such as cirrhosis and cancer of the liver, especially if the
infection becomes chronic. (20% cirrhosis, 1-5% cancer). But please don't stress yourself too much about this,
as it is good that we found it this early to avoid these possible complications.
Because of this, in order to best identify your risk of developing a liver disease, I would like to immediately do
further tests like FBE, ESR/CRP, LFT, a full Hepatitis serology A,B,C,D, HIV serology, HCV PCR viral load,
hemochromatosis studies/iron studies, alpha-1 antitrypsin deficiency (congenital deficiency of this is
associated with liver disease), autoimmune hepatitis screening (ANA, antimitochondrial antibodies, anti-
smooth muscle cell antibodies), (EBV and PSGN tests as it can rarely affect the liver)
We can also do an indirect coombs test to check if there is blood group immunization due to your use of
shared needles.
The management depends on the results of the investigation findings. The special test called PCR to check if the
virus is still in your body or not.
If you have cleared the virus, that means that your body has successfully fought against it (spontaneous
recovery in 15 - 50% of patients).
However in 50 - 75% of the patients, the virus can still be present, and therefore we monitor further with LFTs
(ALT is more important).
If LFT is normal for 3 estimations over a 6 month period (every 2 month check) this means that even though
you have the virus, it is not affecting your liver (carrier).
If LFT becomes high, it means your liver is affected. In this case, I will be referring you to the specialist, who will
do a full liver assessment, which might include a biopsy to get a sample of your liver tissue to check under a
microscope, and he might also consider starting you with a special drug called PEGylated interferon (or
ribavirin).
It is very important to do lifestyle modifications. Please do not drink alcohol at all as it can affectthe liver.Do
not use any drugs which can affectthe liver. And please practice safe sex always. And be careful in eating
contaminated food and water, especially shellfish.
Since it is an infectious disease, it is my responsibility to notify the department of health services regarding
your condition. Notification is for statistical purpose, and we will not reveal your name. We will just use the
initials of your name.
Please inform your partner, and if you and your partner agree, we can arrange some investigations for him as
well.
Can I get pregnant?
It is advisable not to get pregnant while you have the infection. You may get pregnant after 6 months after
stoppingtreatment with Ribavirin, as this drug may cause some birth defects when taken during pregnancy.
Can I breastfeed?
Breastfeeding is not contraindicated. But if you have cracked nipples and areola, please stop breastfeeding
temporarily, and once healed, you may resume breastfeeding.
Will my husband get this infection?
It is possible, but unlikely as Hepatitis C is normally transmitted by blood.
How can I prevent the transmission?
It is important to avoid sharing objects with potential for blood contamination.
Please do not donate blood or organs. Please avoid sharing of toothbrush and razors. No sharing of needles at
any time. If you have a bleeding, please cover the cut or injury with an appropriate firm dressing. Always please
practice safe sex. Before any surgical or dental procedure, notify the doctor about your status.
There is no risk of spreading hepatitis C by hugging, kissing, casual contact, sharing
food or eating utensils.
How about vertical transmission?
5 -10 % in Hepatitis C (it is more in Hepatitis B, around 15%, but there is no hard data about it)
I will review you once your blood results are available
KEY ISSUES
Taking a focused history in regard to determining the source of the infection
Advising the patient appropriately regarding subsequent care, the risk of liver pathology, and the need to
ensure blood transmission does not occur, as this would be likely to result in hepatitis C infection in the
recipient.
CRITICAL ERRORS
Failure to recognize the need for LFT (ALT) assessments
Advising the patient of a benign course of disease in all instances

Hepatitis C is a single stranded RNA virus.
Risk factors
Intravenous drug use (70%)
Sexual exposure (10%)
Blood transfusion (6%)
Occupational exposure (3%)
Unknown (-10%)
Tattoos, body piercing, intranasal cocaine - not well defined
Viral infection is established and chronic at the time of diagnosis in most patients
If identified early, treatment with interferon within 3-6 months of infection can prevent chronicity in 98%
Natural history
15-50% resolve completely with no adverse end results and normal liver function (PCR negative and liver
function and ALT are normal)
50-75% will have chronic infection (PCR positive)
20% of those with elevated ALT will develop cirrhosis
1-5% of which will develop hepatocellular carcinoma
20% will develop liver failure requiring transplantation
LFTs and HCV PCR need to be done to assign the patient to the appropriate group
Ability of the candidate to take a focused medical history, relating to potential source of the infection and any
effects on her health
Necessary investigations
Blood tests; HCV PCR and LFTs
Hepatitis C is a NOTIFIABLE DISEASE with confidentiality maintained
MED - Condition 066 Palpitations and dizziness

Condition 066
Palpitations and dizziness in a 50 year old man
You are working in a hospital emergency department. You are asked to see a 50 year old man complaining of
palpitations and dizziness over the past three days.
He has not seen a doctor for the past 10 years and at that last assessment he was told his blood pressure is
elevated. His current blood pressure is 150/96 mmHg.
MEDICINE HANDBOOK Page 38
The symptoms are still present when you see him to take his history. He is lying down on a trolley.
TASKS
Take a concise, relevant, and focused history
Present a summary of the patient's history to the examiner, who will then give you the findings on
physical examination
Tell the examiner your differential diagnosis
Interpret the ECG to the examiner (the ECG will be given to you by the examiner about 7minutes into the
consultation)
APPROACH
HEMODYNAMIC STABIILITY
If unstable, transfer to the resuscitation room, do DRSABCDE, insert two large bore IV lines, draw some blood,
high flow O2, do ECG
HISTORY
I'm sorry to hear that you are having palpitations and dizziness. Are you comfortable enough to proceed
with this consultation?
Could you please tell me more about your palpitations (rate, rhythm, onset, offset, context)?
When did it exactly start? Was it sudden, gradual? Is it always there or does it come and go?
How long does the episode usually last?
Could you please tap on the table how fast your heart beats?
What were you doing before this happened?
Is there a particular time of day that this happens?
Is there something that makes it worse or better?
Is there any associated chest pain/tightness, flushing of the face, shortness of breath, sweating, nausea,
vomiting, tummy pain along with this episodes?
Was this the first time that it happened?
□ If with previous episodes: what happened during the last
When did your dizziness start? Does it come before/after/together with your palpitations?
How long does it usually last?
Could you describe what type of dizziness you have--is it fainting/lightheadedness or sipinning sensation?
Is there anything that you do to make it better/worse?
Associated symptoms (r/o DDx: Cardiac, Electrolyte imbalance, Endocrine disorders)
Do you have difficulty lying flat on the bed at night?
Cough, fever, changes in your bowel movement, concerns about your waterworks?
Any unexplained nervousness, or shakiness of the hands (tremors), or any weather preferences?
SADHOT: smoking, alcohol, drugs, healthy lifestyle (diet, exercise), occupation, travel
Do you smoke, drink alcoholic beverages, engage in recreational drugs?
Do you take coffee? How many cups do you usually drink in a day?
Do you engage in regular physical exercise? How is your diet?
What's your occupation? Any stresses at work? How about at home?
PMH: any history of medical or surgical illnesses? Do you take any medications (prescribed or over the
counter)? Any allergies?
Family history: Any history of heart disease or arrhythmias? Any family history of a similar condition?
SUMMARY of FINDINGS
'The patient is a 50-year-old company secretary who presents with his fourth attack of palpitations and
dizziness over the past 3 days. Three of the attacks have occurred in the evenings after his meal and one whilst
driving. Each attack lasts approximately 2 hours, they come on suddenly and stop suddenly and the dizziness,
which he describes as a near-fainting experience, always accompanies the palpitations. The nature of the
palpitations is that they appear to be rapid, approximately 150/min and regular. He is currently experiencing
an attack. The attacks are also associated with shortness of breath and sweating, but no chest pain. Considering
possible underlying causes for his attacks, he has a history of high blood pressure but no known cardiac disease.
He has a high alcohol intake and has recently been under stress at work. He is also at risk of ischemic heart
disease because of his smoking, obesity and sedentary lifestyle. There is no evidence on history to suggest
thyrotoxicosis. '
PE findings given by the examiner:
He is an overweight, anxious man in some distress while sitting or lying on a couch. Pulse is 150/min, and
regular, blood pressure is 150/96mmHg. Heart sounds show dual rhythm with no bruits and are synchronous
with the pulse. There are no signs of cardiac failure. Examination otherwise is non-contributory.
ECG
DIFFERENTIAL DIAGNOSES & DIAGNOSIS

Based on history and physical examination and ECG findings, it seems that most likely the patient has a
paroxysmal atrial arrhythmia, probably an atrial flutter. The key features which suggest this diagnosis are the
sudden onset and offset nature of the pulse, together with its rapid, regular heart rate. Based on the
patient's history and examination, the potential causes of this arrhythmia are hypertensive heart disease,
alcoholic cardiomyopathy, ischemic heart disease, or occult thyrotoxicosis
The differential diagnosis includes atrial fibrillation, supraventricular tachycardia, and ventricular
tachycardia.
ECG INTERPRETATION
Atrial flutter with a variable block
KEY ISSUES
APPROACH TO PATIENT -- SENSITIVITY to the patient's discomfort and a calm and professional manner.
HISTORY - the ability to take an appropriate and focused medical history with careful definition of the symptom
characteristics and showing an awareness of the likely causes and precipitants of cardiac arrhythmias
COMMENTARY TO THE EXAMINER - needs to be a succinct summary which brings together the key features of the
presenting complaint, the contest in which it has arisen, the associated symptoms, and the arrhythmia risk
factors.
DIAGNOSIS/DDx - must consider the diagnosis of atrial arrhythmia and the potential contributions of
hypertension and alcohol.
INTERPRETATION OF INVESTIGATION - the most important findings on the 112 lead ECG must be defined: atrial
flutter with variable block.
CRITICAL ERRORS
Failure to consider the diagnosis of atrial tachyarrhythmia on the history
Failure to correctly interpret the ECG features of atrial flutter

Palpitations - symptom of an abnormal awareness of heart rate
Due to change in rate, rhythm, or force of heartbeats or some combination of these
Important to ask the patient to tap out with a finger what is noticed when the palpitatins arise
Anxious patients - aware of their normal heartbeat
Isolated forceful beats (thump in the chest) are usually caused by ectopic beats
Heart misses a beat - compensatory pause after a ventricular ectopic beat, or a non-forceful ectopic beat
Awareness of fast heart rate occurs when this is of recent origin
Development of symptoms depend on the rate, rhythm, underlying cardiac disease, and patient
characteristics
Older patients with hypertensive heart disease who develop atrial fibrillation -- problem of a poorly
compliant left ventricle renders them intolerant to the arrhythmia, where there is loss of contribution of
atrial contraction to ventricular filling, leading to left heart failure
ATRIAL FLUTTER
2:1 atrioventricular block and a regular ventricular rate of 150/min
Misdiagnosed as supraventricular tachycardia
Rarely conduction occurs 1:1, giving a ventricular rate of 300/min, and severe symptoms
Greater degrees of AV block present giving rates of 100 (3:1 block) or 75 (4:1).
May be asymptomatic except when the RATE CHANGES (from 4:1 to 2:1).
Atrial flutter with 4:1 block is seen below
ATRIAL FIBRILLATION
Irregular ventricular rate of 160-180/min.
Impaired AV conduction in the elderly - can present with lower rates
Clinical pattern: THREE P's
Paroxysmal AF - episodes come on suddenly and usually revert spontaneously within 48 hours
Persistent AF - episodes persist for days or weeks unless active measures are taken to revert to sinus
rhythm
Permanent AG - inability to sustain sinus rhythm for any length of time or decision made not to try to
revert the rhythm
Patients with persistent and paroxysmal AF have at least the SAME RISK of thromboembolism as patients
with permanent AF.
Rhythm is irregularly irregular and that no P waves can be seen as shown below
Important to identify and manage underlying causes: hypertension, thyrotoxicosis, heart failure, mitral
valve disease, atrial septal defect
Treatment is divided into:
Treatment of the arrhythmia itself
Prophylaxis against thromboembolic complications
Treatment of atrial flutter commonly responds very easily to low energy direct current shock or to pace
cardioversion, and is often relatively insensitive to antiarrhythmic drugs
MED - Condition 068 Aches and pains

Condition 068
Aches and pains in a 62 year old man
You are working in a general practice. Your next patient is a retiree and aged 62 years. He is consulting you
about aches and pains, and you have just finished taking a history which was as follows:
Over the last six weeks, he has had a gradual onset of pain across the upper part of the back, neck, and
shoulders, which feel stiff. In the past week or so, his hips are also feeling stiff and sore. Since retirement two
years ago, he has been playing golf at least three times per week and thought that he may have been
overdoing it. At first, the pain was just an aching feeling, but is now more definite pain but hard to describe. It
is continuous, worsened by movement and is keeping him awake at night. The aching and stiffness is worse
early in the morning and he finds it difficult to get out of the bed because of muscle weakness and pain which
improves duringthe day. Pain is not relieved by aspirin or Brufen, nor worsened by coughing. There is no
radiation to the arms. Pain is felt in the muscles but not in the joints, although these feel stiff especially after
inactivity. He has not played golf for a week. He has noted a little difficulty in lifting himself up from a chair.
Muscles feel as if they are losing their strength.
He has felt much more tired than the usual over the last few weeks, especially after golf. His appetite is not as
good as usual. He thinks he may have lost a little weight and sometimes feels hot and slightly sweaty at night
in bed.
TASKS
Specify to the examiner the essential features you would like to know from a focused physical examination of
this patient. The examiner will give you the results and ask you questions about your provisional diagnosis
and further management
Answer the questions put to you by the examiner
Advise the patient of your diagnostic and management plans
APPROACH
Good morning, I'm Dr. . I will be one of the doctors who will look after you today. How can I address you.
I can see that you are very distressed right now. Are you having any pain? From a scale of 1-10, how bad is your
pain right now? Do you need some pain killers?
I will just talk to my examiner first, and go back to you to discuss your condition. Will that be okay?
FOCUSED PHYSICAL EXAMINATION TO THE EXAMINER
General appearance: Well-looking or not? Pallor (Anemia), Sweating, Dyspnea (heart disease), Jaundice (Hep),
Lymphadenopathy (infection)
Vital signs: Temp (infection), Pulse, RR, BP and postural drop
Gait
Is the patient able to fully stand up from sitting position, any difficulty/loss of balance?
Musculoskeletal examination of neck and trunk
Look – redness, deformity; Feel – tenderness, warmth; Active movements, Passive movements, Against
resistance
Musculoskeletal examination of Bilateral shoulder and hip joints
Look, Feel, Active, Passive movement, Against resistance
Complete neurological and musculoskeletal examination of all four limbs
Muscle wasting, Tone, Power, Reflexes, Active and passive movements
Coordination – finger-nose, heel-shin, Romberg, dysdiadochokinesia.
○ Quick examination of other joints: hands, knees, sacroiliac (RA,OA) Respiratory: Infection,
○ chronic inflammation, malignancy
○ Breast (IF FEMALE): any visible retractions, palpable masses (malignancy) Abdomen:
○ distention, masses, hepatomegaly (malignancy)
○ PR with the consent of the patient: Prostate lumps (malignancy)
NOTE
○ METASTATIC PROSTATE CANCER, COLON CANCER, AND OTHER CANCERS HAVE BEEN KNOWN
TO MIMIC POLYMYALGIA RHEUMATICA.
○ POLYMYOSITIS (as a DDx) IS ALSO ASSOCIATED WITH INCREASED RISK OF LUNG CA, BLADDER
CA, AND NON-HODGKINS LYMPHOMA.
FROM THE BOOK, ESSENTIAL FEATURES of FOCUSED PE WITH RESULTS:
Temperature 37C
Pulse 70/min regular
Blood pressure 140/80
Muscle groups of neck, trunk, upper and lower limbs should be examined
Active movement of neck, shoulder, and trunk muscles causes discomfort
Normal power and tone and coordination of movements
Examination of joints, particularly hands, shoulder, neck, sacroiliac joints and hips
These show no abnormalities and a full range of movements
Examination of lymph nodes, abdomen, and respiratory systems are expected to exclude any medical
conditions that could possibly give rise to this constellation of symptoms (lymphoma, carcinoma) - normal
findings
Rectal examination to check the prostate: normal
QUESTIONS BY EXAMINER
What is your provisional diagnosis and differential diagnosis?
Based on the history and physical examination findings, most likely the patient is having a condition called
polymyalgia rheumatica, given the history of progressive muscle pain affecting the proximal muscles
bilaterally, with a disparity between the intensity of the myalgia felt by the patient with the physical
examination findings of normal power, tone, and coordination with just a minimal limitation due to pain,
associated with constitutional symptoms of weight loss, malaise, and depression.
Other differential diagnoses that we can consider are chronic fatigue syndrome, fibromyalgia, polymyositis,
and an underlying malignancy
What further tests will you advise?
I would like to request for a full blood examination, an ESR, CRP, and a Creatine Kinase level test.
I would also like to do LFTs, TFTs, U&Es, and fasting blood sugar just to rule out possible conditions that may
contribute to her symptoms as well
TO THE PATIENT
You most likely have a condition called polymyalgia rheumatica. Have you heard about it? Let me explain the
condition to you.
It is an autoimmune disease that causes inflammation, muscle pain and stiffness.
The normal role of your body’s immune system is to fight off infections, and to keep you
healthy.
However, in an autoimmune disease, the immune system starts attacking the body’s
own healthy tissues.
In polymyalgia rheumatica, the immune system targets the soft tissue and lining of the joints, causing the
pain and stiffness. The exact cause is unknown, at it is not usually uncommon. It usually affects the middle-
aged to elderly patients and is more common in Caucasians, and genetics also plays a role in its
development.
As in your case, symptomsusually occur on both sides of the body which may include aches or pains over the
shoulder, neck, upper arms, buttocks, hips, or thighs, and even on your wrists, elbows, or knees, stiffness in
affected areas such as in the morning or after being inactive for a long time. Mild fever, fatigue, loss of
appetite, unintended weight loss, and depression may also be related to this condition.

But again, I need to confirm this condition by doing investigations such as a full blood examination, and blood
tests for inflammatory markers called ESR and CRP will confirm the diagnosis of PMR. We will also test your CK
level to rule out Polymyositis and dermatomyositis, as well as your TFTs to rule out thyroid problems, and a
fasting BSL to rule out DM.
Please be reassured that this a manageable condition and I will help you recover from this. It responds very well
to corticosteroids, but in 15-20% of cases, it does have an association with a serious condition called
temporal arteritis, which can cause irreversible blindness. But don't stress yourself too much about
this, as we will frequently follow you up and monitor your treatment.
After confirming the diagnosis with the results of your tests, I would like to start Prednisolone 15mg/day
for 3 weeks, 12.5 mg/day for 3 weeks, 10 mg/day for 4-6 weeks, and slowly tapering off by reducing 1 mg every
4-8 weeks. Treatment should continue for 1-2 years usually. We will frequently follow you up and monitor
you for side effects of steroids like HTN, DM, Bone thinning, or increased susceptibility to infections.
I will refer you to a rheumatologist who will further investigate and decide on your treatment regimen
As for your case, you can apply warm packs for your muscles especially in the mornings, and you can have a
gentle massage to relieve you of your pain
Just in case you develop headaches, jaw pain especially during chewing, blurring of vision, (signs of temporal
arteritis) please go to the ED immediately
KEY ISSUES
Focused physical examination which must include musculoskeletal system plus rectal examination
Investigate with ESR and/or CRP
Polymyalgia rheumatica as the most likely diagnosis
CRITICAL ERRORS
Failure to request ESR and/or CRP

Polymyalgia rheumatica and giant cell arteritis are linked conditions of unknown etiology.
More common in people of Northern European descent
CLINICAL FEATURES
Middle aged or elderly with diffuse symptoms of muscle pain: neck, shoulders, and hip girdles
Symmetric myalgia beginning in the shoulders
Muscle strength normal, but appears diminished due to pain
Disparity between severity of myalgia reported and the physical findings
Constitutional symptoms also present
Weight loss
Malaise
Depression
Spiking fevers ARE RARE
DIAGNOSIS
ESR
CRP
FBE
TREATMENT
Oral prednisone, initially in high dosage
DIFFERENTIALS
Chronic fatigue syndrome:
Patient profile: Younger, follows a viral infection, incapacitating fatigue with other medical symptoms of
subjective memory impairment, headaches, poor sleep, generalized muscle pains, post-exertional malaise
lasting more than 24 hours, lymph node tenderness
ESR, CRP, FBE ALL NORMAL
Best viewed as a symptom complex resulting from interaction of physical and psychosocial factors
Fibromyalgia
Patient profile: aching pains across the shoulders and upper back, skin tenderness, poor sleep pattern and
often additional constitutional symptoms
ESR, CRP, FBE ALL NORMAL
Polymyositis
Uncommon inflammatory muscle disorder that may be associated with an underlying neoplasm in older
patients
Patient profile: painful muscles and proximal muscle weakness often commencing in the neck, shoulder girdle
and proximal limb muscles, atrophy with disproportionate weakness
ESR, CRP, FBE may be indistinguishable from polymyalgia rheumatica
Elevated CREATINE KINASE and abnormal autoantibodies are characteristic
Positive muscle biopsy is diagnostic
Underlying malignancy
Prostate, breast in females, multiple myeloma, lung cancer
MED - Condition 072 Acute vertigo

Sunday, 21 May 2017 11:02 PM
Condition 072
Acute vertigo in a 50 year old man
You are working in a primary care facility attached to a teaching hospital. This 50 year old man is consulting
you about intense dizziness. He is a previous patient who is overweight and is on medications for control
of hypertension and hyperlipidemia. He appears unwell and distressed, with a slight drooping of the left
eyelid. His wife drove him to the hospital
TASKS
Take focused and relevant history
The observing examiner will then give you the significant findings on physical examination
Discuss your diagnosis and management plan with the examiner
*** DIFFERENTIALS
Acute Labyrinthitis
Benign Paroxysmal Positional Vertigo
Meniere Disease
Migraine
Cerebral tumor
Multiple sclerosis
APPROACH
To the examiner, IS MY PATIENT HEMODYNAMICALLY STABLE? I would like to ask for his current vital signs.
If hemodynamically unstable:
I would like to transfer the patient to the resuscitation room
I would like to start the DRSABCDE protocol, call for help.
Insert two large bore IV lines, and draw some blood for investigations (FBE, SERUM BHCG, BLOOD TYPING,
CROSSMATCHING AND HOLD, UEC, COAGULATION PROFILE, BLOOD GASES)
Give oxygen by mask at 10-15lpm
HISTORY
HOPC
When did the dizziness start?
Is it persistent, or does it come and go?
Persistent: Is it getting worse?
Intermittent: how long do episodes last?
DDx
Was it sudden in onset or gradual? What were you doing when it occurred? Does anything make it better or
worse? Did you have any loss of consciousness?
Any association with headache, any nausea, vomiting, sensitivity to light or aversion to sound?
Any blurring of vision? Any associated weakness of your arms, face or legs? Any problem with speech?
Any neck stiffness, fever, rashes? Any recent head injury?
Problem with hearing? Ringing sensation in your ear? Fever?
Chest pain, Shortness of breath, or racing of the heart?
SAD+SOCIAL:
Do you smoke, drink alcohol, any chance of using illicit drugs?
Any stresses or concerns at home or at work?
PMH+MA:
Any previous heart disease?
Do you have regular follow-ups for your hypertension and hyperlipidemia? What about your blood sugar level?
Do you have DM or PVD? Past history of similar condition?
FHx of diabetes, hypertension or stroke
GA: PICCLED, BMI
VITAL SIGNS
NEUROLOGICAL EXAMINATION
GENERAL LOOK & CONSCIOUSNESS:
Any signs of head injury like bruising, any facial asymmetry, muscle wasting
CONSCIOUSNESS: is he alert, confused, in stupor, obtunded?
GAIT: any abnormal gait like staggard-drunken sailor (cerebellar) shuffling gait (parkinsonism) or high-steppage
gait (posterior column stroke-sensory ataxia)? Able to do tandem gait? Normal pace? Normal arm swing?
Any unsteadiness while standing with the feet together (cerebellar ataxia)?
ROMBERG TEST positive or negative (sensory ataxia-sensory ataxia)
TONE, POWER, REFLEXES?
Any rigidity in the tone, weakness in the power, hypo/hyperreflexia?
SENSATION
Any deficits in pain or temperature sensation?
Any deficits in light touch, vibration, joint position sense?
CEREBELLAR SIGNS
Any dysmetria on past pointing, finger to nose test?
Any dysdiadochokinesia present?
CRANIAL NERVES
CN 2
VISUAL ACUITY
VISUAL FIELDS: any visual field defects FUNDOSCOPY: is there papilledema?
CN 3,4,6
LIGHT REFLEX: equal on both eyes?
ACCOMODATION REFLEX: intact on both eyes?
NYSTAGMUS AND EXTRAOCULAR EYE MOVEMENTS
◊ Is there any nystagmus or limitation of extraocular eye movements?
◊ Nystagmus on looking to the left
HORNER SYNDROME PRESENT?
◊ There is ptosis, miosis, anhidrosis, enophthalmos
CN 5 sensory
◊ Pain sensation on pinprick is lost over the left side of the face intact?
◊ Absent corneal reflex (CN5/7; afferent CN5, efferent CN7)
CN7
MOTOR: any facial asymmetry?
SENSORY: deficits in taste? Hyperacusis present?
CN 8
WHISPER TEST NORMAL
*the rest of the cranial nerve exam is normal*
ENT EXAMINATION
Any ear discharge? Lymphadenopathies?
Neck stiffness?
CAROTID BRUITS
CARDIOVASCULAR EXAMINATION
Apex beat displacement?
S1 and S2 normally heard? Any added heart sounds or mrumurs?
DIAGNOSIS AND MANAGEMENT
I'm a bit concerned about you. On my examination I have found some features that are pointing towards
stroke, given that you developed all of these constellations of symptoms suddenly, as well as in the
pattern of the symptoms you're having.
In this condition, blood supply to some parts of the brain stops or decreases that is why you are having all
of these features. In your case, it most likely the part affected by the stroke is the posterior part of the brain,
responsible for balance and coordination, as well as sensation, causing you to feel the dizziness, weakness,
and numbness, with blurring of vision. Given that you have some risks in your health such as having a high blood
pressure and increased lipids in your blood, this tend to increase the possibilities of having clot formation, as
these make the blood more viscous, which may have caused a blockage to the blood supply to your brain.
At this point, we will admit you in this hospital. We will take a photo of your brain called a CT scan to find out
why the blood supply to your brain is affected. Aside from that we will do further investigations such as an FBE,
UEC, BSL, RFTs, LFTs, Lipid profile, ECG, and 2d echo and carotid doppler ultrasound.
I will also call the specialist to assess and manage you further. You will be managed by a multidisciplinary team
as well. You might be started on some blood pressure control medications and blood thinners to restore the
blood flow to your brain.
If you want, I can call someone to be with you. Don't worry, we are all here to help you.
Once discharged, you will be put on active rehabilitation in orderto regain your muscle strength and restore
your coordination and balance as well.
KEY ISSUES
Recognition of an acute cerebral vascular event affecting the vertebrobasilar system
Appreciation that this combination of symptoms and signs implies brain stem/cerebellar disease
Immediate management including appropriate investigations
Knowledge of the disease process
Recognize the likelihood of a posterior inferior cerebellar artery (PICA) obstruction, most likely due to
thrombosis of the vertebral artery
Embolism is alsopossible
Relationship of this episode to the patient's cardiovascular risk factors should be recognized
CRITICAL ERRORS
Failure to recognize likelihood of cerebral/cerebellar vascular lesion
Failure to advise hospital admission

Vertigo in this case is NOT associated with tinnitus or hearing loss, which means that vestibulocochlear system
seems likely to be INTACT
TRUE VERTIGO (sense of rotation between patient and surroundings) accompanied by ATAXIA is suggestive of an
ACUTE CEREBELLAR DISTURBANCE
Cerebellar dysfunction suggested by motor INCOORDINATION, without any weakness in the upper and lower
limbs
Unilateral LOWER BRAIN STEM disorder features:
Sensory loss to pain is crossed between the face and the body
Loss of pain sensation on the LEFT side of the face, but has DISSOCIATED ANESTHESIA in the trunk and limbs
PAIN AND TEMPERATURE IMPAIRED on the RIGHT side
Combination of cerebellar ataxia and crossed sensory loss suggests a LEFT SIDED LOWER MIDBRAIN AND
CEREBELLAR lesion
Other brain stem nuclei or long tracts involved?
YES ==> cervical sympathetic outflow is interrupted
LEFT HORNER SYNDROME (fits a left sided lesion) catching the sympathetic head and neck outflow
Loss of sensation to the left cheek suggest LEFT 5TH NERVE SENSORY PAIN NUCLEUS involvement with loss of corneal
reflex
Fits a LEFT POSTEROLATERAL LOWER LATERAL MEDULLARY AND LEFT CEREBELLAR LESION, explained by a focal infarct
involving the vertebrobasilar system of the carotid and its branches
Acuteness of onset suggests embolism or ACUTE thrombosis affecting a LEFT SIDED ARTERY SUPPLYING THE
CEREBELLUM AND BRAIN STEM (distal left vertebral artery)

Risk factors present: hyperlipidemia and hypertension
Absence of progression, and sudden onset make hemorrhagic stroke less likely
Cerebellum and brainstem receive their blood supply via the superior and inferior cerebellar arteries, arising
from the basilar or vertebral arteries
Cerebellar functions
Ipsilateral stabilization of motor movements
Coordination
Balance
Sensory ataxia due to loss of position sense is WORSE on dark conditions
Cerebellar disturbances features
Cerebellar ataxic gait
staggering broad-based gait like a drunken sailor
Fall towards the side of the lesion
IN CONTRAST: SENSORY ATAXIA from bilateral dorsal column loss

High stamping gait with positive Rombergism (instability standing with eyes shut)
Cerebellar incoordination
Past-pointing, finger-nose tests with eyes open or closed
Dysdiadochokinesia on rhythmic pronation-supination, knee-shin-ankle placement by other foot, or rhythmic
flexion-extension of ankle
Additional brain stem damage may be found on the following sites
Ipsilateral 5th nerve: muscles of mastication, facial sensation
Ipsilateral 7th nerve: loss of taste to side of tongue and motor weakness
Ipsilateral 8th nerve: disturbance of hearing
Ipsilateral 9th nerve: difficulties with swallowing
Ipsilateral 10th nerve: dysarthria
PICA syndrome
Dramatic onset of cerebellar signs with ataxia and vertigo, usually WITHOUT tinnitus or deafness
Cerebral sympathetic paralysis with an ipsilateral horner syndrome (ptosis, miosis, anhydrosis, enophthalmos)
from medullary brain stem involvement
Ipsilateral loss offacial sensation to pain due to 5th nerve involvement and other medullary brain stem nuclei
may be affected
Loss of pain and temperature sensation fromthe opposite (right) side of the body due to involvement of the
left spinothalamic tract
DISSOCIATED ANESTHESIA
Diminution of pain and temperature sensation with retention of touch and of otherforms of sensation
Classical of brain stem or spinal lesion BELOW the pons
Occurs most notably in BROWN-SEQUARD SYNDROME (hemisection of cord)
Focal ipsilateral lower motor neuron lesion at the level of the spinal cord
injury
Ipsilateral upper motor neuron lesion paralysis below the injury
Ipsilateral dorsal column sensory loss (position and vibration sense) below the injury
Contralateral spinothalamic loss (pain and temperature) below the injury
MED - Condition 092Psoriasis
Sunday, 21 May 2017 11:04 PM
Condition 092
Psoriasis in a 30 year old man
You are working in a general practice. You are seeing a 30 year old man who works as a bank teller. He has
consulted you about a rash on the extensor surfaces of both elbows and both knees, over the sternal and lower
back areas, and in the scalp. It first appeared after a motor accident six months ago in which he suffered a
fractured femur. The patient remembers that his father, now deceased, used to be bothered by a chronic
rash.
It has been getting steadily worse over the last few months with some improvement following the use of a
cream obtained from the local pharmacist (Egosporyl TA). This has helped the rash on his body but not on
elbows, knees, and in the hair.
Examination has revealed the typical lesions of plaque type psoriasis. The plaques vary in size from a few mm to
several cm. They are raised, pink and covered with silvery waxy scale. The nails are not affected. The level of
severity for this patient's psoriasis should be regarded as moderately severe.
You are about to discuss the disease and its management with the patient. The photograph shows details of the
skin lesions on the knees.
TASKS
Explain the nature of his condition to the patient
Advise the patient about management
APPROACH
I can see you are very distressed about this, but don't worry too much as I will do my best to explain your
condition to you and do a management plan for you. Will that be okay?
It seems that most likely you are having a condition called Psoriasis. Normally, our skin cells grow and are shed.
There is a nice balance between growingof the cells and sheddingof the cells. But in this condition, the growth
of the cells exceeds the shedding. These extra cells get
piled up on each other and make this silvery plaques on your skin. The exact cause is unknown. But it is thought
that it occurs when the system in our body that fights off the infections turns against our own body, in other
words we call it as an autoimmune disease. Don't worry, it is a manageable condition.
Typically it affects the surfaces of your elbows, knees, chest, lower back, scalp, and nails, but it can also involve
other parts of your skin. Sometimes, it can also affect your joints as well causing arthritis
The exact cause is unknown. Unfortunately, it can be a long-termdebilitating condition, and thus any
approach to the treatment of this disease must be considered for the long term. You came here in good time, I
will review you closely, and I’ll refer you to the specialist as well.
Sometimesthis can get exacerbatedor flare up in times of stress, changes in theweather, infections, intake of
some drugs (chloroquine, beta blockers, lithium, NSAIDs, OCP), or even trauma to the skin. It typically has a
waxing and waning course. So try to relax and become stress-free. It may be worse in the winter. Asfor now,
please avoidexcessivesunlight. Iwill give you a cream to be put on the plaques to decrease the swelling.
As of now, this is what we can do for you (immediate management)
We can start you on an emollient creams that can be applied on your skin rashes. This will try to maintain the
moisture of your skin to lessen its flakiness.
I will refer you to a dermatologist who will further assess you and might also consider starting you on steroids
and other topical medications such as keratolytics.
If still unresponsive and if becomes worse, it is possible that the specialist will start you on oral medications
(methotrexate, acitretin, or cyclosporin) and even phototherapy.
Can it be cured?
Unfortunately we don't have anything that can cure it but we can manage it.
For now, I will start you on these creams (vitamin D derivatives), and then I will refer you to a dermatologist
Is it infectious?
It is not infectious or contagious.
However, it can affect your joints (psoriatic arthritis)
Can I pass it on to my children?
Yes, thereis an increased chance that you may give it to your kids as it is associated with some genetic
predisposition
One of my friends has a special diet for this. Do you recommend it?
Diet is not found to be effective for psoriasis. But as long as it is a healthy diet, you may try it.
Again please do not worry too much about this condition, as we will monitor you closely and do our best to
manage it.
I can give you reading materials to give you more insight about your condition.
I will review you again after the specialist review.
KEY ISSUES
Approach to patient: must listen to and acknowledge patient's concerns and provide support and
encouragement
Management: knowledge of principles of different local measures. Extent of treatment proportional to
severity
Counselling and explanation of diagnosis: must acknowledge chronic nature of psoriasis and that treatment can
be demanding and will be prolonged. Must be honest and supportive.
CRITICAL ERRORS
Failure to explain appropriate principles of treatment

Etiology of psoriasis is unknown but there is a familial predisposition.
Onset commonly between 1 and 40 years but can occur at any age
Increased epidermal cell proliferation, with vascular proliferation and inflammation in
the upper dermis
Psoriasis affects 2-4% of the population
Not infective, and waxes and wanes
Triggers
Drugs: lithium, beta blockers, chloroquine, hydroxychloroquine
Infections
Trauma
Emotional stress
DIET IS NOT A FACTOR
There is no complete cure but in most cases psoriasis can be reasonably controlled with therapy.
Can be associated with a specific type of arthritis, mainly affecting the hands
Treatment
Mild: emollients or a weak topical corticosteroids

Disfiguring psoriasis may warrant use of antimetabolites or immunosuppressants following the use of more
potent topical corticosteroids
Complicated cases: referral to dermatologist may be considered
Mild to moderate plaque psoriasis

Use topical therapy: dithranol, tars, corticosteroids, keratolytics, and emollients. Occlusive dressings increase
their effect
Dithranol: antiproliferative agent.
Salicylic acid can be combined with dithranol and tars
Tars: anti-inflammatory but can stain and smell which are disadvantages, less when in combination (with
allantoin)
Topical corticosteroids are more potent preparations for thicker lesions, large quantities for widespread rash
Keratolytics for lifting and softening thick scales such as sulphur and salicylic acid
Emollients for scaling or irritation. Harsh soaps should be avoided
Calcipotriol (vitamin D derivative that regulates growth of keratinocytes)
Severe cases
Systemic therapyis indicated
Methotrexate or acitretin or cyclosporin
Phototherapy used by dermatologists
MED-Condition094 Acute idiopathic facial nervepalsy

Monday, 22 May 2017 12:00 AM
Condition 094
Acute idiopathic facial nerve palsy (Bell Palsy) in a 40 year old man.
You are consulting in a general practice. You have just completed taking history from and examining a 40 year
old man who is very upset because of the sudden onset of paralysis of his face.
He felt discomfort behind the left ear last night and on waking today found that the left side of his face would
not move. He arranged an urgent appointment with you. Examination confirms a near complete left 7th cranial
nerve palsy of lower motor neuron type. The accompanying illustrations show the findings. There areno other
abnormal neurological or other signs including normal ear canals and tympanic membranes. The patients
parotid salivary glands show no abnormality. You have made a confident clinical diagnosis of acute idiopathic
facial nerve palsy (Bell Palsy).
TASKS
Explain the problem to the patient
Advise the patient of the management you would advise.
Respond to any questions asked by the patient. The patient is very upset and concerned that this may be a
stroke, and wishes to know the cause, whether recovery will occur, what treatment and tests he should
have and how long it will take to recover.
Time should not be wasted taking further history or asking for any other physical findings. The main issues to be
addressed are patient counselling and management.
APPROACH
I can imagine how this must be very distressing for you. But rest assured, we will do our best to identify the
cause of your illness and to control it. Are you in any pain at the moment? Are you comfortable enough to
proceed with the consultation?
EXPLAIN DIAGNOSIS
From your history and my examination findings, it seems that most likely you have a condition that we call
Bell's palsy. Have you heard about this?
This is a condition where the muscles on one side of our face becomes paralysed because of a problem in our
7th cranial nerve, called the facial nerve that control these muscles. It is a common condition, and may occur
in any age group of either sex.
The exact cause is unknown, although a viral infection causing swelling of the facial nerve or the nearby ear
may be a cause in some instances.
[ILLUSTRATE] The facial nerve leaves the brain through a very small hole in the base of the skull near the ear. If the
nerve becomes swollen, and because of the tight fit in this hole, it does not work properly, causing you to feel
weakness on one side of the face, difficulty eating, and may tend to be hypersensitive to sound to one ear,
impaired blinking, and also tend to weep through your affected eye
I know that you are worried that it might be a stroke, but I've ruled this out since you do not have any other
signs and symptoms that pertain to a stroke such as weakness of the limbs, slurring of speech, confusion, or
loss of consciousness.
MANAGEMENT
ABOUT 70% of patients completely recover within two months, and the first signs of recovery appear within
two weeks. However, about 20-25% may take up to six months for full recovery, and 5-10% of patients do not
fully recover by the end of one year.
But do not worry too much as I will develop a management plan for you.
For now, I will start you with steroids (prednisolone 40-80mgdaily) for three days, and then I'm going to taper
these off and cease it over the next seven days.
I will also give you antivirals (aciclovir) that you may take as it is presumed to be triggered by a viral infection
It is important to take care of your affected eye, as it may become dry and be prone to irritation. So for that I
advise that you wear a patch over it at night. I can also prescribe you with artificial tears to help with that dry
eye.
I will arrange a referral to a neurologist so that he can assess you further, and to ensure confirmation of your
condition, and to manage you for possibilities of incomplete or non-recovery
I will also refer you to a physiotherapist to help you with exercises to regain function of your facial muscles.
[investigations are not essential but CT of the head would be appropriate for reassurance in view of patient
anxiety about a stroke].
I will review you in 3 days to check you again, as we continue to taper off your medications.
Just in case you develop severe headache, or if you develop weakness of your limbs, difficulty walking, difficulty
swallowing, come to the ED immediately.
Here are reading materials that can give you insight to your condition.
KEY ISSUES
Approach to patient -- acknowledging distress about his appearance, providing support and guarded
reassuranceabout recovery
Initial management plan -- protection of eye and possible use of steroids and antiviral agents. Offer referral to
neurologist and physiotherapist
Patient counselling about prognosis and natural history, stressing that complete recovery is usual (although
not invariable)
CRITICAL ERRORS
Testing patient that complete recovery always occurs
Very unsatisfactory counselling skills displaying insensitivity in dealing with an anxious patient

Idiopathic acute facial nerve palsy (Bell Palsy): most common cause of unilateral facial nerve
palsy without a clear history of local injury
Unknown etiology, affects all ages and both sexes
Present with an acute or subacute onset over a few hours
Pain around the ear followed by unilateral facial paralysis of the lower motor neuron type, with complete or
partial paralysis of muscles supplied by the facial nerve
Features are consistent with a lesion due to inflammatory edema and compression of the nerve within the
bony canal of the petrous temporal bone
Clinical features
Affected side of face is immobile, eyebrow drops, lines on the forehead and nasolabial fold are smoothed out
Palpebral fissure wider due to unopposed action of levator palpebrae
Tears fail to enter the lacrimal puncta medially because they are no longer held against the conjunctivae and
the eye weeps
Direct corneal reflex is absent, but patient appreciates the discomfort from testing
Indirect corneal reflex is present (other eye blinks)
Corneal abrasion and ulceration are significant risks
Efforts to close the eyes cause the affected globe to roll up under the upper lid (bell reflex)
Ala nasi does not flare or dilate with vigorous breathing
Lips stay in contact but cannot be pursed with whistling. The angle of the mouth on affected side does not
move on smiling, and causes a "wry-mouth"
Hyperacusis in the affected ear can be troublesome when subjected to local noise
Food accumulates in the cheek and dribbling of saliva can occur during mastication
Articulations of labial consonants (m, b, p) may be affected
Loss of taste sensation may be noted on the anterior tongue on the affected side
Cosmetic and psychological effects of the disfigurement can be profound
Frequently concerned that they may have a paralytic stroke
Pathologic anatomy
Facial nerve
Supply: muscles of facial expression from scalp to neck
Original pons from the motor nucleus and fibers run in an unusual curving course around the 6th nerve nucleus
before leavingthe anterior surface of the midpons to enter the internal auditory canal with the 8th nerve.
Motor root is joined at the internal auditory meatus by the sensory root carrying afferent fibers to the
tongue, and efferent fibers to lacrimal and salivary glands
nerve runs laterally to the medial wall of the tympanic cavity before bending backwards abruptly (genu)
within the petrous temporal bone, giving branches to the stapedius muscle of the inner ear and chorda
tympani
Geniculate ganglion: relay station for secretomotor fibers for tears and site of sensory root ganglion for taste
fibers
Give rise to fibers of lacrimal gland and submandibular salivary gland
Autonomic sensory fibers are then carried from the tongue via the chorda tympani through the middle and
inner ear to the sensory facial nerve root
Facial nerve lesions below the chorda tympani then, will not affect taste
Motor fibers of facial nerve break into a spray of branches and run through the parotid salivary gland before
emergingfrom its anteriorborder to supply the facial muscles via temporal, zygomatic, buccal, mandibular,
and cervical branches.
Differentials
Stroke: usually upper motor neuron in type, and part of a hemi-paresis on the same side as the facial paralysis
Movements of the upper muscles of forehead and eyes (bilaterally innervated) are spared
an infarct in the pons may produce a features of bell palsy
Cerebellopontine angle tumor (auditory neurofibroma) or vertebrobasilar insufficiency: if hearing loss or
other cranial nerve lesions are associated with the facial nerve palsy
Ramsay Hunt syndrome: vesicles present within the external ear or on the palate with 7th nerve palsy. Other
cranial nerves may also be affected
Often elderly patients
Pain precedes facial nerve palsy
Recovery of facial nerve function is RARE
Prompt treatment with aciclovir may improve prognosis and diminish postherpetic neuralgia
Parotid malignancy: mass over the parotids with facial nerve palsy
Benign parotid tumors DO NOT CAUSE facial palsy
Basal skull fractures: of the petrous bone, with history of trauma
MED - Condition 099 Acute gout in a 48 year old man
Monday, 22 May 2017 12:06 AM
Condition 099
Acute gout in a 48 year old man
You are about to see a 48 year old taxi driver who consulted you earlier today in a general practice setting
about continuous, severe, worsening, throbbing pain in the right first metatarsophalangeal joint, which
commenced two days ago. The joint was swollen and felt hot. The overlying skin was red and shiny and the joint
was exquisitely tender. There is a history of previous attacks over the last two years. These have been
diagnosed as gout. Each time response to treatment was satisfactory.
You took blood for serum urate estimation. The patient has returned to find out the result (which was
0.74mmol/L) and for treatment.
The normal serum urate range for males is 0.20-0.45mmol/L. Urinalysis is normal.
The patient has always kept in good health apart from mild hypertension diagnosed two years ago, for which he
takes hydrochlorothiazide. Over the past two days he has taken two or three aspirin tablets for the pain.
TASKS
Advise treatment of the acute attack
Discuss further management of his condition
There is no need for you to take any additional history or perform any examination.
APPROACH
I can see that you're very distressed right now because of pain. But don't worry, I'm here to help you. From a
scale of 1-10, 10 being the most painful, how bad is your pain right now?
Offer pain killers
You were diagnosed to have gout, right? How much do you know about it so far?
I'm here to explain to you further about your condition
Gout is a metabolic disturbance with an inherited tendency, in which there is decreased clearance of uric
acid, which is a waste product of the body. This causes hyperuricemia (elevated levels of uric acid in the
blood) with deposition of uric acid crystals in joints causing swelling of the joints called arthritis), soft tissues
surrounding these joints called tophi, and in the urinary tract causing kidney stones.
As for its cause, these crystals accumulate due to under-excretion by the kidneys, or less commonly, due to
overproduction by the body.
It is a common form of arthritis, and it is more common in men. They are also more common in people who are
overweight, consume certain types of food, and consume excess alcohol. Sometimes it tends to run in families,
and some medications can also contribute to it. It is also frequently associated with hypertension,
dyslipidemia, and type 2 diabetes.
Without a proper treatment, it can progress to a chronic stage permanently damaging the joints, causing
kidney stones and kidney damage as well.
Although attacks of gout are very painful, and they do tend to recur. However, with the right treatment, we
can minimize these recurrences and manage symptoms very well. Acute attacks also respond rapidly to the
right treatment.
For now, this is what we can do for you
ACUTE MANAGEMENT
We will address the pain you're having right now. But first we need to stop your thiazide diuretics as these
tend to worsen gout symptoms (inhibits sodium
reabsorption and increase the risk of developing diabetes). We also need to stop your Aspirin to minimize side
gastrointestinal side effects
I will start you on NSAIDs
Indomethacin 25 mg capsule
3 capsules immediately
2 capsules in 2 hours
1 capsule every 8 hours for the next 2 days
1 capsule twice a day for a week
OR Naproxen or ibuprofen
OR COLCHICINE
1.2mg immediately
0.6 mg six hours later
0.6mt once or twice daily for 2-3 days
OR STEROIDS (PREDNISOLONE)
0.5mg/kg for 5 to 10 days with gradual reduction, OR
25mg orally, daily in the morning, reducing to zero over 7-10 days
OR intraarticular injection of prednisolone
Please increase your fluid intake
You may elevate and rest your foot for 24-48 hours. I will give you a medical certificate so that you can be
excused from work
Once the pain has subsided, you may return to work, and it usually takes around 48 hours to achieve this
LONG-TERM MANAGEMENT
Given that gout is also associated with other cardiovascular events, I will arrange investigations and perform a
CV risk assessment for you
Crucial to the management of gout and prevention of attacks is adapting a lifestyle change. You need to have a
well-balanced diet, and avoid its triggers namely meat, sweetbreads, offal, shellfish, fructose in fruit juices,
and soft drinks sweetened with corn syrup. Avoid drinking too much alcohol--beer in particular. I can refer
you to a dietitian to help you with your diet
If you're happy with it, I can also arrange another review with you to help you with managing your alcohol
intake
Please do regular physical exercises as well. We need to manage your weight as obesity is a risk for development
of hypertension and diabetes and hyperlipidemia which tend to trigger gout attacks
Avoid injury to your feet and joints as at times this can also trigger an attack
We will shift you on other antihypertensive medications such as an ACE inhibitor.
We will check your uric acid levels again in 4 weeks, and we aim to reduce it below 0.4mmol/L. We will start you
with allopurinol 50-100mg daily, gradually increasing to 300mg daily in 8 weeks when the acute attack has
subsided.
Again, I will review you in a week to check for your progress
Just in casethe painworsens further, or if you develop a fever, please go back to be reviewed immediately
KEY ISSUES
Appropriate choice of drug therapy for initial management
Appropriate patient education and counselling regarding prevention of further attacks
CRITICAL ERRORS
Failure to advice change of antihypertensive medication (thiazide diuretics)

Gout (uric acid arthropathy) may present as acute arthritis or be associated with a chronic destructive
arthropathy
Causes
excess synthesis of uric acid
reduced renal clearance of urate
Clinical features
Extremely painful joint, red, tender
Affects the metatarsophalangeal joint commonly
May also present as a polyarticular arthritis
Important to treat to avoidchronicity and renal complications(calculi, renal failure to due interstitial
nephritis
Exacerbated by excess alcohol intake and drugs
Common in elderly patients on long term diuretic therapy with chronic tophaceous gout and renal
impairment
Investigations
Joint aspiration: needle shaped crystals that are negatively birefringent on phase- contrast microscopy
Plasma urate concentration may not be elevated during the acute attack
Hyperuricemia is an independent risk factor for cardiovascular disease
Must review cardiovascular risk factors during an acute attack
Smoking
Hyperlipidemia
Hypertension
Obesity
▪
MED - Condition 111 Tiredness and anemia
Monday, 22 May 2017 12:12 AM
Condition 111
Tiredness and anemia in a 55 year old woman
You are working in a general practice. Your next patient is a 55 year old woman,who consulted you two days
ago complaining of recent fatigue and mild breathlessness on exertion there were no other symptoms. Past
and family histories were not helpful. The patient is a non-smoker, rarely drinks alcohol, and has a normal
diet. She is two years post-menopausal.
On clinical examination the only abnormal finding was pallor. She had a resting pulse rate of 88/min (regular).
Cardiovascular system was otherwise normal. Abdominal and rectal examinations were normal. Urine
examination was normal.
You suspected anemia and arranged a full blood examination. The results are as follows:
Hemoglobin 97 g/L (120-150)

WCC 8.5x109/L (4.5-11)
MCV 74fL (80-97)
FILM: The red cells show some microcytosis, anisocytosis, and poikilocytosis
TASKS
Tell the examiner what further blood tests are required to confirm the type of anemia. The results will be
provided.
Explain the problem to the patient.
Advise the patient about what should be done.
Respond to any questions asked by the patient
You will not be required to take any additional history or perform any further clinical examination. IDA -
plummer vinson syndrome - dysphagia
APPROACH
To the examiner:
I would like to request for the following tests: Serum ferritin, Serum Iron, Total Iron Binding Capacity, and
Iron (transferrin) Percentage Saturation
Results:
SERUM IRON 4jmol/L (10-30)
TIBC 370pmol/L (45-80)
Fe (transferrin) saturation 8% (15-50)
Serum ferritin 22/jg/L (10-200)
Results are highly suggestive of iron deficiency anemia
To the patient
I'm sorry to hear that you are having fatigue and mild shortness of breath. How are you now? Are you
comfortable enough now before we begin the consultation?
I understand that you came here to discuss your blood test results. I have your results now, and it seems that
most likely you have anemia, and specifically, iron deficiency anemia. Sorry for the use of medical terms. But
do you have an idea what it is?
As you can see from your blood test results, we initially tested for three things: the hemoglobin, which is the
pigment in your red blood cells responsible for distributing oxygen to the rest of your body to optimize your
bodily functions, the white blood cells which fight off infections in the body, and the MCV which depicts the
size of the red blood cells. Your results show that your hemoglobin levels in your blood is decreased,
and we define this condition as anemia.
Because of this decrease, your body tends to lack oxygen neededto fully function that'swhy you'refeeling
tired, havingshortnessof breath, and look pale. There can be several types of anemia such as that caused by the
lack of iron or other factors in the blood, or a genetic blood disorder.
In your case, since we could see that your MCV or the size of your red blood cells is decreased, it can suggest
that the type of your anemia can be a lack of iron in your blood caused by several things as well, or can be
related to a genetic blood disorder. We did further testing to identify the type of anemia you're having and
results reveal that most likely you have a condition called, iron deficiency anemia. Have you heard about it?
Iron is a substance that is needed in the development of red blood cells, which carry hemoglobin and oxygen
in the body. Usually this deficiency occurs because of several causes---it may be due to a lack of iron intake
from your diet, bleeding episodes, or absorption disorders in your gut.
In your case, given that you have a good and balanced diet, given your age and that you are already
menopause, and yet you are still having paleness and shortness of breath and tiredness, I am just really
concerned about the possibility that you may have a masked bleeding in your gut. This masked bleeding may be
caused by any conditions in the gut--may it be an ulcer, effects of reflux, irritation from intake of NSAIDS, or a
benign or a nasty growth. This is a possibility that we must rule out before further complications set in.
Because of this, we need to do further investigations to rule out the specific cause of your iron deficiency
anemia. Aside from the basic blood tests, I will refer you to a specialist who will do tests to check your
upper and lower gut by performing a colonoscopy first, and then upper gut endoscopy if the
colonoscopy findings are negative.
This is basically a pain-free procedure, overseen by an anesthetist and a gastroenterologist. A tube with a
camera on the end will be inserted from your back passage to check your gut for any sources of bleeding like
a polyp and other benign masses and exclude a nasty growth, this is usually followed by a barium air-contrast
enema if the right side of your lower gut will not be visualized by the scope. If the results are negative, the
specialist may consider doing an upper gut endoscopy as well, just to rule out possible sources of bleeding in
the upper gut.
As of now, I will start you with iron tablets (ferro-gradumet -- ferrous sulphate 350mg) once daily. This can
have possible side effects such as dark stools, and hard stools so along with that please adapt a high fiber diet
and increase your fluid intake. However, we should stop this prior your colonoscopy date. We may also
consider you to start on antacids (H2 receptor antagonist), while awaiting endoscopy/gastroscopy if still
required.
KEY ISSUES
Determine type of anemia and its cause
Interpretation of investigations to confirm presence of iron deficiency anemia
Identification of possible causes of iron deficiency, particularly an occult colonic cancer.
Patient education and counselling, explaining the problem, answering the patient's questions and advising
furtherinvestigations.
CRITICAL ERRORS
Failure to diagnose iron deficiency anemia
Failure to consider gastrointestinal blood loss
Failure to advise both upper AND lower gastrointestinal tract endoscopy

Iron deficiency anemia is strongly suspected by the LOW mean corpuscular volume (MCV) and microcytic
hypochromic blood film. The low serum ferritin and low transferrin saturation confirm the diagnosis of iron
deficiency.
Circulating iron is bound to transferrin, the iron transport protein. Iron in excess of the amount
needed for hemoglobin synthesis binds to a storage protein apoferritin forming ferritin. Serum ferritin levels
below 10ug/L are virtually diagnostic of absent body iron stores
Once iron deficiency is confirmed, the key clinical diagnosis is that the patient almost certainly has occult
gastrointestinal blood loss, and therefore requires both upper and lower gastrointestinal endoscopies.
Not acceptable clinical practice in a POSTMENOPAUSAL woman with iron deficiency anemia to treat the iron
deficiency with iron therapy and do nothing further.
MED - Condition 119 A man requesting disclosure

Tuesday, 23 May 2017 12:00 AM
Condition 119
A man requesting disclosure of his wife's medical condition
You are a doctor working in a general practice. Your next patient, Bill, aged 67 has been attending the practice for
some tim e. Bill presents to you today for his annual check-up. You have completed your examination when Bill
tells you he is concerned about his wife's medical condition and wants to ask you about how you found her
when she saw you a few days ago.
Background
You last saw Bill's wife, Ann, aged 65, three days ago. You have been looking after her for many years. Ann
came to see you concerned that Bill keeps telling her that she is becoming forgetful and vague. You took a
history and performed a mental state examination and a general physical examination, with no significant
abnormal findings. Ann told you at that time that she was worried that Bill is telling her sons and daughter that
he will need to put her in a hostel or nursing home, though she feels that she and Bill are managing well at
home without any assistance.
TASKS
Respond to Bill's questions and requests about his wife's condition.
APPROACH
Good morning, Bill. I'm Dr. . One of the doctors here today. How are you?
Do you have any particular concerns?
I understand that you are very concerned about your wife. But before I attend to your request, can I ask you a
few questions first if that's okay?
ASSESS RELATIONSHIP WITHIN THE FAMILY
How long have you been married?
How’s your relationship with Ann?
How's your home situation? How are your kids' relationship with you and Ann? How often do you see them? Do
you have grand kids?
Any particular stressors in your life? Do you have enough financial support?
Any major changes in your life recently (children moved out, retirement, etc)?
RULE OUT POSSIBLE CAUSES OF FORGETFULNESS
Did Ann had accidents in the past?
Does Ann have trouble with performing complex tasks?
Does she has trouble with directions and recognizing places?
Has she had any falls or recent head injury?
Any particular incidents like leaving the stove on, or forgetting to close the faucet when she leaves the
house?
COUNSELLING
I’m sorry I cannot talk about your wife’s condition because of confidentiality
Confidentiality is an important legal issue here because it supports a patient’s privacy and help to establish good
and honest relationship a doctor and his patient. Because of this, it is my legal obligation to keep all information
given by patients confidential, and I have to respect that right. I am sorry but I cannot disclose the information
regarding my meeting with Ann.
Your concern for your wife is very natural but there are ethical issues involved here. You could try to talk to Ann
if she can share the information we discussed with one another. If that doesn't work, I’m happy to
arrange a joint consultation with both of you where we can discuss this in further details. I can even arrange
a family meeting to
involve your children to discuss everything, but again it should be done with Ann's consent as well. I’m sorry
I’m not
able to help you in this matter. Do you have any other questions?
Can you write a referral for her for the nursing home?
I am sorry but I cannot give you a referral letter for Ann. This kind of decision must be made between me and
Ann as my patient, as she is the one concerned in this situation.
KEY ISSUES
Ability to maintain patient confidentiality
Ability to counsel the husband where there is a conflict of interest
CRITICAL ERRORS
Disclosing information about Ann without her consent

CONFIDENTIALITY
Duty requires doctors to keep confidential all information they are given by patients and/or which they
discover or learn about patients through their professional interactions
May be breached by mandated reporting--for example in cases of child abuse
Patient expectations
All information patients disclose to the doctor will not be passed to a third party without the expressed
consent of the patient
Doctor will take reasonable steps to protect patient's information
IMPORTANCE OF CONFIDENTIALITY
Benefits for individual patients
Lack of it may prevent people from seeking health care
Maintains trust in the doctor-patient relationship
Necessary for full and effective communication
Maintains community trust in health care
Expresses respect for patient's autonomy
Acknowledges that patients have aspects of their lives that they should be able to keep confidential if they
choose
Part of inherent obligation of becoming a medical practitioner
Maintaining Ann's confidentiality requires good communication skills to explain to Bill why Ann's medical issues
cannot be discussed with him without her consent.
Requires explaining the concept of confidentiality that Bill can understand, and be able to defuse matters and
respond appropriately if Bill becomes angry
MED - Condition 129 Migraine
Condition 129
Migraine in a 30 year old woman
This patient was seen a week ago. At that time, she had a severe headache, and the following history was
obtained. She is a married school teacher aged 30 years with two children. This was the second episode of
headache in the last month. The headache was felt over both temporofrontal regions and was present on
waking up, becoming throbbing as it progressed. It lasted the whole day and prevented the patient from
going to work. It was associated with vomiting and photophobia and a visual aura. Panadol (paracetamol)
gave only limited relief. A physical examination at that time was normal. A provisional diagnosis of migraine was
made, however a computed tomography (CT) of the brain was arranged because of the patient's anxiety about
the possibility of a cerebral tumor. This was normal. You are now seeing the patient for follow-up in a general
practice setting. The patient has indicated to you that no further headaches have occurred since the last
appointment one week ago.
TASKS
Tell the patient the result of the brain CT scan
Discuss the future management of her migraine
The patient will ask you questions about the treatment which you advise. The examiner may request
clarification of this information.
APPROACH
I understand that you are a bit anxious about the results of your scan. I will explain everything to you as best
that I can. But before I discuss it with you, I would like to ask how are you so far?
Did you have any more headaches?
Any nausea, vomiting? Aversion to light and sound?
Do you know why the scan has been done?
Have you ever been told about your medical situation so far?
Based on the results, the CT scan done to you has normal results. There were no masses, or any nasty growths
that were seen. No bleeding from the vessels were noted, and everything looks fine.
I know that it can be distressing to feel these recurrent headaches with the vomiting and the hypersensitivity
to light, and it can be frustrating to see that the laboratory tests done to you revealed insignificant results.
However, I reassure you that based on these negative results, it has just confirmed that you are having a
benign condition called Migraine.
Let me further explain the condition to you, so that you will be aware of the nature of this condition, and so
that we can together put a plan in managing these persistent headaches. Will that be okay?
Migraine is caused by the swelling of blood vessels inside and outside the scalp in people who have very
sensitive blood vessels. The results in more blood pumping through the vessels, causing a throbbing sensation
as what you are feeling. It usually involves one side of the head, and it is usually associated with sensitivity to
light, nausea, and vomiting.
It is a common condition, and usually affects around 10% of the general population, more common in females.
The onset in young adults (can children), reduces in frequency over the age of 50 years.
Usually attacks are triggered by fatigue, stress, menstrual cycle, foods especially alcohol, some drugs
(vasodilators). Please be wary of taking codeine-containing analgesics as these have risk for dependence,
constipation, and rebound headaches--meaning that headaches may recur
because of this.
I will be your GP from now on, and I will help you manage your condition.
TREATMENT OF ACUTE ATTACK
When you have a sudden attack of migraine, this is what you have to do
Please rest in a quiet dark room, and avoid movement, reading, watching TV, using your phones or tablets.
You may apply cold packs to your head
You may start taking the following medications
Mild attacks
soluble aspirin 600-900mg every 4 hours, OR
Paracetamol 500mg 2-3 tabs every 4 hours (4 grams maximum daily), PLUS
Maloxon (metoclopramide) 10mg OR Stemetil (prochlorperazine) 5mg for the vomiting,OR
Panadeine (paracetamol/codeine) or Mersyndol (paracetamol/codeine/doxylamine succinate) but please
be careful as these may cause rebound headache in the long run
Moderate attack
Ergodryl Mono (ergotamine tartrate) 1 mg, repeat in 1 hour ifnecessary, OR
Cafergot (ergotamine with caffeine) 2 tablets initially or 2mg/100mg suppository, OR
Naproxen 250mg - 750mg, to a maximum of 1250mg in 24 hours
Severe attack
Ergotamine trial failed
Imigran (sumatriptan) 50mg tablet repeat in 1 hour, or injection
Remember than sumatriptan is contraindicated within 24 hours of ergotamine
PREVENTIVE ATTACKS
Lifestyle modifications and avoidance of trigger factors
You need to ensure that you stop smoking, eat a healthy well-balanced diet, decrease your alcohol intake to
standard limits, and engage in regular physical exercise.
Please try to avoid the triggers I told you about earlier. You may try relaxation techniques like meditation
and yoga to minimize your stress. I can give you reading materials for these.
Usually preventive medications are not indicated for your case as you only had two attacks of migraine.
However, if you do develop three or more attacks in a month, then we can consider starting you on some
medications provided that you don't have contraindications for these medications
Beta blockers: not for asthmatics. Adverse effect of tiredness and bradycardia
Pizotifen: adverse effect of drowsiness and weight gain
Cyproheptadine: adverse effect of drowsiness and weight gain
Tricyclic antidepressants: impaired alertness, anticholinergic autonomic side effects
Methylsergide: maximum of 6 months' use only. Adverse effects include vasospastic syndromes,
retroperitoneal fibrosis
Calcium channel blockers: for server, life-disrupting cases only. Use is for a limited time only.
I will regularly review you until we control your symptoms
In case your headache worsens, or if you develop severe vomiting, neck pain, fever, please come to be
reviewed immediately.
KEY ISSUES
Counselling and patient education
Appropriate drug therapy according to severity and including preventive measures
CRITICAL ERRORS
Failure to adequately address the treatment of acute attacks
Failure to consider trigger factors

Advice about management requires adequate consulting time in contrast to its diagnosis
Effective patient education and counselling needed, especially patient's acceptance of likely recurrences
Therapy involvesboth attention to lifestyle factors and choice of medication from a wide range of
alternatives
Correct choice of therapydepends on the level of severity of migraine and this initial consultation provides a
starting point of ongoing care
MED - Condition 135 Chronic diarrhea

Condition 135
Chronic diarrhea in a 45 year old man
You are working as an intern in the gastroenterologydepartment of a hospital. You are about to see a 45 year
old insurance agent who is presenting again because of chronic diarrhea. He attended the clinic two months
ago with a history of chronic diarrhea. At that stage his records indicate that there were no abnormalities on
physical examination, and examination of his stools for giardia, Clostridia, and other infestations were negative.
Colonoscopy was done and was normal to the cecum. He was diagnosed as having irritable bowel syndrome
and prescribed loperamide (Imodium) and referred back to his local doctor.
Brief patient profile

Married with two children
Non-smoker
Moderate drinker (two standard drinks two or three times a week)
No personal family or financial problems
Past history: No serious illnesses

Family history: Nil significant. No bowel disorders.
TASKS
Take a further focused history
Ask the examiner for the relevant signs you would look for on repeat physical examination
Discuss your further plans in regard to investigations with the patient
Explain the likely diagnosis to the patient
APPROACH
Good morning, I'm Dr. . I'm one of the GP's who will look after you today. How can I address you?
I understand that you are here because you are having diarrhea. Could you tell me more about it?
HISTORY
HOPC
Since how long have you had the diarrhea? How many times per day?
CCOV + Blood/Mucus = QUESTIONS FOR ALL DISCHARGE
Color?
Consistency?
Odor?
Volume?
Any blood or mucus present in your stools?
Associated symptoms
Do you have any tummy pain? Nausea? Vomiting? Bloatedness?
What meds have you been taking so far? Have your symptoms improved?
DDx questions
Coeliac: is the diarrhea sticking to the pan? Hard to flush? Floats in water?
any rashes or oral aphthous ulcers?
Dermatitis herpetiformis ==> itchy rash in coeliac disease
Giardiasis: stool frothy? Any travel history? Ingestion of contaminated food or water?
Cancer: weight loss, loss of appetite, lumps or bumps? Weight loss over 5-6kg
Hyperthyroidism: any weather preferences? Racing of the heart?
CONFIDENTIALITY: I will now ask you some sensitive questions but rest assured these will remainconfidential
unless it poses harm to your safety.Is that okay?
HIV: Sexually active? Stable partner? History of STIs?
Any prolonged use of antibiotics? Use of antibiotics recently? Sore throat 3 months ago, antibiotics prescribed,
and the diarrhea WORSENED.
Inflammatory bowel disease: erythema nodosum ==> painful rash
Back pain, joint problems
Irritable bowel syndrome: any stress at home or at work?
SAD+SOCIAL
I understand that you drink alcohol. Any chance you engage in illicit drugs?
PMH+MA
Do you have any family history of bowel disease, cancers?
GA: Pallor, icterus, lymphadenopathy, dehydration, edema?
BMI?
VS: temperature, BP with postural drop, HR, RR with o2 sat?
Eyes: signs of anemia?
ENT:
Oral aphthous ulcers, glossitis (signs of vitamin deficiency)
Skin survey forrashes
Abdomen: any distention? Any palpable mass or tenderness? Bowel sounds?
Rectal exam with the consent of my patient: any masses, tenderness, blood in the gloves?
INVESTIGATIONS
All basic investigations and colonoscopy were all done previously.
Repeat stool culture
FBE to look for anemia
TFTs to rule out hyperthyroidism
Coeliac screen: antigliadin antibodies and IgA antibodies
Repeat colonoscopy is needed
CT of the whole abdomen
Confirmation of coeliac disease is through duodenal villous biopsy via endoscopy
DIAGNOSIS AND MANAGEMENT

Most likely you have a condition called coeliac disease.
It is a condition caused by an abnormal immune responseto a dietaryprotein known as gluten. Gluten is found
in rye, barley, oat, and wheat. In people with coeliac disease, sensitivity to gluten causes inflammation and
damage to the small gut leading to malnutrition.
The exact cause is unknown. In your case, most likely it may have been triggered by the antibiotic that you have
been using during the past few months.
Because of this, I need to refer you to the specialist, and arrange baseline investigations including iron profile,
full blood examination, coeliac screening (antigliadin, anti- endomysial antibody). The specialist might do
a small bowel biopsy to confirm the diagnosis
A thin flexible tube called endoscope in the tummy through the mouth, and will take small samples from the
gut. These samples will be seen under the microscope to confirm the diagnosis of coeliac disease. Once the
diagnosis is confirmed, a gluten free diet is started. I will refer you to a dietitian as well
Coeliac disease is not curable, but we will work as a multidisciplinary teamto control the symptoms. There are
a lot of support available for you. I will also refer you to Coeliac Australia which is a support group for
families with coeliac disease.
Don't change your diet until the specialist confirms the diagnosis of coeliac disease.
Once confirmed, we will start you on a gluten free diet.
Here are reading materials that can give you more insight about your condition.
KEY ISSUES
Ability to take a focused history relevant to the patient's problem of chronic diarrhea
Recognition of the important examination features to be looked for in coming to a diagnosis
Diagnosis/differential diagnosis--depends on the knowledge of coeliac disease but the candidate should
recognize the chronicity of the diarrhea and possible causes, and the significance of the negative results of
previous investigations, suggesting that additional investigations should be done
Choice of investigations -- recognition that immunological screening for coeliac disease should be done, and
that small bowel biopsy should be discussed.
CRITICAL ERRORS
Failure to consider the diagnosis of coeliac disease

Main diagnostic challenge in this case is to distinguish a malabsorption state from inflammatory bowel
disease.
Differentials include: coeliac disease, irritable bowel syndrome, ulcerative colitis, crohn's disease, giardiasis,
thyrotoxicosis, carcinoma of the colon, lactose intolerance, antibiotic- induced diarrhea.
Other causes of malabsorption are less likely: tropical sprue, whipple disease, intestinal lymphangiectasia,
pseudomembranous entecolitis, HIV.
Coeliac disease
Permanent intolerance to gluten (present in Barley, Rye, Oats, Wheat--BROW) resulting in small bowel villous
atrophy and malabsorption.
Symptoms improve by removing gluten in the diet
Condition is familial
Increased risk of lymphoma, dermatitis herpetiformis
Presenting features
Onset of symptoms usually follow intake of antibiotics
Fatigue, weight loss (70%), diarrhea (70%), flatulence and bloating (60%), iron or folate deficiency (70%)
Serological tests:
Total IgA (deficiency in coeliac disease)
Antigliadin antibodies: monitoring dietary compliance but are not specific
IgG can occur with crohns disease, post-infection malabsorption, and some autoimmune diseases
Confirmation: small bowel biopsy
MED - Condition 139 An attack of asthma
Condition 139
An attack of asthma in a 25 year old man
You are seeing this patient prior to discharge from hospital.
You are the duty Hospital Medical Officer on your morning round. The patient was admitted to the hospital
Intensive Care Unit last night because of a sudden very severe attack of asthma, the worst he had ever
experienced. He has responded promptly to intensive treatment with nebulised salbutamol and
hydrocortisone intravenously, and subsequent oral prednisolone overnight. He wants to be discharged
today.
You would prefer the patient to remain in hospital for another day. The patient's peak expiratory flow
reading (PEF) this morning is 450 L/min (expected value for age/height for this patient is 625L/min). There is
minimal expiratory wheezing on auscultation of the chest. He is a 25 year old who has worked as an automotive
spray painter since he left school at the age of 15 years. He has never smoked and takes alcohol moderately at
weekends only.
He has had occasional mild asthma attacks since age 16 years. They were never severe until this attack. His only
treatment has been Ventolin (salbutamol)metered doseaerosol usedirregularly, prescribed by the family
doctor. He has had no other serious illnesses.
TASKS
Explain the nature and significance of his asthma to the patient
Specify what medication the patient should take after discharge from hospital
Discuss the future management of the patient's asthma
APPROACH
Good morning, I'm Dr. . I'm one of the doctors who will look after you today. How can I address you?
I understand that you have been diagnosed about asthma, and that your recent attack has been worse
necessitating hospitalization. I'm sorry to hear about this. How are you feeling now?
I understand that you want to be discharged today. However, before we consider your discharge, I would first
like to ask you some questions first about your asthma?
Any particular triggers of asthma that you know of?
Any new pets?
Change in the weather?
Recent cough, colds, fever?
Exposure to chemicals? -- at work?
Any stresses at home or at work?
Any particular allergies that you have?
How much do you know about your condition?
Now I would like to discuss with you your condition, and I will also discuss with you regarding your
medications, and our management plan so that you can avoid severe attacks like this. Will that be okay?
[ILLUSTRATE] Asthma is a common chest condition in which there is a temporary narrowing of the breathing
tubes in the lungs because they are hyperreactive or oversensitive. These tubes have swelling of their linings,
increased mucus production inside, and there is tightening of the muscles in their walls and therefore less
flow of air in and out of the lungs
No single cause has been found to trigger asthma, but a variety of factors have been considered
Infections, especially colds
Allergies (dust, pollens,mold)
Exercise, especially in cold atmosphere
Emotional upsets or stress
House dust, dust mites
Cigarette smoke, or other smoke and fumes
Sudden changes in the weather or temperature
Occupational irritants -- synthetic sprays, chemicals, wood dust
Drugs -- aspirin, drugs for arthritis, heart problems, and glaucoma
Certain foods and food additives
In your case, it is possible that you may be sensitive to the chemical sprays that you are exposed to at work, as
you have said that your asthma developed when you were 16 years old, and that was also the time when you
started working as an automotive spray painter.
Because of this airway narrowing, you tend to feel breathlessness, tightness in the chest, wheezing, and
coughing.
The risk associated with this condition is the fact that severe mismanaged asthma may lead to sudden death,
especially in those whodo not realize how severe the attack really is. But don't worry about this, as with the
correct treatment, most people with asthma should be able to lead normal lives.
SPECIFIC MEDICATIONS
In your case, once discharged from the hospital, you need to continue Prednisolone orally 30-50mg daily over
the next 5-7 days, and then stop it.
I will also start you with inhaled corticosteroids (QVAR, Pulmicort, Flixotide) which you need to take everyday
as maintenance, and an inhaled b2-agonist (salbutamol or terbutaline) as required if you have cough or
difficulty of breathing.
It is important that you know how to use your inhalers correctly as a faulty inhaler technique is a common
cause for medication not working properly. We usually recommend the closed-mouth technique, and I can
arrange a consult with an asthma educator with you for you to know how to use these correctly.
I will also advise self-monitoring by use of a a peak flow meter. This will assess your lung function and how you
are responding to the treatment that we're giving you. The asthma educator will also assist you in using
this
FUTURE MANAGEMENT
The most important means of managing this condition is prevention of attacks. Again, it is important that you
also monitor your condition when you're at home so that we can properly assess your asthma control.
It is also important for you to regularly take your medications as prescribed regardless if you have symptoms
or not to avoid possibilities of attacks.
I will refer you to an allergy specialist so that your triggers can be identified. I will also refer you to a
respiratory physician and an occupational health physician for assessment for work-related triggers that you
may have.
Please follow-up with your GP within 48 hours after discharge
Your return to work will be determined by your progress in your recovery period
We can also arrange a family meeting so that your family can be aware of what to do during your attacks.
I will also create an asthma action plan for you. This will guide you on what to do if you have decreased Peak
Flow Rates based on your monitoring. I can also provide a copy for your family members as well
ASTHMA ACTION PLAN

Personal details:
Name
Age
Address
GP
Known allergies:
Reliever Medications
Ventolin: 2 puffs via spacer as required and keep a record (blue puffer is a reliever)
Preventer Medications
Inhaled corticosteroid (Flixotide) continue as you are advised, 2 puffs twice daily
Prednisolone 30mg: given today continue for 6 more days to complete 7 days
Identification if you are Well, Unwell, or having an Acute Attack of Asthma:
Well: no night time and daytime symptoms, no limitation on activity and used
<3x/week of Ventolin
Unwell: increase in night and daytime symptoms, little limitation, >3x/week
Use of Ventolin 2 puffs via spacer as much as you like
Use of Preventer already: continue same dose
You need to see your GP within 48 hours
Acute Attack: Short of breathe, unable to talk, chest tightness
Do first aid: 4x4x4
1st puff, 4 breaths
2nd puff, 4 breaths
3rd puff, 4 breaths
4th puff, 4 breaths
WAIT for 4 minutes between each puff
Repeat 4x
If improvement: see GP today
If no improvement by 4x4x4x4 for 3 cycles: call 000 or go to the hospital close to you
FROM THE BOOK:
KEY ISSUES
Approach to patient: avoid confrontation and ensure compliance
Initial management plan: knowledge of appropriate medication and its delivery
Patient counselling: use of peak flow meter and asthma action plan
CRITICAL ERRORS
Failure to recommend continuing use of an aerosol steroid
Failure to consider that occupation may be causing or aggravating the patient's asthma

Asthma
Chronic inflammatory disorder of the airways
Clinical features
Recurrent episodes of wheezing, breathlessness, chest tightness, coughing at night or early in the morning
Episodes are usually associated with widespread but variable airflow obstruction
that is often reversible either spontaneously or with treatment
Inflammation also causes an associated increase in the existing bronchial
hyperresponsiveness to a variety of stimuli
Life-threatening but preventable disease
Severity of airflow obstruction will be underestimated unless lung function is measured
regularly
Early intervention is the best strategy: to relieve asthma attack and prevent
deterioration
Medications
All shouldhave a short-actingb2 agonistfor symptom relief and be instructed about its
use
Commence preventive therapy if the patient requires b2 agonist reliever more than 3-4
times per week, excluding that taken before exercise
Advise to patients
Take continuing responsibility for their medication
Make appropriate changes when necessary
Contact their doctor/pharmacist/asthma educator if they have concerns or queries
regarding asthma management
Attend for regular review
Understand the different roles of reliever and preventive medications, symptom
controllers if prescribed
Bring inhaler device to the consultation so that their technique can be checked
Understand the basic pathophysiology and natural history of asthma
Allergy is an important cause of asthma in adults and children
Encouraged to cease smoking
Education with drug therapy and an effective treatment plan reduce morbidity and
mortality
Poorly controlled asthma restricts participation in normal physical and social
activities
MED - Condition 145 Visual difficulties

Condition 145
Visual difficulties in a 50 year old man
Your 50 year old patient presents to you at the hospital Emergency Department with a
nine month history of finding it difficult, while driving, to see cars approaching from the
sides at intersections. He has also noted bumping into things.
TASKS
Assess visual acuity
Assess the eyemovements
Assess the visual fields
Tell the examiner what investigations should be done for this patient
Describe your findings to the observing examiner as you proceed. You can talk to the
patient and giveinstructions as you examine him but this is an examination station and
further history is not expected
Indicate the most likely cause of any abnormality you define
APPROACH
WASH HANDS
Good morning. I’m Dr. I’m the HMO in this hospital. How do you want me to address
you?
I am sorry to hear that you are having vision problems. But don't worry, it is good that
you are here today so that I can assess you and address your concern. I’m going to
examine your vision, cranial nerves (the nerves supplying the head and neck), and I am
going to have a look, feel and I’ll ask you to do some movements. Is that alright with
you?
Before I start. Are you in pain? Where exactly is the pain? Do you need any painkillers?
During the examination if I hurt you or you feel uncomfortable, just let me know so
that I could stop.
EXAMINATION
POSITION: Can you please sit on the chair?
HEAD AND NECK: GENERAL INSPECTION
On general look, there were no scars and neurofibromas on the skin of the head and
neck. There was no facial asymmetry.
There’s no ptosis, proptosis, deviation of the eyes and the pupils are both equal in
size and shape.
VITAL SIGNS: I would like to know the vital signs of the patient.
CN2: OPTIC NERVE
I will check your visual acuity. Please cover your left eye, then read this. Now cover your
right eye and please read this.
REPORT: The visual acuity of the patient is 6/6.
I will test your visual fields. This is a red pin, and I will move this to different areas of
your vision. Now, please cover your left eye with your palm and please don't put
pressure on your eye. Please fix your gaze at my right eye and please don't move your
head. lease let me know if you can identify the color of this target by saying "red" or
"not red" when you see it.
Now, let's do this on the other eye
REPORT: There is a visual field defect in the bitemporal areas of the visual field. There is
bitemporal hemianopsia
To complete the examination of cranial nerve 2, I would like to do a fundoscopic
examination.
CN3: OCULOMOTOR & CN4: TROCHLEAR & CN6: ABDUCENS NERVES
Inspection:
REPORT: The pupils look normal in size and shape. There was no ptosis.
Direct and consensual light reflex: I am now going to shine some bright light into your
eyes. It might be a little bit uncomfortable, but please bear with me.
LIGHT Reflex: Shine it from the side to the center
REPORT: The direct and consensual light reflexes were both normal.
Accommodation reflex: Please focus on the wall in front of you. Now focus on the tip of
this red pin (right in front of the tip of the nose). Check for convergence.
REPORT: The accommodation reflex is normal.
Can you please follow the red tip of this pin with your eyes without moving your head
and please tell me if you're having double vision. (H pattern)
REPORT: There’s no nystagmus seen.
REPORT: I would like to complete my examination by doing a full cranial nerve
examination, as well as an upper and lower extremity neurological examination, testing gait,
coordination, tone, power, reflexes, and sensation.
FURTHER INVESTIGATIONS
Cranial CT Scan or a Cranial MRI to look for a possible pituitary space-occupying lesion, as
well as endocrine investigations testing for pituitary function such as Serum Prolactin,
TSH, 8am Cortisol, fasting glucose, FSH/LH, IGF-1, UEC, osmolarity)
[To examiner] Most likely cause of a bitemporal hemianopia is a pituitarytumors
affectingthe optic chiasm, causing a bitemporal field defect that the patient is
currently having.
KEY ISSUES
Adequate and accurate technique of examination of eye movements and clinical
assessment of visual fields
Identification of bitemporal hemianopia
Suspicion of pituitary origin
CRITICAL ERRORS
Failure to demonstrate the visual field defect

A bitemporal hemianopia indicates involvement within the optic chiasma of the midline
decussating optic tract fibers fromthe nasal halves of each retina, which subserve the
temporal visual fields on each side.
Central lesions, such as pituitary tumors, are the usual cause
First fibers compressed: those supplying the inner, lower part of the retina---therefore
commence the assessment with the upper outer quadrant of each eye
Assessment of visual fields by confrontation
Use a RED TARGET (pin with red top).
In any comprehensive or other lesion of the visual pathways, COLOR PERCEPTION IS THE
FIRST VISUAL PROPERTY TO BE LOST, before the development of absolute scotoma,
Assessing field by waggling fingers requires the patient to still make several decisions
which are unnecessary
All that is needed is to demonstrate a DIFFERENCE IN RETINAL SENSITIVITY IN DIFFERENT
AREAS, and testing COLOR PERCEPTION is the most sensitive way of doing this
Instruct patient to cover the left eye with the palm of the hand (without pressure on
the eye), and fix the gaze on the examiner's right eye
Target is presented in the midperiphery of each quadrant of the field.
Subject is instructed to identify the color of the target -- "red or not red"
A defect in the optic nerve/radiations/visual cortex
Produce a field defect with a vertical edge
VERSUS a Retinal defect which produces a field defect with a horizontal edge (altitudinal
defect)
Instruct the patient to cover the right eye and fixate on examiner's left eye, and repeat
the test

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