Contents 1 180-UTI ina child (Ped). Pseudocyst of pancrease (inv) Fever with cough pediatric (online)... Infectious mononucleosis (inv) Condition 064 Investigation for male factor infertility Condition 030 Jaundice in a breastfed infant. Condition 012 Thalassemia minor in a 22 year old woman. Condition099 Acute gout in a 48 yearold man 260-Fibroadenoma counselling (Gen). 10. Cyclical mastalgia 11. Rotator cuff tear. 12. esophageal atresia 13. Adenocarcinoma prostate . 14. Ureterie colic. 45, 16. Stoke Ct interpretation . m Renal colic 18. SCCin-situ (ref from different websites) 19. SCC nn 20. Melanoma 21. Liver metastasis. 22. Hyperparathyroid.. 23. 220-Obstructive sleep apnoea (Med) 24. IDA. 25. Atrial Fibrillation . 26. SVT 27. Urticarial. '55-Pneumonia risk assessment (Med)... 63-Acute pancreatitis. ACUTE CHOLANGITIS... haemopneumothorax ‘Lung abscess Haemoptysis. Spirometry COPD 202 95, 96 56 35, 97 B 101 103 69 104 119 142 146 148 150 28 151Spirometry restrictive pattern. Lung cancer (Med) 264-Post viral runny nose/cough (Med)... Pleural effusion (Med) Occupational lung disease/Mesothelioma/Lung cancer (Med) Pneumonia (Med). 119-Haemopneumothorax CT Pneumothorax 28. NIPT counselling... 29. Condition 097 Abnormal GTT. 30. 357-HPV 16 positive (Gen).... 31. 359-Urine obstruction, uterine fibroids (Gen)... 32, 360-Vaginal discharges. Table (Gen) 33, Endometrial thickening. 34. Mid cycle ovulation (mittelschmerz) 35. osteopenia 36. 22,HIV during pregnancy ....» 37. Thalassemia Minor. 38. _59-Parapneumonic effusion (Ped) 8 cases (inv) 1. Renal colic 155 56 158 161 at 169 176 179 186 53 ..186 181 Error! Bookmark not defined. 2 2 182 184 2 33 + You are HMO, 40 years old Freddy came with complaints of pain in the tummy lasting for more than 10 mins probably A few hours back. The pain is radia stable now. A CT has been done and provided below. + Tasks- + Interpret CT scan to the patient + Management to patient \g from loin to groin and lasted 15 mins. Patient is,* Explain CT scan and structures — this is the CT scan in cross section of your tummy. It’s a mirror image so the structure on the left can be seen on the right side. These shadows are the kidneys. There is a stone in the left kidney which you can see as a white dot. * Management -urinalysis, serum calcium, uric acid and electrolytes + Treatment for kidney stones (ref. better health channel) * Most kidney stones can be treated without surgery. Ninety per cent of stones pass by themselves within three to six weeks. In this situation, the only treatment required is pain relief. However, pain can be so severe that hospital admission and very strong pain-relieving medication may be needed. Always seek immediate medical attention if you are suffering strong pain, Small stones in the kidney do not usually cause problems, so there is often no need to remove them. A doctor specialising in the treatment of kidney stones is the best person to advise you on treatment. Ifa stone doesn’t pass and blocks urine flow or causes bleeding or an infection, then it may need to be removed. New surgical techniques have reduced hospital stay time to as little as 48 hours. Treatments include: extracorporeal shock-wave lithotripsy (ESWL) — ultrasound waves are used to break the kidney stone into smaller pieces, which can pass out with the urine. ESWL is used for stones less than 2 cm in size. Side effects — pain, blood in the urine significant + percutaneous nephrolithotomy — for stones larger than 2cm. A small cut is made in your back, then a special instrument is used to remove the kidney stone. Pain and infection common? Hospital stay will be like 3 days.* endoscope removal — an instrument called an endoscope is inserted into the urethra, passed into the bladder and then to where the stone is located. It allows,the doctor to remove the stone or break it up so you can pass it more easily. Pain, infection, blood in urine and injury. * surgery — if none of these methods is suitable, the stone may need to be removed using traditional surgery. This will require a cut in your back to access your kidney and ureter to remove the stone. Risk of bleeding, infection and pain from the surgical incision. It is rarely performed nowadays as it has a week of hospital stays and 6 weeks recoveey period for the patient to return to normal activities. * Stone prevention — + increasing fluid intake, especially water, sufficient to maintain dilute urine output avoiding added salt maintaining a well balanced diet and avoid oxalate rich foods if it is an oxalate stone which is common variant. 2. Infectious mononucleosis (inv) 22 years old girl Emily is having sore throat, mild fever. Her examination and inv done which showed following results. Examination: ‘+ Temp 37.5, Tonsils enlarged with little pus. Cervical lymph adenopathy, Hepatosleenomegaly. Investigations: ‘* Che: Hb, pitsnormal, Wbesand lymphocytes increased * Hiv, hep b nc, syphilis serology negative ‘© Cmvigg n IGM -ve, EbviGg-ve, IGM +ve, Transaminitis ve ‘© Explain findings to pt © Tell her condition | Management‘1 understand u having some fever, are u ok at the moment. We have done examination and inv. lam going to explain them to u. On examination: ‘Temp is high. Tonsils are enlarged, tonsils are part of immune system which fights against infections. There is pus over them as well. There are small glands in your neck called lymph nodes, they are also enlarged. Liver and a small structure part of immune system called spleen are also enlarged in size. Did u get it. inv: *We have three blood cells. ‘*Hb which is iron rich protein carrying oxygen to body is normal. Plt: which helps in clotting, normal as well. ‘*Wbes: which fight against infections are increased. ‘Transaminitis-there is also ERSSSSGURINVEEERRYAREE which is a feature of this condition Sometimes there is yellow discoloration of skin and eye may transiently occur. ‘Serology for viral infections done( name all above) . but its good they are normal. SBrOloBy forone Virus called EBV Is positive. 1g G which shows the previous infection by this virus is negative and IgM which shows the current infection is positive. So u are having a con called infectious mononucleosis or glandular fever. It’s a viral infection causing these all symptoms and examination findings. ‘*Symptoms include fever, sore throat, swollen lymph glands, tiredness, and feeling generally unwell. The doctor may find swelling of the spleen or liver ‘The illness usually lasts between one week and several weeks. A small proportion of people can be sick for months ‘*Most people make a complete recovery .Once infected, the virus remains in the body for life. ‘*Infectious mononucleosis is spread from person to person through direct contact with saliva So people with IM should avoid kissing others, regularly wash their hand and not share drink containers. ‘it can be spread from people who are sick with the illness or by healthy people who carry and can spread the virus intermittently for life ‘The time from infection to appearance of symptoms ranges from 4 to 6 weeks ‘Similar symptoms can be caused by other viruses such as HIV, Hepatitis B and C, CMV, Syphilis but they are ruled out.So far you following me? ‘Management: “This is self-limiting condition. Will get better in some time. *Only thing u need to do is ‘Take a lot of rest. | can give u certificate for leave. *Take plenty of fluids. *Paracetamol for fever. *if fever gets worse or your condition is not improving, or when there is difficulty in swallowing or tummy pain, just get back to me. *Please be careful. Don’t take any antibiotics as u don’t need them and also they will cause rash if taken. ‘contact sports and heavy lifting should be avoided for the first month after illness because of risk of damage to the spleen, which often is enlarged during acute infection. ‘*Most patients with glandular fever recover uneventfully. 3. Pseudocyst of pancrease (inv) You are HMO in ED. 57 years old Male Alex, presented with abdominal pain. Your colleague found a mass in epigastrium and went for a CT. Tasks: © History © Explain CT ‘© Explain the causes or most probable cause © ManagementXtDeu tM rcs mena Positive findings ‘© Upper tummy * Goutof10 © Stabbing ‘* Panadol relieved sometimes ‘© Less than one month ‘© First time pain for that long © Smoking 10 yr, 4-5 cig ‘© Alcohol for 10 yr, 4-5 glasses ‘+ No LOW, LOA, lumps and bumps ‘© Dark urine, yellow skin, itchiness — nil © Heart burn — nil ‘+ Fatty food - sometimes + No previous Sx History : Abdominal pain Q Ddxa‘+ Gall stone -nausea, vomiting, bloating after meal © PU-heart burn ‘+ Hepatobiliary -yellow colorskin, dark urine ‘© Chronic pancreatitis nausea, vomiting, diarthoea. Fatty stool, don’t flush away easily Any surgery done in tummy? (Adhesions leads to pseudocyst), LOW, LOA ‘© Past medical © SADMA Explain CT: This is the CT scan of your tummy in transverse section and it is the mirror image so the things we see in left here will be the actually the organs from the right side of our body. So this area here is liver. This is the stomach. And this is the back bone. So what | am concerned is the black area here compressing the stomach. tis originated from pancreas and since it is black in color, itis’ cyst. So it is most likely pseudocyst of pancreas. Pancreas isthe gland located in our gut system to produce ERS yi TSRBIgEE So now, there is collection of flui of pancreas init Itis most likely because of éhronie pancreatitis, the inflammation of the pancreas leads to forming like a cyst lil structure what we called pseudocyst «Again, the cause of chronic pancreatitis are all tSReS) SleOHOHG praviouS ZUrEEAI ‘* But in your case, most likely it could be gallstones blocking the passage of pancreatic enzymes to the guts ‘+ So those enzymes go back to pancreas, iritating it and causing inflammation. (still possible for stones in CBD even after cholecystectomy) Rx (not in task) refer go surgeon ‘© Small-watchful waiting ‘© Large -5-6cm —drainage ~can rupture, can press on nearby structures, can lead to septicemia (infection spread to whole body) Blood test for CEA)ICANSIS) BaRERESHE BABY and baseline check-ups Management:‘Since you had pancreatitis in the past, the duct carrying the pancreatic juices to the small bowel ruptures, leading to collection of pancreatic juices in the pancreas forming a cyst called a pseudocyst. Management depends on 2 factors, one is size, the other is duration of the cyst. small cyst: usually resolves spontaneously + Repeat CT Sean inl6 Weel to see if theres resolution ‘+ >6cm: large cyst: needs active surgical management Duration + RBWEREE: immature cyst: usually resolves spontaneously © Repeat CT scan in 6 weeks to see if there is resolution © >6 weeks: mature cyst: needs active surgical management In your case, it seems like that it is a large and mature cyst, that is why we need to operate on it. Iwill refer you to the surgical registrar who will consider doing: + Ultrasound:guided percutaneous drainage: nonoperative, ultrasound-guided placement of a catheter through the skin to drain the pseudocyst + Open cystogastrostomy: create an opening between a pancreatic pseudocyst and the stomach when the cyst is in a suitable position to be drained into the stomach 4. Adenocarcinoma prostate* You are a general practitioner. A 68 years old Mark who initially presented to you with frequency, urgency and dysuria coming for follow up. On examination before, you have found enlarged prostate. You referred him to urologist. Who did DRE, urine tests and sent the results. Investigations are given below: + Urine test— MSU growth of E.coli * Blood test — PSA — 6ng/ml (normal <4ng/ml) + Core biopsy - show adenocarcinoma prostate with gleasan score 7 * Cystoscopy —normal, no bladder neck obstruction + Radio nucelotide scan — shows no metastasis * CT pelvis- Ca cells within prostate capsule (stage 1 and 2) * CT Spine — normal Your tasks: Explain the results Offer the management options + Greetings! + Explain the results one by one + The first test we check is the urine culture to check for any infections in the urine tract. We found the growth of E.coli which is confirmed as infection in the urine tract. The second is PSA which's a protein produced by the cells of the prostate grand. it's level isa bit increased which means that there is increased number of cells in the prostate. We also took a bippsy fram the prastate and zhe result shows adenocarcinoma, a type of nasty etputh and it’s mediurr-graded with a Gleason score of 7. Don’t worry. it's a cammon condition in men in their 60s. We also checked the urine bag from the urinary opening with a flexible tube and we found no obstruction in the bladder outlet which means that the enlargement of prostate is not obstructing the urine flow. Another tests, radio-nucieotide sean and CT spine which ate the scans to detect the spread but luckihy there iso spread: In addltion, when we checked the CT pelvis, we kno that the nasty cells are still inside the capsule of the prostate, So it’s a very early stage. * Diagnosis ~ UTI and CA prostate + Reassure —early stage, no metastasis, can be cured + Management—1 st problem is Ca prostate * Option 1 - Radical prostatectorny- Removal of whole prostate ~ Retnaval by surgery under anaesthesia ~ Suitable for young patients and early stage ~ Benefits — can be cured, treatment completed in one day. Drawbacks ~ Incontinence, Impatency, infertility and blood in urine {short term and long term)* Option 2 — Regular observation “Active surveillance - wait and see regularly and monitor =PSA, Clinical'exam and DRE and MRI in regular intervals- suitable for patients over 70 years and low risk patient who do not #ant surgery like in your case. The pros are fewer side effects than active management, can still monitor the cancer closely, may never need further treatment. The cons aré you may need regular examinations and biopsy and might worry that you are not doing anything. Others Radical radiotherapy, Brachytherapy (radiation by inserting implants) Radiation is also a curative treatment ut may result in bowel and urinary problems and skin changes, infertility.), Hormonal — suitable for patient with advanced disease 2nd problem — UTI — infection in ui to prostate enlargement ~ Less common in male, happens when there is obstruction of urine flow - Will be treated with antibiotics changed after culture result) Brothers? Recommended for screening program ary tract most likely because of the stasis of urine due ‘Gleason Score Gleason Seore | 5,67 8.910 | Matin gdetunor Tipit Unpredictzble Growth Ag ive Growth Tntermedite canes may | Hghendecanesareuslly ° betavelike lov-gadeorigh- | reryaggresiveand quick to Célsbokmos ie moma | grade canes ‘pred tetsu prs cls and ards surunling hepsi, asbeng "wel-diferetiaed". | The cell behavior may depend onthe vohmect the | These emer als ok est cancerandthePSA letel. | ikenormalprosat els and are aul esi as ‘politi, Tent be sw growing 5. Mid cycle ovulation (mittelschmerz) 24 year old Mary, presents to you at your GP with complaints of Right lower abdominal pain for the last 1 hour. You ordered a pelvic and abdominal ultrasound which showed ‘© aruptured ovarian follicle, ‘© free fluid in POD, ‘© appendix not visualised ‘© gall bladder with 3 stones, each of 1.5 mm ‘gall bladder wall thickness to be normal Her last menstrual period was 2 weeks back She had appendicectomy at the age of 12 TASKS +1 Explain ultrasound results to Mary ‘+ 2 Discuss with her the most probable diagnosis ‘+ 3 Explain to her further managementExplanation of USG findings * Ovaries are a part of female reproductive tract * During each period cycle, several follicles develop in your ovaries out of which one matures which then breaks open to release the egg or ovum. This happens approximately around 14 days of your cycle If you undergo unprotected sex during this time the ovum will get fertilised resulting in pregnancy The scan shows that there is a follicle that has broken open to release the egg EXPLANATION OF USG + There is a small pouch called POD between your womb and back passage ‘= Scan shows some fluid in this pouch which happens due to various causes and ovulation is one of the reasons as some fluid released during this time due to rupture of follicle can collect in this pouch ‘+ Appendix is a small finger like tube attached to your large bowel on the lower right side of your tummy * This is not visualised as you had your appendix taken out before ‘The gall bladder is a small sac that holds bile, a digestive juice secreted by your liver that is Used to break down dietary fats ‘+ Scan shows 3 stones in your gall bladder which are formed from fats, calcium salts and bile pigments * But the wall of GB is not showing any signs of infection or inflammation as the wall thickness is normal 6. 220-Obstructive sleep apnoea (Med) Mum, Christina, is concerned about son, Ben, having difficulty breathing in hospital setting, The boy had cold recently. Fine now X-ray of lateral view head and neck given showing upper airway narrowing. Graph of $a02 (polysomnography?) showing chart of Sa02 going down to <92% Tasks: -History (3 min) -PEFE -Explain xray -Dx/DDxtae ef @ Gate | Glen | tn | es!“The Matlampat Score Sree = = SS STOP-BANG Sleep Apnea Questionnaire Chung F ot al Anesthesiology 2008 and RJA 2012 STOP Do you SNORE loudly (louder than talking or loud Yes No enough to be heard through closed doors)? Do you often feel TIRED, fatigued, or sleepy during Yes No daytime? Has anyone OBSERVED you stop breathing during Yes No your sleep? Do you have or are you being treated for high blood Yes No PRESSURE? BAN BMI more than 35kgim2? Yes No AGE over 50 years old? Yes No NECK circumference > 16 inches (40cm)? Yes No GENDER: Male? Yee No. TOTAL SCORE High risk of USA: Yes 5-8 Intermediate risk of OSA: Yes 3-4 Low risk of OSA: Yes 0-2What is obstructive sleep apnoea (OSA)? OAs slow or absent breathing (amos) for short periods of 10 seconds or more while sleeping These periods of apnoea can occur many times daring the night so that an observer, ‘who is often alarmed by the problem, will notice normal breathing low down and then stop completely The eleeper then struggles to breathe, makes a choking or sputtering noise and resumes breathing The cycle then repeats elf, What are the symptoms? ‘Thesuffee has periods of absent breathing as described abore but is not aware of it He or she wakes feeling unrefreshed, ‘hed atl ina oF one le Oder spi gy Ines irritability, morning headache, poor concentration, general Joss of interest and sextal dysfunction, Who gets OSA? {kts more common in middle-aged men who ar overweight ‘Wornen can alo get OSA bu usally after menopause People ‘wun aterentatatonnal sructufes Wat cause narrowing ofthe back of the throat are at risk This includes a large tongue, a small jaw, «blocked nose, and large tonsils and vila, Hypothyroidism s another ease. Whats the cause of OSA? Itisbasially «phystcal problem, espectally in obese patients, ‘when the soft issue suc asthe floppy partof the soft palate flops against the back of the throat This obsructs the free flow of alr uo the aur passage, Aggravating factors are medications and aleohol, espectally inthe evening Somerlmes the eae {is unknown but some people with illnesses ofthe Iungsand nervous system can get it. Whatare the risks? (OSA can be life threatening, Increased daytime drowsiness Jeads o increased road and workplace accidents. prolonged, Fs Tsk cto foe heart protean ml toes How are people tested for OSA? ‘The observations ofthe eeeping partoe ae very iaporen However, the best testis overnight admission (0 sleep dlsorder cline where a computer econ slep patterns at flow and bran act Whats the treatment? (OSA ts difficult problem to treat but simple measures can help These include: ‘Lose weight if overweight—even a small amount can help. + Get physically fit with regular exercise + Avold sleeping tablets and tanguilisers ‘+ Avoid alcohol for up to 3 hours before going to sleep. + Use a short course of nasal decongestants for nasal congestion, + Avoid sleeping om your back. CCorzective surgery for any obstruction to the airflow from. the nose to the back of the throat ean help those affected ‘The most effecuive treatment currently avallable for severe cases Is CPAP IF this 1s not tolerated, a special mouthguard can be used, (| back of throat Normal airway when sleeping \. tongue soft palate Obstructed airway when sleeping (sleep apnoea) What is CPAP? (CPAP, which sands for ‘continuous postive away pressure’, isthe most widely used reatment for OSA.The affected person swears a cose-fiting mask over the nose during sleep while a stnall alr compressor forces air under low pressure into the Upper airways to keep them open.‘Take Consent: | will need to examine you, I will maintain privacy and chaperon will be here. sit ok with you! Thank you Can you please sleep comfortable on the bed (‘ake you shirt off for me) while | wash my Ina? Tha pou Explain willexaive: ght be Hike bit wneifor table but it shivuld 0 be pal Please let me know if you feel any pain and | will stop immediately. For the purpose of examination. | will hhave a look, fel, listen to your ... and may ask you to do some manoeuvres (joint). sit ok with you? Thank. you When finish Offer tissue to web. Give patient chance to wear iq privacy ‘At the end: Thank you for being cooperative during the examination and sorry ifit was uncomfortable. Can ‘we st together now and discuss what was found during the examination? Thank you NB: 1) Examination include: General examination, local examination, MSE, MMSE 2) Local examination means all systems related to site of pathology. ig patellar hyper reflex is a part of local ‘examination of thyroid gland 3) Try to get the patient expecially child to sleep on the bed without help especially f you suspect abuse History L-breathing difficulty Qs -What do you mean? -What time day or night? -Does he turn blue or pale? -Does he Stop breathing at night? Affect sleep? -Is he Sleepy during the day? 2-Associated symptoms -Mouth breathing? “Snoring a lot? -Runny nose? -Recent viral infection, recurrent infection (tonsillitis or OM) ~Fever? -Cough? -Poo & Pee? 3- Others. -Eating? Swallowing difficulty -Growing? -Performance at school and behaviour? -Hearing problem? (Does the child watch TV with high volume. when call the child, does he respond?) Contact hx -Smoking at home-Allergy hx or Family History 1-6/8 -mouth breathing, adenoid facies 2V/S 3-ENT Ear- (TM congested, bulge, red and retracted +ve) Nose (polyps, discharge, pale, swollen, boggy mucosa) Mouth (tonsils enlarged, red and exudates) LN None. 4-Growth chart 5-General system 1 ‘Quostionnsie negative, ESS 28 ies { uate pong 88 estat = (anos bint 058 | atau ray bs coral coor oe esas a eth ASAMNATA academe BRA ay 1 \Nocate sars O9Ken POOH IGOR Wn onan ayes ‘ch woah creas ng nsf sep Spc a fae) 1 (GP pad 08 tata poe iad nts wth aces pit pet Inpmentceamert wt ese moss and 2 Canale tl rE ‘sonata opens Mags carinaraus as mabe smite 1 Meni sets OPA aha,Explain X-ray and diagnosis -Point out the adenoids and nasopharyngeal airway and tell this structure here is enlarged called adenoids, which is causing the airway to be narrowed. -From history and Examination, X- ray provided with S202 chart, your child most likely having a condition called OSA, where the child stops breathing for a short time when they sleep. It tends to happen repeatedly during the night. -Usually occurs due to the airways being blocked, and the cause most likely to be due to big tonsils (soft tissues at the back of the throat to fight infection) or big adenoids (soft tissues at the back of the nose to fight infection too) So, this causing the child to have difficulty breathing mainly at night leading to mouth breathing, snoring and recurrent infection and sleep disturbance with episodes of breathing obstruction, Treatment -Therefore, | would like to refer your child specialist (ENT) who will decide upon the Mx. Might consider taking the tonsils or adenoids out to relieve the obstruction. (key of all). To Sleep Clinic. -Hearing test and speech therapist if problem with speech -Avoid smoking exposurePolysomnogram (PSG) ectroeloram (measees muscle actly Nasal aiiow DA peel Lan itt $$ Paani abdorial $0 ermgbin dessturation —— % os oo Se $ sadyrt'a $$» Your next pt in GP is a 40 yr old male comes for bid test result. He is a known case of psychotic depression bid test — © Na~reduced © Lipid - normal© potassium, urea cr normal © TsHnormal © UrNa increase Task ‘© Explain result to pt ‘* Explain possible reasons to pt Feeling unwell Antipsychotic © mirtazapine © Quetiapine Explain result Psychotic depression h/o SE - Effect on heart rhythm ‘Ask (increase loss, increase water intake since ur sodium is increased) - Vomiting - Head inj ~ Water pill = Underlying d/s ~ Loss motion Dx. SIADH? Drug induced hyponatremia? ‘Theory thinking If Sodium reduced Dehydration ss Oedema = cardiac/liver/renal failure Ur Na = increase \edication/ kidney loss/ SIADH Ur Na = decreas water overload = psycho drinkingConfusion Ifall symp neg ‘Think of SIADH if serum osmolarity decrease and urine osmolarity increase with urine Na increase Mx Refer to specialist Treat hyponatremia need to check BP first © Hypertensive with hyponatremia "Fluid striction ‘© Normotensive with hyponatremia = 0.9% NS fluid © Bp reduce Na reduce = Salt tablet Red flag - Confusion - Weakness ~ Feeling thirst You are working as an HMO in a regional hospital. Mrs Sophia, 86 years of age, is a own home resident who was admitted to hospital following unwitnessed fall. She had been feeling unsteady on her feet for the past week. Her past medical history included osteoporosis, HTN, GORD and depression. She was on multiple medications, including escitalopram for depression, telmisartan for HTN, oxycodone for back pain, simvastatin, pregabalin for sciatica, esomeprazole for GORD and six monthly denosumab injection for osteoporosis. Investigation hospital showed hyponatraemia-120 mmol, another test normal Tasks: -Further approach for this case with focus physical examination -Further investigation with examiner. -Management with patient. Creatinine (40micro mol) eGFR- 90mI/min/m2 Serum osmolarity (254mosm/kg) Urine osmolarity (140mosm /kg) Urine sodium (39momI/I) ‘62-year-old man is brought into the emergency department after experiencing a generalized tonic-clonic seizure. He was recently diagnosed with small cell carcinoma of the lung but is takingno medications and has not received chemotherapy. Physical examination reveals a patient in the postictal state. His blood pressure is 138/86 mm Hg, and heart rate is 76/min without orthostatic changes. He has no lower extremity oedema. Relevant laboratory findings are as follows: Serum: Nat: 105 mEq/L K+: 4.0 mEq/L Cl: 70 mEq/L HCO -: 25 mmol/L Nat: 91 mEq/L. K+: 64 mEq/L Urea nitrogen: 140 mg/L 3 Urinalysis: BUN: 5 mg/dL Creatinine: 1.0 mg/dL Glucose: 85 mg/dL You are HMO in ED seeing an old man John who lost consciousness a few hours ago with weakness of left side of his body. He has long standing hypertension and on ACEI and aspirin. There was no HO of fall. Wife Mary has come to discuss about her husband condition. Tasks: * Explain CT scan findings to wife uss about possible causes, * Explain about prognosis (No management) © Authority* Hello. I can see that you are here to discuss about your husband's condition. Let me reassure you that he is in the safe hands and stable now, we will do our best to help him. Do you have any particular concern? Do you have any questions for me? + Sonow let me explain you about your husband’s condition. This is his CT scan. And this is the the skull bone and this is the gray this shadow is the brain and this is the left side and this is right. This gray colours means soft tissues and the white colour means the solid or bones. As you can see here in this gray colour there is a whitish circular area here which is not supposed to be here. This circular area can be something like bleeding or infections or Abscess which isa collection of pus in the brain or some sort of growth. * But according to the history and according to the nature of his acute weakness, Most likely, So this white area most likely is the bleeding from the ruptured brain vessels. * There are several causes leading to this bleeding, one cause is he has a history of fiigh blood pressure so when this blood pressure is so high and when the brain vessels cannot tolerate it, they got raptured causing the bleeding Sometimes it could be due to or some remnants of the Also he is taking v vvv which is a blood thinner so it can cause the bleeding as well. So the problem is when the bleeding occurs, and that bleeding becomes a blood clot pressing on the brain tissues, that compressed area stopped working which control the other side of the body. So that’s why he got the Weaknessiin opposite side of the body. * So far are you with me? As you can see the blood clot is quite large in comparing to the size of the brain. But we still have hope that he can recovers from it. So first of all, a Specialist will check whether we can do the surgery to remove the blood clot. Ifit is removed successfully he can get well. But still we will need to go through a series of ‘to recover from the weakness. Because he * After the removal, we have ongoing management for such patients and he will be under the care of the fiutidiseiplinary team including > physiotherapist,neurologist, GP and also occupational therapists and speech therapist as well We called this fehabilitation phase vvVY He will be followed up by GP to prevent infection or clotting problems and also be seen by psychologists and neurosurgeon as well ‘We will try our best for his convenience and best quality of life. He needs to be followed up regularly and for his blood pressure in also for the residual weakness. } Approach * Explain the contrast X ray and CT scan. (abnormal bulging of the aorta which is the main vessel from heart, this is the two kidneys and you can see the dilation here just below the kidneys) (CT — bones and vertebra and show dilation) tt originates from heart, normal size is less than 3 cm. In your case, we will need to invostigata with USG fer the size but in this ceane, wa can soo that it le obviously cilates. + The extent It’s relation (above or below) the bifurcation to the renal arteries. + The causes are due to the fat deposition in the artery wall and reduced elasticity {artherosclerosis), increased blood pressure hypertension, smoking, degenerative diseases, collagen diseases and familial + symptoms — pulsatile mass, dragging sensation, tummy discomfort * Leak—pain and buttock discomfort + Rupture tummy pain followed by collapse and death* lunderstand that you don’t have any symptoms. But when the size is increased — increased risk of rupture - massive bleeding — lack of blood supply to lower part of the body — fatal * Once it is ruptuged — mortality rate is very much higher — too late to be treated * Good point ~ now we have detected it - we can do the repair before the complication. * Your trip ? Where are you going? With whom? How long will you stay there? What activities will you enjoy? * Management —we will check the size frst. The managements depending on the size. 33.8 followup 2 yearly, 4-4.5~1 yearly, 4.6 to'8.0— monthly, >5~3 monthly, >5.5~ intervention) * But your case— significantly enlarged —| am concerned — caravan trip read is not smooth, and + So | would like to check with a vascular surgeon after knowing your size. + Elective surgery may lye considered If size Is larger than 5.5 em— +L endoluminal repair (inserting the aortic graft through femoral artery through groin incision) or + open surgery + Complications — injury, bleeding, risk of anaesthesia, clotting problems and minority reported Impotency but less likely under experienced hands + So for the mament, | am sorry, | want you to postpone the trip for a while and check with vascular Surgeon, + Red flags — back pain, tummy pain, dragging sensation or collapse (tell the farnily members}- ED 8. esophageal atresia You are a HMO. A nurse, Lily, has come in after passing NG tube in a new born who started vomiting on day1 of life. Task take history from the nurse PEFE explain the given xray to nurse give your diagnosis* History: * Vomiting Hx * tell more about it, when start, colour and amount, forceful/not, related to feed/food DDx * Obstruction - Associated with lump and bump(tummy) + Infection "rash , fever? * TE fistula - cough? Turning blue while feeding? (aspiration) * VACTERL-vertebral defects(defects in backbone?) , anal atresia (passed meconium?), cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities (any limb anomalies?) ~ VACTERL should be 3 of them positive * Severity - general condition? Floppy? Appetite? Pee and poo? * BINDS + PEFE — general appearance, vitals, Dehydration? * Dysmorpgic features + Respiratory, CVS, Abdomen * Anal patency * Dx: This Xray is as you can see, the NG tube coiled back in the oesophagus so that means there is. no lumen to go down, So it can be diagnosed as oesophageal atresia, which is a congenital condition. * It occurred due to the fault in recanalization of oesophagus during fetal development. It is highly associated with tracheo-oesphageal fistula + Draw a pic and explain types, with or without TE fistula. In this case, fundal gas is seen so most likely itis type C which is commonest type. * Mx — NPO, IV fluids and surgeryCLASSIFICATION = Trechen ross = inoue T Td f t™ 8 cases (inv) vocr You are a GP. A 70 years old lady, Jenny, presented with SOB for quite some time. She had lost weight, night sweats as well. She is coughing phlegm which has streaks of blood in it. Your tasks: + take hx, * explain X-ray findings to the pt + give dds.History or SOB history — onset, duration, with activities? How severe ? Daily activities? At rest? Can sleep well? HAGA SIGNS WONSUNESEROUSEREIEEDY Ageravating factors, relieving factors? ‘Any cough? If yes, how long? Dry or producing phlegm? Continuous or off and on? Phelm - yes ~ color? Amount? Was it produced anytime you cough? DDx - Any fever? Chest pain? palpitations? How many pillows do you use to sleep? LOW? LOA? Any lumps and bumps all over the body? LOW +, how much weight did you loose? What was the duration it took for that weight loss? Is that intentional? Have you travelled anywhere before this SOB and cough? Occupational history (silica, coal, asbestos), Bird, allergens (not only about current job, please ask about any previous jobs associated with these!) SADMA* Any family history of lungs diseases or cancer? Explanation * This is X-ray of your chest. Let’s see it together. * This is your windpipe its central that’s normal position + These are your collar bones and these bones are ribs. This is the muscle diaphragm that separates tummy from chest. This shadow is your heart in the center, which is normal. These black shadows are your lungs. There is a whitish opacity at the upper part of right lung. Please check the left lung and there is no such opacity as you can see. + It could be anything like : + CBRBBIIGEHIGA (when sir sacs are filled with fluid [ifSEHSREY BU eae BREURRIA but u don’t have fever. + It can be Golleetion of pus inside lungs called abscess, but again less likely. * It can be another infection which is called although rare is Australia but can be ity since you have . * Another condition that | am éonéerned is this mass(can be’ tumor, anasty condition which But please don’t worry | am just telling u all possible causes still we have to do further investigations for confirmation. + Although S08 can be due to other causes like heart problems or anemia but | don’t think your history is consistent with those. + Reassure — We will work on it together and still we need many more investigations. Even if, it is cancer, we have specific treatment for it. 10. Viral Encephalitis,CSF findings in various CNS disorders ‘conditon Color Normal Clear ‘Acute bacterial Opalescent ‘meningitis to purulent Tuberculous _Opalescent meningitis Viral lear ‘encephalitis teucocytas Protein mg/l 0-5 20-45 60-70% ymphocytes 4100-20000 100-500 PMN predominate 10-2000 250 PMN early but lymphocyte later 5-500 30-150 ‘Mostly lymphocytes: PMN early ‘Glucose me/At >50 oF 75% of blood glucose <40. May be none <40 May be none 30-70 22 year old male brought in by friends to ED. He had acute ¢hangelin behaviour, inappropriate words and confused. All PE done and normal. No neck stiffness. investigations done: Bloods -ve, vVvVVY Urine drug screen pending All Investigations negative lumbar puncture: Protein high, Lymphocytes high, @lucoselnormal: CT scan was normal. * Explain Investigations to mum, Jenny * Explain dx and differentials and reasons + Explain the implic: ns of your diagnosis Authority + Reassure ~ he is in the safe hands now and stabilized* He was here brought in by his friends because of seizures. Now we have done some investigations and the results are with me, + Explain all the investigations one by one. We did check his blood for any infection but it showed negative. Other investigations are all normal. We also check the CT scan of his head for any haemorthage, abscess or tumor but it turned out to be normal. * What | am concerned here is we did check the nature of the fluid that circulates around the brain by taking it from the spinal cord through the back bone loin region. It showed a clear fluid and sugar contents was normal but there is increased number of cells we call lymphocytes and also the protein is high which we can interpret it as there is viral infection and inflammation of the brain we call viral encephalitis. Most likely viral encephalitis, Sa + He will be getting the best care we can including = > also antiviral if the organism is identi + This condition may associate with but will resolve later v * Later after recovery, it may associate withZZ but less likely to happen if treated early. 11, parapneumonic effusion (online) Father came with 5 years old Child having cough and fever 39 + 4 minutes for history ° PEFE + Explain chest X ray + diagnosis Dx parapneumonic effusion. So | get there this is the diagnosis and rest of the cough DD like coupe epiglottitis and foreign body POST VIRAL COUGH ASTHMA/Bronchiolitis PERTUSSIS PSYCHOGENIC COUGH ALLERGIC RHINITIS GERD CONGENITAL HEART DISEASE CYSTIC FIBROSIS IRRITANT INDUCED like parental smoking Foreign body Sinusitis Habit cough/Tics cooocoooocoo Full cough history Does it wake him up from sleep?Anything makes it better or worse(like change of season, dust, pollen or smoke)? Is it dry or productive? cevo How is the child in between the episodes? [psychogenic, pertussis normal in between the episodes} Ho) it affecting his life? Does the breathing stop for a while? ‘Associated Features: Along with the cough does the child has any [Fever ,Chest pain][Shortness of breath /fast/noisy breathing/ drooling of saliva? Any unusual chest movements? Does his chest suck under his ribs? ] D/o: Post viral cough: any recent flu like illness? ‘Asthma: (Cough+Chest tightness+SOB+Musical sound from the chest) any hx of allergy/eczema? Any FHX of Asthma,allergy,eczema or hay fever? Pertussis : Does the child turn blue during cough?/ is the cough followed by whoop or vomi [makes a noise afterward, and her face becomes red afterwards?) Psychogenic: Does the cough occur at any particular time or situation? Allergic rhinitis: any runny nose,sneezing,watery eyes CF: Does he get recurrent infection/flu like illness? Any diarrhea? Any FHx of lung disease? Failure to thrive? CHD: Any difficulty in feeding/playing? [is he gaining weight? Failure to thrive? Recurrent/repeated chest infections?] GERD: any bitter fluid in the mouth?/does the cough come after feeding? HABIT COUGH/TICS: Repetitive throat clearing? FB :Any choking episodes?/Any time that the child is unsupervised? 6? Well baby ques: Is he Active /irritable /drowsy? Is he feeding and sleeping well? Any change in the pee or poo? Any change in no. of wet nappies?>for child not infant ‘Any change in the weight? BINDS: Birth History:Baby has any problem after birth Immunization History: How about his immunization or vaccination? Contact with covid pt or other Nutrition Developmental history: How is his growth and development? Allergy bx: Contact hx: Any one in the family having similar cough?Does the child go to childcare?Any recent contact with covid + patient? Visited to covid hot spot? Physical examination from examiner 1-General appearance 2-Vital signs especially RR + 02 saturation (temperature 39) 3-Growth chart 4-ENT 5-chest examination inspection: deformity, chest movement palpation: chest expansion, tracheal position percussion: dullness. (dullness in the bottom of rt lung) ‘Auscultation: air entry, breathing sounds, no wheeze or crackles ( bronchial breathing.) 6-CVS, abdomen Explain X-ray -this is the chest x-ray of your child -lung field looks clear, heart border size looks normal. -when comparing both lungs there is white shadowing on the bottom of the right lung field, -the X-ray findings showing what we call a Para pneumonic effusion which is accumulation of fluid between two membranes surrounding the lung in this case the right lung that occurs secondary to pneumonia or infection of the lung usually by a bug; a bacterial one as he has high fever. - Croup - Epiglottitis - Upper RTI - Bronchiolitis/Asthma - Pneumonia - FB 12. Liver metastasis Your next patient is GP is a 75 years old Simon, who had been seen by one of your colleagues in the practice a week ago. He had a complaint of 6 months history of nausea, jaundice, pale stool, dark urine and right upper abdominal discomfort. He has undergone colectomy in the past and treatedfor colorectal cancer a year ago. Inve: — Haemoglobin ~ 9.7 g/dl and a CT stions were ordered and he came today for the result. FBE Your tasks: + Explain the test results + Most likely diagnosis to the patient * Further management to the patient Approach * Breaking bad news © SPIKES — Setting up and start, Perception, Invitation, Knowledge, Emotions, Strategy and summary Colon cancer — how was it treated? Follow-up?* CT —Here is the CT scan of your tummy. Actually in CT scan, it’s the mirror image so the organs from the right side of the body appear on left side of the CT scan. This white area is the back bone. The large grey area on the left is liver. As you can see, there are some * Other possibilities : liver tumors itself as primary, Liver cyst or abscess or infections but less likely. + (aemia - you also have reduced haemoglobin levels in the blood which is commonly associated with the nasty conditions * know this news may shock you. Please tell me what is going through your mind? * Do you want me to discuss the treatment plan now or do you want to make another appointment? * Ido understand your feelings. Remember | am here to help you. You are not alone. There are many treatment options available for patients like you. * First, you need blood tests and imaging. FINAC - the cell samples from the lesion of liver will be taken (risk of bleeding present but we will do it of that you Won't have bleeding.) It will be under topical anaesthesia and that won’t cause you pain + CBIBRBSEBBY again Other investigations — RFT, LFT, urine tests, tumor markers. CXR, full body PET scan, Bone * Consequence of the condition is liver failure which means liver cannot function properly. You will get some problems with digestion, bloating and jaundice etc. * A team including will be taking care of you* After the assessment ~ specialists will decide the best treatment plan for you. If possible, a surgical resection will be done. The extent of liver resection needs to be balanced against the functioning capacity of the liver remnant so as to avoid liver failure. It will be followed by chemo ot radiation. * We also have advanced ehemo'land radiation techniques! for unresectable|tumors and as adjuvant therapies. we have > (SIRT), > (which will destroy the tumor cells with electric current) > Trans-arterial chemo embolization (which is a therapy that involves vessel occlusion, delivering high doses of chemotherapy to the target lesion. ‘These techniques have proven dramatic increase in survival rates. * Aim — to improve the quality of life to the most, make sure the patient is comfortable — no depression, no pain, no worries, * Support groups for bowel cancers Middle aged woman Jessica has come to ED due to pre-dialysis assessment. Complaining of palpitations. Nurse did ECG which shown in the stem. Bp: 130/80, Pulse 60 and irregular, temp: NL, RR: NL. Tasks: -Take relevant hx -Explain the ECG to the examiner -Ask from relevant investigation from examiner -Tell the diagnosis to the patient with the reasons story 1-Approach -Hil can understand that you are here for pre dialysis assessment. -Do you have any concerns? 2-Current conditions -Palpitations? (Yes) -Duration? Sudden or gradual? Tap it? Regular or irregular? 1* time? -Confusion, dizziness? -Chest pain, SOB, cough, ankle swelling? -Nausea and vomiting? (fee! nauseated) -Urine output?-Diarrhea? (has diarrhea) -Headache, LOC, BOV? -Weakness, tingling or numbness? 3-Chronic renal failure -Since when? -What medications do you take? Do you take it regularly? Any SE? Any other medications? (perindopril, Ca bicarbonate, calcitriol, erythropoietin) -Have you ever increased the dose? (yes recently) 4-General -past medical history (DM, lipid, HPT, renal stone, heart disease) -smoking and alcohol Explain ECG to examiner This is 12 lead ECG and | can say the rate is 60 and sinus as there is p wave before QRS complexes and it is narrow. ‘Axis is NL and | can appreciate that T-wave is tented and there is a strain of ST interval. The most likely condition regarding this ECG is Hyperkalaemia Ask Investigations 1-Full blood count 2-Kidney function urea and creatinine (KFT impaired) 3-£lectrolyte Na, K, Ca, Mg (Na =145, Explain condition -from history, ECG findings and investigation it seems that you have a condition called hyperkalaemia which is increase level of potassium in the blood which is one of the mineral body salts. Ix showed that your kidney function is also impaired. -this can be due to several possibilities: *could be due to effect of medication perindopril that can inhibit an enzyme called ACE which in turn suppress the secretion of aldosterone hormone which is responsible for excretion of potassium out of the body. This causing retains of potassium in blood. “could be due to diarrhea causing more fluid loss leading to dehydration. “other is acute kidney failure as your kidney function is impaired. Case 2. Middle aged woman has come to ED due to pre-dialysis assessment. And ECG has been taken shown in the stem. Bp: 130/80, Pulse 60 and irregular, temp: NL, RR: NL.Tasks: Take relevant hx, Explain the ECG to the examiner, Ask from relevant investigation from examiner, Tell the diagnosis to the patient with the reasons. Task1 entered and introduced myself. There was a nice RP. No Vomiting but the patient was nauseated. NO cp or sob or cough no problem in waterworks but the patient has diarrhea. No AB no other PMH and FH. Her medication: Perindopril, Ca bicarbonate, Calcitriol. Task 2 | told the patient if you are OK, | want to talk with my colleague regarding your problem. So, | said dear examiner, this is 12 lead ECG and I can say the rate is 60 and sinus as there is p wave before QRS complexes and it is narrow. Axis is NL and I can appreciate that T-wave is tented and there is a strain of ST interval. The most likely condition regarding this ECG is Hyperkalaemia (examiner said OK) Task 3 Then | asked for investigations. Examiner said what you are looking for. | said: Na, K, Mg, Ca level and RFT. Na was 145 and K was 6 and RFT was impaired (I don't remember the exact numbers). Thanks examiner. Task 4 I turned to the patient. | said your ECG has some problem which is due to high amount of potassium in your blood which are the electrolyte and chemicals in your body. Also, Na is decreased, and your kidney function is impaired. This is due to many causes. - One of them due to kidney failure that you are having (I did not mention ARF on CRF!! - the other condition is due to your medication which is perindopril and - the other one is due to diarrhea that u were having causing your symptoms of nausea and heart arrhythmia. Bell rang.SPOR at ed a a a i i tee { LHe i Fe fe A A ale te Ad iat) S Ran AL AE a WOW a ye hyperkalemia De tar concern nse. >Sent. ri Lk a Ssnmoi) ‘Gasitcaton at hyestalemin Potassium level (mmel/) its 5559 Moderate 606. Severe 265 0: EG changes + witha serum COrsymptoms + (canbe nenspecifi) | potassium <6 5 13. Occupational lung disease/Mesothelioma/Lung cancer (Med) 70 years old man with SOB, he was seen by a doctor and came back with chest x-rays, both AP and lateral. Tasks: History -Explain the X-rays, -Possible dx and DDxAsbestos exposure (working ina boiler room Without protective respiratory apparatus isa rsk fac tor for ung cancer; concurrent smoking and asbestos exposure vastly increases the risk up to approxi mately 90-fld), Exposure to slcates (sandblasting) also increases the risk of lung cancer in smokers, I can see from the notes that you feel SOB. Do you feel comfortable now? Explain X-ray -I can see that chest x-ray has been done for you and you are here for the results. Let us see it together and if you have questions at any time please let me know? -this is the X-ray of your chest. These are two views; this is taken from the front and the other from the side. The X-ray is showing a whitish shadowing surrounding the right lung field while the left lung field is clear. In addition, it showed that the windpipe is deviated towards the right side (if you really see it mention it) -there are several possibilities it could be pleural effusion or accumulation or fluid around the lung, but it is unlikely as the windpipe in that case should be pushed to the other side. It could be infection, pneumonia but the windpipe usually in centre in such cases. -what | am suspecting is due to either collapse or fibrosis of the right lung with reduced and diminished lung volume or size. -However, | still need to ask you a few questions in order to know more about the diagnosis is that ok with you? Positive findings ‘SOB 2 months (I felt relief because of that duration). ‘SOB worse on exertion and walking distance becomes shorter and shorter, No SOB at rest, no orthopnoea ,no PND, dry cough present, no wheezing, no fever, no LOW, no LOA, no lumps or bumps, no night sweat, no chest pain. no history of travel, no leg swelling, ‘Smoking 40 years 20 cigarettes per day, stops for 5 years (appre: alcohol, no drug allergy. VVVVVVVVY fe him for stopping) no > Medical history HTN | asked what medication > (he looked at the examiner and gave me the medication card, ACEI, Ventolin and steroid inhalers). > asked those inhalers help him, he said sometimes. > Surgical history-history of CA prostate got surgery, he said it is ok now. > (Lasked him do u get regular follow up, he said yes, how long ago, he looked examiner, so! realized he has no answer, so | said it is ok if u have regular check-up.)> Occupational-retired, when | asked previous job-boiler worker for 30 years. Boiler = wood dust History 1-SOB questions. -for how long? has it started suddenly or gradually? Constant or come and go? Is it getting worse? -are you short of breath on exercise or rest or both? -how much distance is necessary to get SOB? -do you feel SOB on lying flat? -do you wake up at night short of breath? -is this the first time? 2-Associated symptoms questions -do you have any cough? for how long? Do you cough up anything? do you cough up blood? -any fever or night sweating? -any chest pain, funny racing of the heart or leg swelling? -any LOW, LOA, lumps or bumps? 3-General questions -PMH (DM, HTN, lipid, heart D. Lung D. -PSH do you have regular check-ups -do you smoke? -do you drink alcohol? -do you take any medications or OTC? -what would be used for? -have you travel recently? -any trauma or injury to chest? -any contact with patient with similar symptoms? -occupation: what do you do for living and what have you done in the past? -family history heart and lung disease Diagnosis and differential diagnosis,-from history and X-ray findings you most likely have an occupational lung disease. Which is repeated and long-term exposure to certain irritants in the job that can lead to a range of lung diseases that may have lasting effects even after exposure ceases. -from history you were working as a boiler for 30 years in the past, so you most likely exposed to an inorganic dust particle called - asbestos leading to asbestosis; which is a condition caused by inhalation of microscopic fibers of -other possibilities could be nasty growth of the lung or mesothelioma; is a cancer affecting the, the pleura or the outer membrane of the lung. Do not worry | am just telling possible causes it does not mean you have it, we still need Ix to be done. -Secondary spread of cancer cells from other organs like the prostate although this is less likely from the history and you have regular check-ups. -Could be pleural effusion, COPD. -others could be infections or heart problems but less likely. Xray explanation trachea is deviated to Rt side mildly. (the Rt side lung is surrounded by white area from top to bottom, | was also thinking pleural effusion but no tracheal shift to opposite side, it should be deviated with that large amount of fluid, left lung quite normal). [because of trachea shifted to same side mildly | chose pulmonary fibrosis or collapse] lexplained X rays like fibrosis and collapse. Explained-occupational related lungs problem, because of longstanding inhalation of dusts and chemicals. He asked what kind of Chemicals (I did not expect like that, so | chose Asbestos and told him, | was also thinking silicosis in my mind, but patient agreed with me oh, ok asbestos). So, followed him like, as you know at your time, the rules and regulations about occupational health was not fully developed. J also give corp lung cancer Metastasis from prostate but unlikely because of regular check-up heart failure chest infection chronic PE lung cancer VV VVVVY please don’t worry | am just telling possible cases, it does not mean u have it, we still need to do many investigations to confirm your problem. Iwill refer you to specialist.14, Condition 064 Investigation for male factor infertility VOLUME 6mi Count 2 milion/mi Motility 20% Velocity 20 microns/second ‘Abnormal morphology 95% Antisperm antibodies Nil (2-6ml) (greater than 20 million/ml) (greater than 40%) (Greater than 30 microns/second) (Less than 80%) (nil)Male Infertility Factors SPERM COUNT Systemic factor/Smoking Psychological illness Endociinopathy Rettograde ejaculation Medications Chronic disease Obstructive Unexplained Narcoics Testicular IDIOPATHIC/UNEXPLAINED: 40-50% of cases Testicular: Varicocoele: 35-40% of infertile males Meds: cytotoxic agents, GnRH agonists, anabolic steroids, nitrofurantoin, sulfasalazine, spironolactone, alpha-blockers Drugs; Alcohol, tobacco, cocaine, marijuana Exposure: radiation, heavy metals APPROACH understand that you are here to discuss your test results with me. But before we go through that, | need to ask you some more questions to assess for possible factors that might affect your fertility. Will that be okay? | might also ask you some personal and sensitive questions in this consultation, but rest assured everything will be kept between us unless it poses harm to you or to others. Is that okay? HISTORY ‘SEXUAL HISTORY How long have you trying for a baby? I'm sorry to ask you this but | need to know, Have you or your wife have any kids from previous relationships? How often do you engage in sexual intercourse? Do you live with your wife? Do you or your wife experience any difficulty during intercourse? Does she have any pain on penetration? DO you have any difficulties in maintaining an erection? DO you think you are able to ejaculate completely? Do you or your wife have a history of STIs?SAD Do you smoke, drink alcohol, or engage in recreational drugs like marijuana or hashish? Do you take any medications? Steroid use? WORK AND EXPOSURE ‘What is your occupation? Have you been ever exposed to certain chemicals? Any stresses or concerns at work? INJURIES/CONDITION TO THE TESTES Do you have any history of hernias, undescended testes, or surgeries to your lower tummy and genital area? Have you ever had any injuries to your genital area? Did you have any other medical illnesses, suffered from frequent URTIs (Kartagener's syndrome and Cystic fibrosis), especially mumps? PSYCHOGENIC How is your mood lately? ADVICE | have the results of your semen analysis that was done for you. This contains information about the number, shape, and function of your sperm which may affect your fertility. In your case, the sperm count and motility is low, and the number of abnormal shapes is high. Please don't worry too much about this. ‘As sometimes, certain conditions can affect the functioning of your testes like $€f688) febrile iles3e5) {ettainimediestions. Usually these are temporary and on repeating the tests, the sperm count usually reaches the normal level. Because of this, we ff] FSs Wee == aHieajSTs 251TH BUSUETAFER [RGREFEUEAIE| Fan abnormal test again is found, we will SBGSSHENGNSSE Sein Tors thIFdRIn= IA SHSHNEES HEBREEE. | will give you written instructions regarding haw to obtain a sample. You will need to follow them carefully as they can affect the outcome of the test. Andithese show the same fing 35 the fist anda second on, then clay here isa problem whichis atmast certainly amajorfactorthat contibutes toyourinferilty, ven you se that there ae sil sperm present, it still does not reach the optimum number needed and activity that a sperm must have in order to successfully fertilize the egg cell. However if the semen analysis results improves spontaneously with time, the possibility of achieving a pregnancy is increased. \We wise perform other investigations to entity possible causes of your ow sperm count. This wt incl blood test which include serum FH, LH testosterone, ané prolactin evel We will lo do‘an But in most cases unfortunately, the exact cause of an abnormal sperm analysis is still unknown. And in terms of treatments or medications, there is no documented evidence for use of any treatment in improving the semen specimen.Now, in the case we'll not have good results with these investigations, it seems that there is a definite place forthe use o intro frtization VF with intraytoplasmi sperm injection, or what we cll an IVE with IEBI sorry forthe medical term but let me explain this procedure to you, This involves getting a sperm sample from you and gat he eee elf ot Wife id [GBREEPSRIEMESHSATNEREBIEEE, This procedure is done by a fertility specialist and has @ GASH ‘Are you open to consider this procedure? ‘Another consideration is a use of a donor sperm and performing artificial insemination, again sorry for the Use of the medical terms. The pregnancy rate is about 20% per cycle of insemination, and this use is, cheaper and more straightforward than other methods of treatment. However, the baby would not contain any of your genetic material if we do this method. I'm afraid that if we use your sperm for intrauterine insemination it would have a very poor success rate (1- 296) as your sperm Again please don't stress yourself too much about this, as we will still do a repeat sperm analysis test and ‘we have pending results for the investigations that we plan to do to determine the causes of your low sperm count. | will arrange another review with you once results become available and itis best if you bring your wife along. For now, | would like to give you reading materials to give you more insight about your condition and about IVF with ICSI. Rest assured, | will do my best to look after you and support you for whatever decisions you make with regard to your plans of having a child. KEY ISSUES Need for appropriate history from husband Knowledge of appropriate tests to assess him, and of the possibility of improvement with time Need for empathetic counselling Ability to understand that a definitive cause is unlikely to be found CRITICAL ERRORS Failure to advise that at least a second semen specimen (3 months after the first) must be examined Failure to recognise that persisting severe abnormality of the semen specimen as currently obtained will result in a very low pregnancy rate Failure to understand that ICSI ( material in IVF) is the best method of achieving pregnancy using his genetic IMPORTANT POINTS FROM THE COMMENTARY MUST be recognized that a single sperm test is UNRELIABLE MUST be repeated 2-3months later and preferably again after further 3 months Common problemsFailure to repeat the semen specimen analysis. Failure to ask questions to define the possible causes of abnormal semen specimen Failure to ask whether the use of donor semen would be acceptable, as this is very effective and cheap, though the child produced would not obtain DNA from the husband 15. Condition 030 Jaundice in a breastfed infant Baby Helen is brought to see you in a general setting, as her mother is concerned about her continuing jaundice. Helen is now two weeks old and was born at term by easy vaginal delivery weighing 3.7kg. APGAR scores were 9 and 10 (at 1 and 5 minutes respectively) She became jaundiced in the neonatal period starting on day three. Investigations then revealed no blood group incompatibility, both mother and baby being group O positive and no red blood cell (including enzymes) abnormality. The infant was treated with phototherapy for two days. Since discharge from hospital at eight days of age the jaundice has persisted and the mother is concerned. Baby is feeding well from the breast. Current weight is 3.9kg. Examination findings ‘The baby was active and clinically normal apart from the jaundice when you saw her yesterday. You arranged Investigations as set out below. The mother has now returned with the baby to discuss the results and your advice about treatment. Investigation results Serum bilirubin Total: 250 umol/L Conjugated Less than 10umol/L Neonatal thyroid screening | Normal Urine culture Sterile Full blood examination normal TASKS Obtain any further necessary history you require. You should not take more than 2-3minutes to do this. Discuss the results of investigations with the mother. Explain the diagnosis to her and advise about future managementAPPROACH Congratulations again on becoming a new mother. Helen is a very beautiful child. | understand that you are concerned about Helen's skin, and is here to discuss Helen's lab results with me. But before we talk about itis it alright if | ask you a few clarifying questions to help me assess her further? HISTORY \s she your first baby? How is her general health so far? Well Baby Questions Is he crying too much, sleeping too much or difficult to wake up? How is he feeding? How many feeds has he been taking for the past few days? After every feed, did he produce a wet nappy? How many wet nappies have you changed so far? Any changes? Is it foul smelling? Rule out sepsis and conjugated hyperbilirubinema symptoms Any fever, rash, vomiting, and lethargy? Have you noticed any fast breathing? Has he been breathing harder than the usual? ‘What's the color of his stools and urine? Has it turned dark or pale colored? Did she have a heel prick test done? Mother How is your general health so far? Are you taking any medications? Do you smoke, drink alcohol, or engage in recreational drugs? Do you enjoy your motherhood so far? DISCUSS INVESTIGATION RESULTS ‘There can be several factors that could have led to the yellowish skin color of your child, and medically we call it as jaundice, that is why we ran some investigations to identify what is causing this. Infections can be ruled out as the full blood examination and urine culture tests turned out to be normal. Thyroid conditions can also be ruled out because the thyroid neonatal screening turned out to be normal as well. However, we can see here that the serum total bilirubin is increased. Bilirubin is a pigment in the baby's blood which is. usually absorbed by the body in the gut. However, in some conditions there seems to affect its absorption, ‘making it accumulate and deposit in the skin and some organs, causing it to manifest as a yellowish tinge in the skin. There can be several causes of it-like a blood disorder or anything that causes obstruction in the part of the gut which tend to prevent this bilirubin absorption. In your baby's case, the conjugated bilirubin is low, which means we can easily rule out the conditions causing obstruction in the gut, and point our diagnosis towards the blood-breakdown related or absorption causes of jaundice. DIAGNOSIS AND FUTURE MANAGEMENTHowever, based on the history and examination findings, most likely she has a condition called, breast milk Jaundice. Have you heard about it? Sorry for the medical terms but let me explain the condition to you. There are some factors within the breast milk that increases the absorption of the pigment in the blood called bilirubin in the baby's gut, and accumulation of this pigment then causes the yellowish tinge in your baby's skin. It is a benign condition and does not require treatment. | can tell this because your baby is gaining weight, well, feeding well, and active, and she has normal physical examination findings except for her yellowish skin. Just as your baby is still developing, her organs are also still adjusting to the milk that you give her, and in time as she grows more, she will then eventually be able to metabolize/digest/use this pigment and subsequently the yellowish tinge of her skin will disappear. There is nothing wrong with your breastmilk, and you can continue breastfeeding, It can persist for as long as three months of age, but the baby will remain active and gain weight. We can confirm the diagnosis by temporarily suspending breastfeeding for 24-48 hours which results in the fall of the bilirubin levels in the body. After which, the breastfeeding can be continued. During the time of this temporary suspension, please express your breastmilk in order to maintain lactation. | can refer you to the lactation nurse who can teach you more about this method. However, if you will see that the jaundice is progressing, where it already includes her palms and the soles, or if she becomes overly sleepy or irritable, or if not feeding well, please report back immediately so that we can check her again. | will arrange regular reviews with you to check for Helen's progress. Here are some reading materials that | can give you to give you more insight to your child's condition and about breastfeeding. Do you have any questions? Ure fciba/ aceas binbiem <2 pel peta) Gradual - Worsening over 3 weeks - worse with activity - Walking distance is reduced - no orthopnoea = NoPND - Coughs + - Yes - fora few months now - Productive of yellow sputum - lately blood streak in the sputum - Chest pain -ve - Wheeze -ve - Fever-ve - LOW Kg (10 kg) - weight loss and loss of appetite - Used to be heavy smoker but stopped 5 years ago - sed to work as Retail for many years History 1-Check hemodynamic stability (vital signs and 02 saturation) 2-shortness of breath questions -for how long have you been short of breath has it begun suddenly? is it constant or come and go? s it getting worse? are you short of breath at rest or exertion or both? -if‘on exertion ask how much distance is necessary before you get SOB? -can you lie flat without feeling short of breath? -do you wake up at night short of breath? How many pillows? 3-symptoms related to chest questions Coughhave you had any coughs? -How long? -do you cough up anything? Or you can ask dry or wet? -have you seen any blood in the phlegm? -is it smelly? How much? DDxQ -do you have any pain in your chest? -any noisy breathing? Palpitation? any funny racing of the heart? Fever? -any ankle or leg swelling? -any LOW, LOA, Lumps or bumps? how many Kg? -any change in your voice or hoarseness? -any weakness, tingling or numbness? 5-General questions -Past medical history (HPT, DM, LIPID, Clotting) -Past surgical history-medications -travel history “trauma -occupation: what do you do for living and what have you done in the past smoking? (Cancer) alcohol? appreciate that. -contact and family history Explain X-ray to patient = you can see this is the X-ray of your chest, these are your collar bones, ribs, chest bone, windpipe and your heart. -the blackish grey area on each side of your heart is your left and right lungs. -on comparing right and left lung, we can see white rounded shadow in left top part of lung, this is abnormal findings. It is most likely the cause of your symptoms. -otherwise your heart size is normal, your lungs are increase in size, but | don’t see any abnormality in other parts of your lungs.Explaining possible Dx and DDx -well from history, examination and X-ray findings there are few possibilities why you have weight loss, coughing red phlegm and SOB. -Could be infection; a bacterial infection in the lung but less likely as you don’t have any fever “Tuberculosis infection which is possible cause we need to rule out, however it is rare in Australia, you don’t have travelling history and contact history, but as you are living in nursing home, we need to consider it as well -what | am suspecting these symptom could be due to a lung cancer but we still need to do Investigations for definitive diagnosis. -Other possible causes are Benign or non-cancerous growth in lung but very less likely. -it could be pus collection in the lungs we called abscess, but again less likely. -could be a blood clot blocking in blood vessel of lung but your symptoms are not acute onset, it is unlikely. - lam also thinking about COPD, which is inflammation and narrowing of airways strongly associated with smoking, it may coexist but it’s not the main cause of your symptoms. -other cause of SOB like heart condition, anaemia is less likely, but | can do further testing to rule them out.21, 180-UTI ina child (Ped) Whatis urine infection? A ain inn is an infection caused by bacteria that get Into the urinary tract system where they grow in the bladder (called sits) and sometimes inthe hdneys (called kei) Tels common in children, especially under the age of S years hy the age of 10 years, about 3% oP boys and 10% of ike wail hive had atleast one episode of urinary tactinfection Whatare the symptoms? The infection is similar for children and adul rymptone andl Alagnena ate not as clean they are in adults. For example a baby with a urinary tact infection may simply seem sane, have an snexplained Sov tel foe noe p Chain mde? yore el peri 3 years) of age cannot convey a symptom of stinging pain ‘om urination, On the other hand, oder children are Ukely eas cba agate sopaaib {ncuding poor conta. Symptoms inchldren over 3 years age + Dysurs—tinging pain on pssng urine + Rqueney of fg urine = Upeey epee Acterfaly wen thr pnts + Loss ofappetite 2 oer rane ihr ice lly Und haan ‘eco ne tat a nero spe Whatare the risks? ‘hore ae fiw its from one ort isolated infections but Geeetre std ofveions inion enrling oq) Bone bladder via the ureter tothe kidneys This is ike to occur if pa i | (eo \Vesico-uretercreflxcan cause a bladder infection travel upto thekidneys vesco- uteri eax badder infection 18 months girl has been brought by her mom, her mom believes that she is not well since 2 days 7.7. A.urine sample with bag has been taken that shows leucocyte 3+, no other cells, no nitrite. ago. She does not eat and drinking well. Task: the child has a condition called vei antar flus, where the valve fous the blidder tothe ureter is open and the urine Jeflins nau die Vhs pos stew de Is serious, a it may cause kidney infecion, earring and damage Another serious isk sinfection in the blood seam (qocemi) from the baceria, Collecting a urine specimen [is essential to collect a urine specimen for a suspected Infection so that we know exactly what bug we are dealing ‘with and what antibiotics will kil them. Furthermore, urine Infections are prone to recur and we need to be prepated for farther episodes, Geting a sterile specimen is imporant since urine prone io contamination from the outside The collection of a sample using astick-on collecting ba is not acceptable “The methods used are: ‘+ ‘clean catch, which can only be managed by 2 very + Seampl froms fine catheter pase into the chiles badder ‘+ drawing trine out of the Hadder by a needle pased Uhrough the abdomen over the Bladder (forthe best specimen. Whatis the treatment? Aer the urine i collected, the child may be started on oral ‘ilnous evotntce 4 ume tn el ule elev iene the treats are avalble. However, hey ay need to be changed if the bacteria are found to be resistant ¢o ‘them on culture and sensi testing, which may ake the laboratory 24 to 48 hours to proces, TCs important to complete the eourse of antibioues as irected by your doctor Some children may need annibiotics ‘through 3 drip in 3 win, “The child shold drink extra fideo Bush out the urinary syste and empty the bladder and bowels completly when they goto the toi, What further tests will beneeded? Asaraleall children, boysand gts, presenting with urinary injection require investigation, especially 10 test for efx ‘Mos children wil require an ultrasound test, while others ‘jstogram ors DMSA Key sea What is the outlook (prognosis)? In most cae, the ostlook is excellent ain many rine Infection sa‘one-ofF cvent-The infection usualy ars any tne the child recover Fly Hoover some have ecuring infections and require ongoing courses of asibiotics. I av anatomical problem such refx Is presen, Ic can be corrected by surgery.1. Explain for the mother the most probable diagnosis 2. Talk about the management 3- Talk about the further measures (if necessary) GP, 6 months old, referred by the nurse because of leukocyte 3+ in urine. Alert, no dehydration, examination normal. Tasks - H/0 3 mins. ~ Explain result - Management History 1-Can you tell me more? 2-Urine: -Number of wet nappies? -crying on passing urine? -any colour change? -is it smelly? 3-Bowels any change in colour or frequent than usual? 4-Vomiting, crying a lot, fever, rash 5-SOB, cough, runny nose 6-BINDSMA -Birth (Before pregnancy (Preterm), delivery (home or hospital) and after delivery) -Immunisation + Hell prick test (no heel prick test) -How is her feeding and sleep -Development and growth -Medication, allergies, PMH Explaining results -So here is the result of urine dipstick with me let see it together.-it showed the presence of WBC which is a type of blood cell that usually responsible for fighting infections and its presence indicates the possibility of urine infection by a bug usually a bacterial one. -However, | still need to confirm by urine culture to find out what kind of bacteria in the urine because dipstick is not specific test. -Even though your child is active and playful, | am goi investigations and management. 1g to specialist to decide for further Investigations: -FBC, inflammatory markers, renal function test. -Blood culture and USG of kidney and urinary tract. - For taking urine sample, in babies of this age group, a sample or urine usually obtained through aspiration from the tummy to look for possible infections. Please don’t be stressed it will be done bya specialist. The nurse will give him some painkillers before the procedure. A very small needle is passed through the skin into the bladder and the sample is withdrawn. ‘The purpose is to obtain a sterile urine, but specialist will decide. Wipe technique ~ cleaning (from front to down or up to down), - Ifnecessary, specialist will arrange repeat USG or put dye into urine pipe to see any structural damage. ns and symptoms of UTI If your child has a UTI, they may have pain or burning when passing urine (doing a wee) have pain in the lower part of the abdomen (under the belly button) need to go to the toilet frequently to urinate pass some urine before getting to the toilet (wetting or incontinence} have smelly or discoloured urine have a fever or vomiting. or eeNe Young children with a UTI may not show any of these symptoms, but they are just generally unwell. What causes a UTI? A.UTIis usually caused by bacteria (germs) getting into the bladder or urethra. The germs most often come from the bowels (gut), or from faeces (poo) that is on the skin and then gets into the urethra. Treatment is mainly with antibiotic: for 7-10 days and when the result come back, specialist wil change to specific antibiotic for that bacteria. Repeat urine culture 7 days after tx. -| will follow up regularly.to prevent recurrence change diaper frequently and clean from front to back because of short urethra and infection can go from back passage to front passage. -Any financial problem. any support. - Reassure her that it is a common condition and do not be much worry as baby will be under safe hand very soon. With effective treatment, she will be fine. Give her reading tips and check understanding. 22. SVT er = jai | Betae tee! Na vie ly het i ii el Bee Bee A een AA / Lh EEE LL Ui hun fe bap LB Li ELD LLELEL . 70-year-old man comes with wrist pain. Tasks: “HK -Dx -DDx, mx Handbook case 99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 0.74 mmol/L) and for treatment. The normal/serum Urinalysis is normal. The patient has always kept in g00d 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 YOUR TASKS ARE TO: * 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. ‘The AIM OF STATION: To assess the candidate's ability to manage an acute attack of gout and give advice about its prevention. EXAMINER INSTRUCTIONS: ‘The examiner will have instructed the patient as follows: You are suffering from severe pain in your right foot which began two days ago. You saw the doctor earlier today who diagnosed gout (which you have had before) and arranged for a confirmatory blood test. You have returned to find out the result and receive treatment. You are a 48-year-old taxi driver and usually keep in good health. You do not smoke but drink three or four stubbies of beer, after work, daily. No serious past medical problems but you are taking tablets for mild blood pressure diagnosed two years ago. You are overweight. You have no family or social problems. You are anxious to get relief from the pain which is preventing you from driving your taxi. You are somewhat irritated that you were asked to have a blood test, because this was not done during previous attacks which responded well to treatment. You have little knowledge about the cause of gout and are unaware that recurrent attacks are to be expected and can be prevented. You have not suspected that the blood pressure tablets could have something to do with gout and are annoyed that you were not warned about this. Questions to be asked if not covered > How long before | can resume work? >» What causes gout?