Contents History taking format. 1 u 2. Fe 1 15 16 v7 18 19 20 21. 22 23 24 2s, 26 27 28 29 30 31 Autism spectrum disorder Dark urine due to obstructive jaundice nnn nnnnnnnnnnsinnninnnnnniiiinninnnnnnnnnnii Insomnia due to depression. Cranial nerve examination... Obstructive sleep apnea due to enlarged adenoids Obstructive sleep apnea PE Serotonin syndrome. Borderline personality disorder CVS examination... Gastroenteritis PE.... 15 yr old Alcohol binge drinking Absence seizure OCP counselling for 15 yr old girl Body odor, Parotid gland enlargement... Delirium, Non-compliance on medication Sertraline. Adjustment disorder... Unstable gait Cervical spondylosis. RA counselling... Non accidental injury of 3 months old baby. Itchiness with DM .. Hypertension... Apixaban (NOAC) counselling respiratory system examination... Pain in periumbilical plus PR bleeding PE. Trigeminal neuralgia PE Scaphoid fracture PE.. De Quervain Tenosynovitis PE Rash/ haematological examination32. Primary dysmenorrhea with simple ovarian cyst on USG ... 33. Global developmental delay 34, Alzheimer counselling... 35. Compartment $ PE. Face to face Online format. 36. —Clavicle fracture 37. Wrist cut injury PE. 38. _ Elbow examination... 39. Poor progress of labour 40. Delirium due to UTI... 41, Asthma with obesity. 42. Shoulder joint dislocation Shoulder jt examination in general... 43, Lower limb problem, 44, Common peroneal nerve injury 55 55. 58 62 62 65 67 69 74 76 7 on 79 80 81 Ey 87History taking format Sey reer nae yw footie vr retrane a pat Ne: moad doors, Seem inee — cra ‘intone rovers renege eens, ‘ce Soe ance vane al arias drys om tami PC SED ESE pet Ose pate eotpeer arene etree ty oe) cee ae os ‘SDtouhar an wenberselctrsfecnareroid ‘mao ee sea ¢-wies-wnmyc | ier negra ont an eae corosintesen cr ene ‘ie meooreneemee ety -sgtton, ot ‘org Re cece ie1. Autism spectrum disorder 18 months old boy came to your practice with his father because of odd behavior. His father noticed this for quite a while and would like to know ifit is because of any vaccination he recently received. = Tasks ‘Take a history from the father * Give your Dx and Differentials with reasons + Further management if required History Intro + 0 : Doctor, my son has been behaving oddly for quite a while now and | would like you to have a look please ? + Can you please elaborate for me when you say ; behaving oddly ? ‘+ He just keeps to himself and does not interact with anyone else and even when we try to play with him, he starts to make noise or shouts and cries Sometimes, he even keeps on banging his bed repetitively. And, we don’t know what to do ? Assurance - + HOPI © 0 :not quite sure ‘+ D: few months since he noticed +P :same + a/R: he remains quite when he can do his usual activities but starts showing tantrums or crying if ‘#1: yes, this is first time I have noticed this. Associated : fever, rash, cough, n/v, runny nose, discharge from ear, distended tummy, * Differential Diagnosis: key q) ‘* ADHD : Does your baby finish his/her given task and move to another one ? + Does your child stay in line with others ? Have you felt your child very active then other child of his age ? + Autism : Does your baby follow same routine all the time? If disturbed, does your baby get agitated or cries ? + Does your baby make . Does your baby turn head or respond to your call? NO Does your baby speak few words? ‘+ Absence Seizure : Does your baby stare somewhere for few seconds while having normal conversation ? Pee/poo : any concerns ? «any weight loss? «Appetite, sleep -normal. + BINDSMA * Birth : normal vaginal delivery, normal weight, no concerns during pregnancy, + Immunization: Complete, just received MMR Waéing* Development : * Communication : Does the child say any words? (ABIERO Hae ORE Body Park, or combines two words or, speaks six or more words) « Activity : Climbs stairs, waves goodbye, MaKESEOWEFORABIGES « Siblings : First Child '* Medications : none * Allergy: None * PMH/PSH : nothing ‘+ FH: nothing positive Autism +ve poin isolated, not maintain eye contact, delayed speech, rigid in routine, not get together with siblings Diagnosis: MOST LIKELY it is Autism spectrum disorder (ASD); which is a developmental disorder most commonly involving problems with communication and Social interactions as your son showed some symptoms such as no eye contact while having conversation, getting agitated when his routine is changed and not responding to any calls. Nevertheless, this is a life-long disorder with no cure and is something diagnosed by spe also thinking about ‘+ ADHD : but your son does not show anything about being hyperactive or not completing his task ‘* Hearing or speech problem : but there was nothing in physical examination * Absence seizure: but there is no phasing off for few seconds while having conversations Refer to MDT(Multi-di * Pediatrician + Audiologist and speech pathologist * Inv: Audiologist * Look, | understand there must be a lot going through now and | totally understand, | would be the same if | was in your shoes. | just want to you to understand that | will be with you along the way to support and guide you. Also, | will be arranging appointments with different specialist who will be working one to one with your child such as to help him learn how to learn(Applied behavior analysis) , how to increase concentration and focus(Occupational therapy), how to reduce stress when certain environment are changed(Environmental changes) and so on. * Please understand it is nothing to do with vaccination and there is no evidence or scientific proof that any vaccination given by doctors has effect to this. Are you following me ? * Are you understanding me until now? Yes doctor. '* | am trying to keep it as simple as | can because along with baby, | am also thi well-being. * Look there are few support groups with whom you can share your experience and see how similar families are going through. * | will print some reading materials for you and if you want, I can call anyone you like ? ADHD (only two to three questions to exclude if Autism symptoms positive) n Qs (6 criteria): /e you attention? If he gives you the attention, can he maintain it? Can he concentrate on doing one task? But, | was plinary team) ing about yourDoes he like to do homework? Can he finish his task? Is he forgetful? Hyperactive Qs (6 cri ia) During dinner when you're eating together, can he sit still? In the supermarket, can he wait for his turn in a queue? Is he talkative? Does he interrupt others? Ishe anoisy boy? Follow similar HB case 032 (ADHD ) © autism spectrum disorder In May 2013, the DSM-5"° made significant changes to autism terminology and dassifiction that reflected recent reesarch, Auiom epectrum digordor (ASD) superseded autistic disorder, pervasive developmental disorder not otherwise spectied (PDD-NOS) and Asperger disorder, though the latter tarm ie also still widely ueod by clinidane and the public. This resulted in a change in the way autism ‘was diagnosed, with three domains (social deficits, ‘communication deficits and repetitive behaviour) roducing to two (cocial-communication dafiite and repetitive behaviour). Another change is a ‘severity’ criterion that is designed to better capture the ‘spectrum’ nature ofthe disorder: level 3 (very substantial support), lavel 2 (cubstantial suppore) and level 1 (some support) ‘ASDs are common, with the latest Australian data pputting the inddence at 1 in 160 children.® While autism diagnoses are much more common in recent ‘decades compared to previously tt was first descnbed asa disorder only in 1944). whether there has been a true increase in incidence is unknown, as increasing awareness and widened diagnostic criteria make companson with previous prevalence data unretable. Identification When an autism spectrum disorder (ASD) is suspected, a GP is likely to face one of three different scenarios: A. A family meraber presents with his or her own ek it Cas devdoperent BA familly member reports that a third party, auch ‘child care worker or teacher has empresoed concarna about thelr duis developenent. © Tho CP himsolt/horsot identifier concerns with a che evsial ened languege devslopenens thevegh routine developmental screening or general Geeerastion Scenario A should always be taken seriously, as dee concerns of parents are counmonly justifbed. Many arenes prevent co dhclr GP durtog tse pecond to hed ear oftheir child's Wfe when it becomes epperent that Tir Shakte development Ieee stalled compared his or her peers. While cocial deficte of ASD (ouch delayed or absent joint attention—see below) often present earher, they trequently go unrecogmsed by parents and is usually speech delay chat prompes a ist to the doctor. ‘Other parencs ma a hearing assessment, fee asl W ances be ake ee may be actual regression, with the child beginning to ‘say words but stopping, commonly between the ages 9f 15 and 24 months, Parents may also report loas of ye contact and geetures such a waving oF pointing.When to suspect ASD -ALgpically developing child should smile in response to a familiar caregiver's smile or ‘baby tall’ by 2-4 ‘months. A'8 months, an inant wil follow a parent’ ‘gaze thats, look in the same direction asthe parent is looking Children should be able to follow their ‘parent's point by 10-12 mous and start pointing ‘themselves by 12-14 months. They then begin to point to share (look 2 cis) by 16 months. As they point, children will look back and forth between ‘the object and their parent—it' the shared socal experience, not the tangible objec, the child seeks. ‘These joint attention behaviours are often absent or ‘reduced in a child with ASD. Social deficits ‘Younger children with ASD often appear tohave litle frends higher-unctonng ‘RenspaaprahrensesmepeCommunication deficits ‘Communication deficits in autism include deficits ‘in both non-verbal and verbal communication, and ‘expressive and receptive language. Some individuals remain mute throughout life. Although present, language may not be functional—children may be able to roe learn shapes and numbers, buc not follow ‘one-step commands. Stereotyped and repetitive language, induding echolalia (‘parroting’ of learned phrases or scripts) is common. Other signs include ‘unusual vocal qualities, such as tone or speed, and pean eS Affected individuals ily have a very concrete and literal understanding of language. such as not understanding idioms, lies or jokes, and miss social cues such as body language and cone of voice. Even relatively mildly affected children (and adults) may have difficulty initiating and sustaining two way conversations. Children with ASD tend not to play imaginatively (e.g. pushing the car along and saying ‘brrm’) and ‘mstead will engage i unusual repetitive play, such as lining up toys, or spinning tho wheels of a car ‘They frequently show litle interest in socal play (eg. peek-a-boo or pattycake) and their play is often object-focused (eg. computer games) rather than people-focused. * Lack of babbling or pointing by 12 months + No sharing of inlerest in objects or actives with ‘another person + No single word by 16 months, or no two-word (nonechoed) phrases by 24 moths © Any loss of language or social skills at any age ‘A GPeriendly screening tool for ASD is the Checklist for Autism in Toddlers (CHAT)— abbreviated version (see TABLE 94.2)” This can be administered at approxmately 18 months ot age and. takes only a couple of minutes Ifa child fails all three items, referal is indicated, as the chances of autism are high. It a child tails onlyTable Checklist for Autism in Toddlers (CHAT — 94.2 abbreviated version Section A: Ask the parent 1 Does your child ever pretend, for 10 make a cine ecne 2 Does your child ever use his/her index finger to point, to ask for something? ‘Section B: GP's ‘observation ‘Get the child’s attention, then give the child a miniature toy ‘up and teapot and say, “Can you make a cup of tea?’ Does the child pretend to toa, drink it, otc.? (if you can elicit an example of in some other game, score a ‘YES for this tom.) Get the child's attention, then point across the room at an Interesting object and soy ‘Oh look! There’s o (name of toy)!’ Watch the child’s face. ‘Does the child look across to see what you are pointing at? (To record a YES for this item, ensure the child has not simply looked ot your hand, but has actually looked at the object at which you are pointing.) Say to the child, cari the light?’, or ‘Show me light’. Does the child with his or her index or the light? (if the child does not understand ‘light’, this win Where's he teddy” or Smeeneee record a YES for this item, child must have looked up Jour lave around detime oFFurther assessment If there are concerns that a child may have ASD, it is ‘essential nat te child is promptly referrediw egeneral or developmental or toa developmental. ‘asccaament unit, for an autism epecifie diagnostic assessment. Takinga ‘wait and see’ approach, or saying ‘come back in 6 months and we'll reassess’, is not acceptable. Getting hearing checked or assessments iiloahimatat Onarophayabenass bbe done in chis work-up phaso. Management Incensive early intervention for ASD, which is what guidelines recommend as gold standard and does ‘improve long-term outcomes, involves intensive mt of often expensive behavioural/developmental therapies, and the earlier it commences the better. However, this type of therapy may be beyond the so care should be taken in what is recommended. Parents should be directed to reliable information sources'”* om these options, which they may find daunting. Thore is also 2 lot of misinformation on autism, particularly regarding complementary and alternative therapies, for which there is no evidence of efficacy.”* State-based autism associations can also with advice. Ifthe waiting times for diagnostic Sacer ing Gas tend oe should be referred to early mtervention services hil they wat.The role of the GP in management A child being diagnosed with ASD can have a massive impact on the family. GPs should monitor how family mombors are coping, and provide a ‘medical home’ for reliable advice on management options. Children with autism also have particular vulnerability to certain medical issues, and the GP will be involved in the management of these. These include: ©) minor traumas and injuries © restricted diet (due to sensory issues or special diets used by some families) © behavioural issues constipation (due to sensory issues causing, voluntary faecal retention, or from medications used for co-diagnoses) * dental issues (sensory issues making brushing difficult, or grinding) When consulting children with autism, special tactics cam be employed to help things run smoother. Alerting front desk staff so they are aware of potential behavioural issues, allowing easier access for families in stress (e.g. calling the patient from the car if behaviour in the waiting room is problematic) and reassuring parents that challenging behaviour by the child is not an issue will help. The decreased eye contact and interaction means that the GP needs to work harder to engage these children, but it can be done, and parents will appreciate any effort made. Adjusting for sensory issues, for example, letting children hold and examine equipment before it is ased, can also help 2. Dark urine due to obstructive jaundice ‘Amiddle aged Man Joshep, complaining of high colour urine. Task © History, © PEFE in descr © give differentials istory is my patient hemodynamically stable (VS and 02 Sat) 2-Dark color urine? What color is it? Red or Dark yellow or Cocoa colored? Any loin pain? Any pain while passing urine? Any burning sensation? Increased frequency? Smelly? Reduced flow? Any injury? What about stool? Any stool color change?3-associated symptoms Pain questions “severity (painkillers + allergies) (SH6/0) -onset? Sudden or gradual? Constant or come and go? Getting worse? (eenstant) exact site and radiation? (RUQ) -character? -does anything make it better like sitting or leaning forward? Medications? -does anything make it worse like breathing, coughing, movement or fatty meal? -if itis the first time? (he might reveal the history of cholecystitis if you asked this question) -nausea and vomiting? How often and what color and content? -fever, rash and recent infections (es fever) so ask how high is it? Is it associated with chills, night sweating? Constant or come and go? -LOW, LOA, lumps and bumps -yellowish Biseololration Of SKIN|(VE) any itching -chest pain, SOB 4-General questions Past medical history (gall stones, stomach ulcer, hype! past surgical history (ERCP, cholecystectomy) -medications (NSAIDS, steroids) Smoking, alcohol, drugs -travel. Sexual history, blood transfusion DM, HTN, mumps) Physical examination findings from the examiner 1-General appearance anxious, sweaty, in pain pallor, jaundice, dehydration, LAP. 2Vital signs 3-Focus abdomen inspection: movement with respiration, distension, visible masses, scars, dilated veins palpation: tenderness (RUQHVE)) rebound tenderness, guarding, rigidity, murphy sign (-ve). auscultation: bowels sounds -complete with: hernia orifice, genitalia, LN, per rectal a-cVS apex beat, thrill, heave, heart sounds and murmur 5-Chest -dullness, air entry, breathing sounds, crepitation or wheeze, 6-Offiec tests -urine dipstick (Sea) “BSL -ECG Explain diagnosis and differential diagnosis -Draw diagram-there are several possibilities most likely it is here which could be due to: caused by a stone obstructing the flow of bile and this lead to ascending infection from the gut causing inflammation. Which is what | am suspecting the most likely one as you have the triad of this condition (fever and chills, RUQ pain, jaundice) It is acommon condition after surgery we called Post cholecystectomy syndrome *other possibilities are: pancreatitis: inflammation of the pancreas which is a gland that secretes both digestive enzymes and important hormones that could be caused by gall stones or chronic heavy alcohol intake, rarely trauma, surgery or medications. -Stricture: narrowing of the duct after lap cholecystectomy. -Choledocholithiasis (stone got stuck here) -pneumonia, hepatitis or MI but less likely Immediate Mx: Iwill contact the specialist to come and check | will take blood samples for investigation ( FBC, Renal function (U&€), liver function -AST, ALT, bilirubin, phosphatase, gama-GT , amylase, serology for hepatitis A,B and C, cardiac enzymes) and ECG -abdominal X-ray, US and CT scan. “ERCP, ECG, x-ray. ~lV fluid, -IV antibiotics and painkillers 3. Insomnia due to depression Young girl, Fiona, 19 years old, has been taking temazepam for 1 year due to sleep problems. Tasks: © Take history ‘* Discuss cause of insomnia with patient Sleep details -why can’t she sleep? Waking up early morning or unable to sleep? Since when? Who prescribed Temazepam? Dose? For how long? Did it help? Dis you increase the dose? Was there any period in between when you don’t get Temazepam? Could you sleep well without it ? DSM V for depression -Criteria: MSIGECAPS (key q) M-Mood, S -Sleep, |—Interest, G guilt, -energy, C-concentration, A Appetite, P psychomotor, S— Suicide (Depression -5 out of 9 for at least 2 weeks) Psychosocial hx-detailed HEAADSS -How is everything at home? With whom do you live? How is your studies, are you doing well? ‘Are you working too? Do you smoke? Drink alcohol? Organic causes —Any weather preference? LOW, LOA? ‘Any medical illness? Any mental problems in the family or yourself previously? Dx -Mild depression leading to insomnia. So | don’t think sleeping pills is the right option for you. We must treat the underlying cause. So | will refer you to psychologist for talk therapy about how to manageyour stress. Ifnnot better, you will need to see a psychiatrist who will prescribe medications for your low mood. | will also arrange a family meeting to discuss this issue too. ‘Advice to reduce stress -take days off and enjoy your free time. And family meeting. Advice about sleep hygiene. Causes of insomnia: life style stress, adjustment disorder, GAD, PTSD, bipolar mood disorder, Drug induced , substance abuse, other organic causes 4, Cranial nerve examination 30 years old lady Marie coming to your GP. ‘© Do cranial nerve PE ‘© running commentary to examiner 5. Obstructive sleep apnea due to enlarged adenoids ‘An 4yrs-old child brought by his father to the ED yesterday because of breathing difficulty. The baby was admitted for URTI and pulse oximetry readings were taken over night. Tasks History PEFE Explain the investigations to the father Dx and DDx Fever when did it start? Did you measure the temperature? How long? Persistent or off and on? Any shakiness?‘SOB How long? How severe? Can he sleep and eat well? Any chest indrawing? Persistent or off and on? Isit the first time? -OSA -day time sleepiness and lack of energy. Snoring, mouth breathing? Causes -recurrent upper respiratory infection, Tonsillitis (sorethroat), ear infection Infection ~any cough? Sounds like croup or whoop or barking? Any SOB? Any blue discoloration? Any \de that stop breathing? (apnoea) Noisy breathing? Drooling of saliva? Staying like bending forward position? Fever? Runny nose? How is he now? Active or drowsy? BINDS Contact history -PEFE: -General appearance, Vitals, growth chart -Dehydration adenoid facies-open mouth, dry lips, projecting teeth (incisors), inactive ala nasi, short upper lip, high arched palate -| will do ENT exam very carefully because | suspect epiglottitis as well (dangerous in epiglottitis) -Neck stiffness -CVS and chest ‘Abdomen Explanation of investigations: -X-ray: lateral view of head and neck. Black area is air, white areas are bones and grey areas are tissues. The problem here is this black line is airway and the opening of the airway has been narrowed and covered by small grey tissue Sleep study: This is the horizontal axis is time and the vertical axis is oxygen saturation. There are tolaround 60% which should always be more than 94%. This happens because of some episodes where the breathing stops and because of airways obstruction as you see in the X ray. All these are pointing towards and part of our body defense system. They can be enlarged when there is infections in your son’s case, When they're enlarged, it blocks the airway too as you can see in the Xray. So it’s leading to a condition we called obstructive sleep apnoea. (obstruction and stopped breathing episodes while sleeping) This is the source of snoring as well. (key point) It could be because of tonsillitis as well but the tosils have been removed. It could be because of some infections such as pneumonia which is infection in the lungs or epiglottitis which is the infection in the lottis which is flap in upper airway, croup which is the infection in the upper airway as well but less likely. 6. Obstructive sleep apnea PE ‘Amiddle aged truck driver c/o tiredness and sleepy almost all the time. The patient had in the morning, sleep problem, snoring and feeling unfreshed. Task - Perform PE (explain to patient) - Explain Dx and contributory factors to ptDx Obstructive sleep apnea (ENT examination, neck gland examination, sinusitis examination) DDx ‘* Alcohol (liver insufficiency signs) ‘+ Hepatitis ‘© Obesity (BMI) ‘* Complication of obstructive sleep apnea (signs of heart failure) + Tiredness causes (HEMIFAD) 7. Serotonin syndrome 32 year old patient on treatment for depression for 6 months with duloxetine with no improvement, was seen by another doctor in the practise 2 days ago and was prescribed another antidepressant mirtazapine. He has to come to see you because he is presenting with restlessness, abdominal cramps, fever 40 and sweating Tasks History -diagnosis with patient -explain initial mx History L-hemodynamic stability 2-C/C presenting symptoms (abdcramps, restlessness, sweating, fever) -how long have you been having these symptoms? -did it all start suddenly or gradually? -is it continuous? 3-when were you diagnosed with depression? How long have you been on medit 4-Medication hx -were you on any medications before that? (if only one medication given in stem) -do you know why it was changed? (No improvement given in stem) -do you know the current dose? -how many days did you wait before starting the new medication? Or are you taking both medication together? (For washout) -are you taking your medication regularly? -are you taking any other medications like herbal or OTC? 5-Systematic symptoms+ psychosocial history PEFE (if coming) 1-General appearance 2-Vital signs (+/-high temp, +/-high BP. +/-high PR) 3-eye (pupil size, shape) 4-CNS (gait, clonus, tremor, reflex, tone) 5-CVS Explain Dx-most likely you have a condition called serotonin syndrome when you have excess of serotonin chemical in the brain leading to these symptoms (fever, tremor, sweating, etc. -usually here because of the use of 2 medication and both of them are antidepressant with same mechanism of action (SSRI) and inadequate washout period leading to increase serotonin. -Usually when we stop and start medication, we cannot start the new medication straight away as the first med needs to be cleared from your system before starting the new med to avoid excess level of serotonin that can lead to these symptoms. Washout period needed. (key point) Management -Admit you to hospital here (if in ED) firstly we need to stop your antidepressant med at least for 24 hours.(key mx) -be put on monitor to observe your vitals, giving IV NS, antipyretics for fever (cooling blanket +cold IV fluid). -Cyproheptadine medicine -Call the psychiatric registrar to see you and depending on your situation, will either cut down one of the med or reduce the dose. “if in GP talk accordingly (like feedback 27/10/ 2018 refer to hospital for admission and etc... Q/ if you stopped med will my symptom come back again? -MDT will monitor you and will reintroduce medication once symptom settled down. 8. Borderline personality disorder QUES: 30 years old lady presented to RD with superficial cuts on her thigh, cleared by psych team. She was dx with BPD. UTASk: UOtake hx Odo risk assessment advise mx plan HISTORY: Ohi jenny, | am Dr Tasrifa. One of the Dr here. Nice to meet u How are u feeling right now? Any pain in your cuts? CRP-| wannago now, already | am cleared. yes , | am really happy to hear that u are cleared by the psych team. But before discharge, | would like to ask u few questions, It wont take much time I can assure u, Also I can assure u whatever we talk will be absolutely confidential. Would you mind telling me what made you to cut yourself? (I feel relieved when cut myself) well, can | ask what was the reason that made you really stressed? ( my BF didn’t show up) Uokay, is this the 1st time you have done this? (no) CaHow many times? What were the reason at that time? Did you also cut yourself at that time?Since when you are doing this? | am sorry to ask but any bad memories at that time? CiHow is your mood? Sleep and appetite? Any time you thought of harming yourself that u wanted to end your life? Any thoughts of harming others? Any such plan in the future? Any access to weapons? (Do u feel/ see/ hear things that others don’t? (Do you think you need some medical help? QHEADSS CsaDMA UPMHX Chat is your plan when we will send u to home Box 4. SAD PERSONS scale for assessment of suicide risk: Sex (male) Age (< 20 or > 44 years) Depression Provious suicide attempt Cthanol abuse Rational thinking loss (psychosis) Social support lacking Organised suicide plan No spouse (divorced or separated, widowed or single) Sickness (presence of a chronic or debilitating Iliness) Each risk factor that is present is accorded a score of 1 point, for a maximum of 10 points. Patterson et al’ recommended: Close monitoring for patients with scores of 3 to 4 To strongly consider hospitalisation for those with scores of Sand 6 Hospitalisation for further assessment for patients with scores of 7-10 Note: Regardless of the score obtained, overall clinical assessment is still paramount and the primary care physician should err on the side of caution. Explain: well, I understand you are in a lot of stress and what your boyfriend did was, not good at all but the way you have responded to the situation is also concerning meMary, | really want a happy and cheerful life for u with stable relationship and I can help u with that. But for that | need u to understand that there are also some healthy ways to deal with this type of situation rather than cutting yourself. Do u understand me Mary? Urhat’s why I would like to refer you to a psychologist for talk therapy. If u give me the consent also ! would like to involve your family. you can go home cause | haven’t found anything that might put you or others in risk for the moment, but before that my senior will have a look on you and I would ce to call someone to pick u up because | am really concerned about your safety. Qi will also write a referral letter to your GP who will regularly review u OFinish with 48 9. CVS examination Your next patient in GP is 42 years old male who comes to your GP as he is travelling to Asia. But he is concerned that he wants your advice as one of the doctors said he has murmur 2 years back when he complained of flu, aches and pain. Tasks 1. Perform physical examination 2. Running commentary to the examiner 3. Discuss with patient Checklist 1. WIPEC 2. General appearance and vital signs 3. Hands 4, Face 5. Neck 6. CVS 7. Dynaemic maneuvers8. Abdominal examination 10. Gastroenteritis PE 12 year old child come with loose motion for 2 days accompanied by mother. Do relevant physical examination explain mother about possible DDx after examination. Checklist + Intro * GA and vital signs (you may need to check yourself in this case) + Dehydration status * Abdominal Examination + Intro * General appearance Dyspnoea Drowsiness Conscious level Age and gender + Vital signs Blood pressure (lying and standing) Pulse rate and volume Respiratory rate Fever Dehyration status + thirsty or not + Face - Mouth- Mucous membranes are normal or dry : Eyes - Sunken eyes + Neck — Check for IVP (may skip) + Arms and hands ~ cool hands capillary retill skin turgorSign and Symptoms of Dehydration Dry or sticky mouth + Lethargy Sunken eyes Weight loss Low or no urine input Dark yollow urine * Poor skin turgor + Delayed capillary refill * Dizziness + Confusion/changes in menta status + Lack of tears/sweat + Falls/difficulty walking, + Low blood pressure Sn wn deen tre fea essed ater Sim ede at Rapid heart rate Abnormal labs/clectrolytes 11. 15 yr old Alcohol binge drinking STATIONI *You are HMO at ED. 15 years old male who had binge drinking last night, alcohol level can’t remember now. Vitals were stable. ‘Tasks: Take medical and psychosocial history Present key issues and risks regarding adolescents to the examiner before discharge. APPROACH: Can you tell me what happened? Is it for the first time? Since when? ‘How frequently/often do you drink? Where? With whom? ‘Have you increased the amount since you started? ‘Are you aware of safe limits? ‘if you don’t drink do you get any symptoms? ‘Any trouble with law so far? Any accidents ? Psychosocial Hx sHEADSS ‘Any stress at uni? How is your academic performance? COUNSELLING: ‘At this stage | would like to discuss to connect him my senior as he needs proper alcoholic counselling. | would like *To alcohol anonymous and youth support group. ‘elf he agrees | would like to arrange fai meeting as well.12. Absence seizure ‘Agrandma, Chole, with a 9 year-old boy, Brandon, came to your GP clinic complaining of her grandson school performance is going down. He sometimes go out of the world and stares and feel out of the world. ‘Task take history, diagnosis, management. When did this happen, did it happen for first time ‘*Any trauma/ head injury, any infection, any headaches before it happened ‘who witnessed it, how long does it last, ‘Any shaking/twitching/jerky movement/tongue bites/loss of urine or bowel during fit ‘*How did he feel after that/ any weakness or numbness in legs/any vision, hearing or speech problem ‘Any past history or family history of epilepsy ‘BINDS question For any epilepsy, ask: ‘shead injury fits ‘infection/meningitis ‘febrile convulsion ‘family history of epilepsy tumour Physical examination General Appearance: alert, active or playful any anaemia, jaundice, cyanosis, dehydration, edema, any shortness of breath or any distress I'd like to see the growth chart Vital Signs---temperature, blood pressure , heart rate , respiratory rate, Ear: any discharge, redness Nose, air passage, any polyps, nasal mucosa, water discharge Throat: oral cavity, tonsil, adenoid enlarged or not, Lymph node enlargement Neurological examination Respiratory examination: inspection Pattern of breathing, chest retraction, Accessory muscle working, Nasal flaring, Symmetrical air entry, Supraclavicular indrawing palpation: Tracheal tug by palpation ‘Auscultation: Any wheeze, added sound or basal crackles CV system examination: ‘Abdominal examination «From the history, it looks like your grandson has a condition called Absence Seizure. It’s one type of epilepsy, common in children from 4 years to puberty. In this condition, child suddenly stops the activity and stares. They become motionless.‘Outcome is good with treatment. ‘Most of the children grow out of it, sometimes it leads to generalised seizure in adulthood (5%). I need to confirm the diagnosis. I'm going to refer your grandson to a specialist and he will do EEG asa confirmatory test. After confirmation, he will be put on medication. The first line medication is Ethosuximide or Sodium valproate, the specialist will decide. ‘we need to do some basic test like : FBE, BSL, U & E You'll be followed-up by me and the specialist. ‘Need to take the medication regularly. ‘He needs to wear medi alert bracelet. ‘Need to take a good balanced diet. ‘School teacher should be informed. if you like, | will inform the school teacher. *We can arrange a family meeting if you like. ‘Also there is epilepsy support group. ‘+1'll give you some reading materials. *If you have any concern, please don’t hesitate to call me. 13. OCP counselling for 15 yr old girl ‘15 years old Naomi came to your clinic. She wants to talk to you as she is going to start her sexual life and want to talk about some advice on OC pills. Tasks: “Take relevant history Physical examination from the examiner on card ‘Explain about OC pills *Greetings (confidentiality must) ‘Any knowledge on other contraceptive methods? Wanna know? *Some questions may be private and sensitive, please bear with me. ‘Ever tried contraception before? Which method? slunderstand that you are going to start a sexual life. May I know how old is your boyfriend? Period Q (LMP, menarche, cycle, bleeding days, pain, regular) *Pregnancy (espif older) any plan to become pregnant near future? Gardasil vaccine? *Contraindications ~Clotting problems, nasty growth in breast and womb, active liver disease, bleeding from down below without reason, Any recurrent headache? *SADMA ‘+Family history of CA PEFE on Card: ‘*General appearance “Vitals espBP BMI‘*With consent ~breast examination ‘Abdominal -liver VE -only inspection if gin MANAGEMENT: *According to information you have given me, I can see you are a good candidate for OCP. Since you are minor | need to test your competence. Its very important for you to know everything clearly about OCP. Can you please tell me how much you know about OCP? Before starting going to do UPT (key point) *1.am going to explain how to take pills, how it works & what to do if you miss a pill. After that | want a feedback from you. Listen to me carefully & give me feedback after I finish. Alright? if see you have a clear idea | am happy to prescribe pills for you. *{you can draw dummy pill packet) There will be 28 pills in a packet, among them 21 are hormonal pills. They contain 2 types of hormones which are naturally present in our body. The last 7 pills are sugar pill & they don’t contain any hormone. +The function of these hormones are to prevent egg release from ovary & also changes the secretion in the mouth of womb so that sperm from male partner & egg from female partner cannot meet & thus prevents conception You can start pill at any time provided that you are not pregnant. Ideal time to start pill is from the 1st day of your period, after starting from here as you can see just follow the arrows. Each pill isto take at a fixed time each day. You can put an alarm each day so that you don’t miss. Once you finish one packet just buy a new packet & start from the Ast pill & continue like this. sit takes 7days to start the action of pill so if you get sexually active in that period there is a little bit chance of getting pregnant. So for that use condom/ any other method OCP just prevents conception but doesn’t prevent STI. If you are worried about that use barrier method along with OCP.(key point) *If you miss one pill, whenever you remember take the missed pill & continue taking regular pill like any other day. You don’t need to take any extra precaution. +If you miss more than 2 pills, in that case, when you remember take the latest missed pill but discard the previous days missed pill & continue regular pills(key point) if you had no sexual intercourse in that period, for the next 7 days along with pills you need to use another method of contraception like condom because you have some abnormalities in hormonal balance due to missing pills & hence there is a chance of getting pregnant. but if you had intercourse in that time go to your GP. He might give you emergency pill along with normal pill Advantages along with contraception are it helps to keep your period regular, specially in someone with heavy bleeding it will make the period lighter & shorter Disadvantages are initially you might experience some nausea, vomiting, breast tenderness, breakthrough bleeding. These are minor side effects, don’t get scared. It will go away with time.Bilfits very much troublesome come back to me. Now can you please give me some feedback? If | feel you understood, | am more than happy to prescribe it for you “Type of a inducer. ‘Special case is Lamotrigine, OC pills reduce it’s levels and causing fits Please read about Enzyme inducing and non-inducers. ‘Enzyme inducer- ‘double the estrogen dose. Microgynon-30 (not given) to microgynon50(key point) +Other options —barrier, Mirena, Copper IUD and Depo ‘Not an option -Implanon, vaginal ring, Mini pills leptics, for example, Carbamazapine, Enzyme inducer. Sodium Vulporate, Non-enzyme 14, Body odor «Mum came today because of bad body odor of daughter 9yrs. Task . HK, © PEFE, © Dx, DDx ‘Approach: -Greeting -Whats your main concern for todays consultation? -Only you can smell or others as well? -Since when? Any particular area? -Does she sweat a lot? -Does she maintain personal hygiene? Does she takes daily shower? Wash clothes regularly? -Is she toilet trained? Any issues with her wee? How about her bowel habit? Is she constipated usually? Have you noticed any soiling in her undergarments? -Any discharge from down below? ‘*How about your diet? Do you eat a lot of garlic, onion, curry? ‘Anything significant at birth?(phenylketonuria) ‘1s her immunisation up to date? ‘How about her development? Has she developed pubic and axillary hair? ‘How is everything at home? ‘*Any bullying at school? how about her school performance? ‘*How is her general health? Any H/O DM, liver/renal disease? ‘1s she on any medication(penicillin, bromide)? ‘Any exposure to heavy metal? ‘How is it affecting her life? How is her mood? ‘*Any F/H of similar condition?PEFE: *GA BMI *Growth chart Tanner stage (4) Other systemic exam ‘*Inspection of private part *Office test Breast Development Pubic Har Growth Erm one wr a a ry ° a > meee (OO) |: stage 3 2 © snes ee ecsansial ‘ Se cians conenaan Aj Seer feel Oe ee) Sse aes SE tpt 2 9 Fe cssenncine a \ eeeeccnre oe 8) Ble slkers me rs 9 PS memaia eens) Spears Sea eanerciaal By) cote = ° ° ‘Most likely your daughter is having a condition called Bromhidrosis. Excessively foul smelling sweat is considered pathologic and termed as bromhydrosis. Its generally diagnosed when noticeable body odor has a negative effect on an individuals self view, social interactions or quality of life. «its not uncommon. Its of 2 types. Apocrine bromhydrosis mostly affects axilla and eccrine bromhydrosis, affects feet. ‘it can be due to many reason-poor hygiene, food habits like ingestion of garlic, onion more, some inborn disease like pheylketonuria, triethylaminuria, due to some medication, underlying DM, kidney/ liver disease or inflammation. But all these seems unlikely in her.‘1 think she is having premature puberty-so during puberty children go through a lot of hormonal changes that lead to variations in their body and behavior. 15. Parotid gland enlargement You are a GP. A 50-year-old man came to your clinic because he noticed a lump on right side of his face for S years Tasks: ‘© Perform Physical examination ‘© Explain the diagnosis and management to the patient Checklist 1. WIPEC 2. General appearance and vitals 3. 7 cranial nerve: Inspection Sensory, Motor WIPE “(need to examine you today to know the nature of the swelling and its associated conditions. ok?” General appearance “Middle age male is sitting comfortably on the chair. Dr, may | know my patient's vital signs?” “Firstly, | will focus on your face and lump.” Inspection Facial asymmetry 2 Drooping of the eye-lids Loss of naso-labial folds ¥ Loss of wrinkles “There is a lump at the angle of the jaw on the right side. Size ...x... cm. Shape is oval Surface seem smooth. Clear cut margin. There is no redness over the skin,No signs of inflammation in the ears and no dental caries in the mouth. No other swelling. ” “(need to feel the lump to estimate the nature. Is it alright?” Check for ‘+ Temperature + Tenderness Site, size * Consistency © Mobility Lymph nodes “I need to feel your neck glands now.” “Dr. | suspect that this is most probably a parotid tumor. So | will proceed to 7" cranial nerve examination.” Do 7" cranial nerve examination. “Hello, after my examination, | am happy to say that the swelling is most probably a benign tumor of the parotid gland (because long duration, if short- think of parotitis) because there is no associated nerve damage. The parotid gland is a salivary gland lie at the angle of the mouth which produces saliva to smoothen swallowing and chewing. Somehow I need to refer you to the surgeon for a and the definitive treatment will be the removal of the swelling by surgery. Are you clear with my examination?” 16. Delirium You are HMO at hospital and about to talk to a daughter of a 80 year old woman who has been admitted with lobar pneumonia and heart failure for a few days. The patient is an medication antibiotic and 02 IV line. On exam, the pt is being agitated, shouting and not cooperated. The pt is not well orientated and has visual hallucination. Vital sign «7-38 * BP-150/90 © RR-30/min © Sap 02-41. ‘© Explain Dx with reasons to daughter ‘* Explain possible reasons to her © Discuss mx to her Feedback - Medication ~ olanzapine, risperidone (psychotic drugs) in case of underlying lung d/s - Delirium — reversible condition and manageable : Drug h/o- Alcohol h/o Other heart d/s — IHD 17. Non-compliance on medication Sertraline Young male, Chris, came to your GP 2 weeks ago, was diagnosed with depression, started on sertraline 50 mg to be increased to 100 mg after 1 week. Now the patient has come for regular follow up as advised by you Tasks: -Take relevant history -Your management with reasons dings | do not take the medication. | heard it cause side effects my sister told me and | googled it Sister told that | won’t be able to sleep) problem with cost? (No) has suicidal ideation but no plan or attempt live with sister and supportive ‘© take 4 glasses wine / day so advise about safe limit and another consultation History 1-Approach -Confidentiality -How do you feel now? -Do you think your condition is getting worse? 2-Medication questions -do you take the medication regularly at the prescribed dose? -may | know the reason why you are not taking it? and may | know from where did you hear that. -so for how long did you take it? Have you ever had any SE? -any problem with cost? (No) 3-Good psychosocial history -how is your mood? Any time you feel high? -have you lost interest in things you used to enjoy? -have you ever thought of harming yourself or others? Any plan? any previous attempts? -how is your sleep?how is your appetite? -have you lost weight recently? -do you find it difficult to concentrate on things? Do you feel guilty? -do you feel, hear, see things that others do not? what does it tell you? -do you think someone is following you or spying on you? -do you think someone is trying to harm you? -do you think you need a professional help? -let us suppose there is fire in this room, what would you do? 4-HEADS -who do you live with? Any stress? Support? -what do you do for living? Any stress? -SAD -social activities 5-General -previous and family hx history of mental problems/ PMH/PSH/ other medications Counselling -well John, let me assure you that any medication we start we do a risk benefit analysis and the benefit of taking sertraline outweighs the risk. -if you do not take the medication, your depression can worsen. You might have to struggle with the activities of daily living. You can develop suicidal ideation. You can neglect your food and drinks which again could be life threatening so it is always better to take medications at the prescribed dose. -Each medication has side effects but if you feel concerned about any, feel free to come and contact me. We can reduce or change the medication accordingly. -Usually, antidepressants take 2-4 weeks to work. are you taking CBT? Management -NO ADMISSION (as just suicide idea and also has support) -refer to psychologist for CBT (if no CBT) and also a good idea to refer u to psychiatrist to review your medication and teach you some methods to overcome your stress -life style modifications -family meeting with consent -support group.-see you regularly and that you can always come back to see me if there are any issues with taking the medications and we will help you. 18. Adjustment disorder You are a GP. A mother 45 years old came to see you because she felt overwhelmed by her daughter's case. Her daughter was recently diagnosed with schizophrenia Tasks * b/o © DDx © Mxtoher Approach Daughter's condition Tiredness ~ when? How long? At rest or with movernent? What about at night? Any SOB? Racing of heartbeat? Is it the first time? Tiredness (HFMIFAN) - Haemochromatosis any discoloration in the skin? (Bronze color) = Endocrine ~ DM, Addison's, hypothyroid (increase frequency of urination, postural hypotension ~ any episcde ‘of bleckout, weather preference) = Malignancy ~ lumps and bumps = Infective endocarditis - any fever? SOB? Dental procedure? Infection — fiusike illness ~ Fibromyalgia, Polymyalgia Rheumatica — joint pains ~ Anaemia (pale). Atypical pneumonia, Apnoea (OSA. snorine) = Depression, Drugs * Confidential statement * Depression questions -MSIGECAPS + Anhedonia, depressed mood, suicidal ideation, sleep problems (early awakenings), lack of energy, problems with concentration and decision making, lack of sexual desire and appetite + Less sleep — how many hours? How long? Any stress? How is everything at home? School? * Anxiety — are yowgenerally an anxious person? Do you worry a lot? + Organic — period ? Weather preference? + Past medical, past surgical * SADMA+ adjustment disorder which is just an emotional response to a stressful event. can understand you are having ahard time coping. Others could be anxiety, acute stress diorder, depression, PTSD, or infections but less likely. * Somost probably your tiredness is likely to be because of lack of enough sleep. + Other causes of tiredness can be because of depression, anaemia, hormonal problems, heart diseases, respiratory problems, infection but these are unlixely in your case. * Normally, a person needs 7-8 hours of good sleep a night to keep refreshed and healthy. From your history, you are sleeping like only 4 hours a day and Obviously this is not enough for your body and your mind. Many days of these leads you to have tiredness. + I will refer you to the psychologist to teach you how to manage your stress, * Please try some relaxation techniques such as Yoga, meditation. * Seems like your daughter is doing well now, so it’s time to take care of yourself, Please take some davs off from work and take a good rest. * Iwill talk about some sleep hygiene and will give you reading materials too. Proper sleep hygiene (if time allows} Get into a regular routine. In particular, get up at the same time each morning even if you haven't slept wel. Ifyou are not asleep within 30 minutes, et up for awhile before returning to bed. If you don't drop off wthin 36 minutes, get up again and so oh s ” “Try to avoid caffeine (coffee, te2, cals, chccalata) fram 6 am onwards. Ayoid alcohol and, if possible, Gigerettes from dinnertime onwards. Try not to eat a meal within a couple af hours of going ta bed. Starting a gentle exercise routine and lozing come weight often helps with sleep, Don't do anything in bed except sleep (and, perhaps, sex: don't watch T, read, do cross-words, or think Socal worry Get into the habit of doigg something relaxing before bed isten toa relaxation tape or some relaxing music, have awarm bath, slow down! € " Ty notta worry abour not sleeping: the mare you worry about ft the less likely you are ta crop off to see ‘YeU'can survive without much seep, even though you wil be red. ve ° ° Sleep, ike ay habit, takes a while to change. Try to stick to the abeve guidelines for atleasttwo weeks before deciding whether arnottheyheipe . ings: Reserve bed for sleeping. 19. Unstable gait You are a GP. You are going to see 55 years old coming to see you because he’s got recurrent falls because of unstable gait. He has a radial fracture 5 years ago, Your tasks: * Explain the patient what you are going to examine for an unstable gait.20. Cervical spondylosis *You are a GP. Your next patient is S8years old Lady, Cristiana, with history of breast cancer coming with complaints of neck pain and unusual sensation in her hands. Your tasks: Take history *DDx to patient Investigations & Prognosis ‘*Empathy about her breast cancer ‘Neck pain -pain questions + differentials tingling and numbness positive (cervical spondylosis), Any injury? Any inflammation or pain in other joints? (RA, OA), Did you carry any heavy object recently/ repetitive usage of the hands? Enjoying any sports? (disc prolapse), any weakness? (stroke), any SOB? (Pancoast tumor) Unusual sensation in the hands -what exactly is the feeling, pain or numb or tingling? Which side? Which part? Any relieving factor? Aggravating factor? Any part of the day it happens? ‘Breast cancer -which side? How many years ago? How was it treated? Follow up regularly? Any swelling in the arm? (Iymphedema) LOW, LOA, lumps and bumps all around the body for metastasis ‘*Occupation ‘Medical, surgical, SADMA “Differential diagnoses Draw two cervical vertebrae and nerve. ‘It could be cervical spondylosis (a wear and tear process leading to narrowing of the space between the two pieces of back bones and that’s why giving pressure to the nerve supplying the hand) due to cervical radiculopathy. *0r it could be cervical disc prolapse where the cushion between the two pieces of bone has been slipped out. *0r it could be RA, OA, AS *0r it could be trauma, lymphedema (which is the collection of the fluid called lymph in the arm which is. common after breast cancer treatment) , nerve damage because of radiation ——— Invx- iiilaging Xray and MRIof the Spine may be needed later and also the blood tests including tumor markers, LFT, RFT, FBE, CXR, maybe PET scan (esp if she is not following up regularly for breast cancer) (mammogram if breast tissue present) (key point) Prognosis: Regarding breast cancer it could be recurred , metastasis to bone we need to r/o. only cervical spondylosis prognosis is favourable, many people improve within few weeks. However long term pain can be present , myelopathy can happen (less likely), bone damage.21. RA counselling You are a GP, and 28/F Samantha is a professional pianist, who came to you last time with swelling and pain in her hands. You ran some blood tests that show RF+, and mild anaemia. Diagnosis is early rheumatoid arthritis. She has been taking ibuprofen. Her mother has RA and takes corticosteroids. Tasks: ‘* Explain the condition and management. ‘+ No further history or examination is required KEY POINTS ‘* Progressive condition Early diagnosis and treatment can slow the progression, but will not cure the disease ‘We can start DMARDS Refer to rheumatologist CRITICAL ERRORS ‘+ Not explaining side effects ‘+ Not referring to rheumatologist, COUNSELING FORMAT ‘© -Whatis the condition ¢ -Is it common/uncommon, © Serious/not? © Cause -Symptoms -Diagnosis/Investigations * -Management - Pharma/non-pharma/support -S/E or complications ‘APPROACH © COUNSELING FOR RHEUMATOID ARTHRITIS: * Good morning, | understand you are here to discuss the results of your test. The test has confirmed what | was expecting. I'm sorry to inform you that what you have is rheumatoid arthritis. Have you heard about it? © WHATISIT?. The normal role of your to fight off infection to keep you healthy. However, in an autoimmune disease, the immune system starts attacking the body's own healthy tissues ‘© In RAin particular, the immune system targets the lining of the joints, causing inflammation and joint damage. COMMMON/UNCOMMON * Itis the ROSEEBRRMRGR form of autoimmune arthritis SERIOUS/NOT ‘© It canbe serious when diagnosed late. But in your case, | am glad we caught it early. © lam here to help you. Let me explain more about it. CAUSE The exact cause is unknown. But it is more common in patients who have a family history, © SYMPTOMS + ttusually affects the SASlJSIAR@ SPINE RERGEBRURSEL However, large joints like the BBA KES might also be affected at a later stage. The main symptoms are joint pain, swelling, and stiffness, especially in the morning ‘© Itis usually Symmetrical-where both sides of your body are affected ‘© What's good in your case is that you are at an Barly stage and with early diagnosis and the right treatment, most people live a full and active life. Course (key) However, the course of RA varies, and no two cases are exactly the same. It is a PrOBressiVe that runs a chronic course + You may experience flFSBBFBEUESBHESER when joints become iflha BABIBBIARAI This happens with no obvious cause + These flares are usually followed by months or even years of remission, where there i little inflammation and symptoms if treated in a good way. MANAGEMENTMx will involve a MDT Myself as GP Rheumatologist Physiotherapist ‘© Social worker © Occupational worker. ‘+The good news is that currently we have that can be used These meds have improved dramatically over the past 20 years and are extremely helpful in all patients of every stage. * Unfortunately there is NO(CURE for RA. The role of these meds is to reduce or slow down the degenerative process © will organise a referral to a rheumatologist who will tailor your treatment to your symptoms and he will decide which ones will work best for you He may try different treatments which could be ASAIBR) €=BEIsijm MCS SEESIECSXB) (CGHICSEEETETGESTEMEEEUPMESEURETEPEUB and then tapered off and stopped to minimize side effects ‘+ The cornerstone of treatment is known as DMARDS = disease fiodifying antirheumatic drags like + More recent OMARDS are BIIGBIGSI BER lke FA SAGAS SIDE EFFECTS * Each DMARDs does have side effects which we will be on the lookout for. Some cause Aausea) (GHIEIARNORBISEIES They may also make you prone to ‘+ The advantages or using these meds will we assessed against the side effects and benefits should outweigh the disadvantages before we use them in the long term NONPHARMA MGT I would advise you for short term, not to play the piano, as your Iican give you a+ Lwould advise you to get a Second Opinion from the rheumatologist about the impact ofthe ‘© In Australia, there is a lot of help and support available. If you are Uinable to work because of your You can als hich is an BRliN@BESSEEION with other people going through the same condition, who share their experiences and give and gain inspiration + Weightloss if the patient is overweight ‘+ Healthy balanced diet, fish oils, glucosamine + Use joints to full range of motion during remission to prevent stiffness. The physiotherapist will advise on this. IMPORTANT POINT: REGULAR FF UP WITH LFTs and FBE IS NECESSARY! | will organize regular follow ups to recheck your inflammatory markers ‘+ Iwill give you these reading materials to give more insight to your problem * Do you have any questions for me? 22. Non accidental injury of 3 months old baby Your next patient in GP clinic is a 19-year-old mother who has brought her 3 months old baby boy because he cries a lot, poor feeding and rash on the cheek for last 2 days. Both parents are university student. Baby growth at birth was 70 centiles now its 50 centiles. TASKS LTakeahistoryfromthemother(4min) 2.x 3.lmmediate management positive finding: ‘© no fever, S/s for 2 days, ‘© while changing the nappy by her partner baby fall down from the table, ‘* partner was biological father non supportive, ‘they were stressed, having financial issues, PEFE card on the screen showing * growth decline,‘© bruise in 3 different area Hil am Tasrifa one of the doctor in this GP practice, How may | address u? X Howr u and how's ur baby doing? -HOPC: SIQORA (Patient is not making eye contact. You seem stressed, what happened? If not speaking, assure confidentiality) -Associated $/S -Well baby Q -BINDS -Pmh/psh/fhx. Dx: Well X, based on ur hx it could be many possibilities like meningitis but no fever, some blood problem like ITP, viral infection, allergy, drug reaction but | couldn’t find it, it could be Accidental injury or what | am concerned most it could be ‘Non accidental injury’ Look it must be very hard for u as u both are student lots of stress going in family, looking after a baby is very difficult. Saying some polite words, Immediate mx: atthisstageasheis3monthsoldandhavingbruise First, we fied to admit him in hospital, call senior, doing inv to rule out possible causes of these bruises, such as bleeding and clotting disorders. X as this is my legal responsibility as | am suspecting non-accidental injury, | must inform child protection services. ‘And arrange center link support for you Oh my god, they will take away the child from me: It is not always the case X. They will alk to you and ur partner separately and assess your condition. And if they decide that the child is not safe with you, then that's the moment that they'll take your child How does it sound to you? 23. Itchiness with DM ‘68 yr old lady, Monica, comes to your GP because she has noticed a lump comes out from vagina and heaviness and dragging sensation as well. At the same time she has noticed rashes around the vulva. Tasks © Take relevant history © PEFE ‘+ Explain Dx and Mx to pt PEFE Pelvic examination Inspection — rash + Speculum ~ Grade 2 UP + Bimanual - NAD BS—15.9 mmol/lUDS = sugar + 24. Hypertension Your next patient is a 38-year-old lady who came to check her blood pressure. You saw the patient couple of months ago and you noticed her blood pressure is high 145/100mmHg. You suggested to monitor her blood pressure at home. Average blood pressure is 150/90 mmHg. Your tasks: 1. Perform physical examination 2. Explain the most likely cause of the condition Discuss the management plan Checklist 1. WIPEC 2. General appearance and vitals, 3. Hands 4. Face 5. Neck 6. Fundoscopy 7. CVS exami“Hello James, | recently checked your blood pressure again and it is still high.” WIPEC “Today, | need to examine you to check for the possible causes of blood pressure and assess the severity. That will involve me checking your heart and proceed as needed. Is it alright?” General appearance : “The patient looks well and moderate height and weight. Vital signs “Iwill measure the blood pressure on standing position first. (Right arm) Could you please lie down for me now? | will measure in lying position again.” (Check both arms and compare, not equal- check BP in lower limbs)Hand -Polycyther -warm and moist palms Pulse “| will check the blood supply in your hands now” Check radial, ulnar pulses bilaterally. Mention | will check the blood flow on your feet.” Check dorsalis pedis. “let me check the pulse on your groin” Check radio-femoral delay. Face -Features of hyperthyroid — eye signs -Xanthelasma ~ Features of Cushing’s (moon face, facial hair, acne) “Can you please open the mouth?” Check for high-arched palate. “Teeth and gums are healthy. Neck “Can you please do swallowing?” check for thyroid enlargement, Fundoscopy ““| would like to look into your eye using this instrument called fundoscope to check for the eye changes.” Check for hyperten: a photo. Hypertension can cause damage ~ to theretina othe eye fetea Hard 42Pein ems CVS examination 45’ position on a cardiac bed. Exposure — chest Inspection ~scars -visible pulsations Visible apex beat Palpation “I need to feel your chest now. Ist alright?” Locate apex beat ~“apex beat is not displaced” Palpable thrill (mitral, tricuspid, pulmonary, aortic) Auscultation 1. Mitral, Tricuspid, pulmonary and aortic “Normal first and second heart sound and no added sounds” Volume overload - $3 Pressure overload -S4 2.JVP. “Please turn your head to the left. | would like to have a look on neck vessel” JVP is not raised. 3. Carotid bruit “(will listen to your neck. Please hold a breath” “No carotid bruit on both sides. (Note : check hepatojugular reflex only when the JVP is raised. Sitting upright 1. Bilateral basal crepitation “Can you please sit upright and breathe in and out slowly” 2. Auscultate between the scapula ~ aortic dissection 43Pee om ne 3. Abdomen examination Palpate for adrenal enlargement ¥ Liver and spleen “| ill press over on your tummy to check for organ enlargement.” ¥ Kidneys — ballotable or not ¥ Auscultate for abdominal bruits (above umbilicus and renal bruits (2cm below and lateral to umbilicus) Nervous system “Do you have any problem with speaking?” “any tingling and numbness?” Pitting oedema on lower limbs Bed-side tests — urine dipstick , blood sugar, ECG Task 2 and task 3 | did thorough examination on you to find out the causes of increased blood pressure. | couldn’t find any abnormality except increased blood pressure. So the most likely cause is Essential/idiopathic hypertension ‘We can manage it effectively by life-style modification. ABCDEFS (risk factors) ‘A~ Alcohol ~ avoid B-BMI- control C=cholesterol - keep within normal range D - Diet ~ eat healthy balanced diet. Avoid fast foods. E -Exercises — do a lot F ~ Family history ( unmodifiable factor) 44Pein ems 5 = Smoking - avoid -stress ~ manage accordingly. Investigations to exclude other causes -FBE -Blood sugar level -Lipid level -urea, creatinine and electrolytes -24 hr catecholamines -renin aldosterone ratio -thyroid function tests ~ Chest Xray -Angiogram for renal artery stenosis 25. Apixaban (NOAC) counselling You are a HMO at a hospital. You are going to see Nickol, 57 years old patient, diagnosed with diverticulitis, now it was infected and resulted in diverticular abscess. He is currently on antibiotics and IV and under watchful waiting. If not improved in 2-3 days, surgery will be carried out. He is a case of AF but it is controlled and he is on Apixaban (NOAC) and Atenolol and Atorvastatin. ‘Address his concerns ‘counsel the pt ‘introduction ‘*Ask about his concerns. Ask about any history of stoke or VTE previously? If present, when? ‘First concern: | am concerned for the operation. | am going to die. Is it necessary? Counselling - First of all, let me explain you why we need this surgery. As you have already known, there is, collection of pus in the outpouching of your large bowel. Currently, you are on antibiotics through veins. Sometimes, the collection of pus can be drained a needle but depending on the patient's condition, a major surgery is needed to remove part of the large bowel which is already dead. ‘Second concern: | am on blood thinners due to a stent placed in my heart. They will stop my medication for this surgery. If you stop this medication, | am going to have a stroke and if you don’t stop this medication then | am going to bleed to death. | die both ways. ‘1 understand that you are afraid of having a stroke when your medications have been stopped. Let me explain you about this. ‘The surgery we planned is a major surgery which has relatively higher risk of bleeding. So we need to stop the Apixaban which is a blood thinning medication you have been taking. If we don’t suspend this medication, the chance of major bleeding is so much higher than the chance of stroke. But the good thing is these drugs like Apixaban are the new agents that have quicker actions and live shorter in the blood. So they allow a short-term cessation and early re-initiation after surgery. So we can stop it only 2-3 days before surgery and no other bridging drug is. 45,Pein ems required. And we can restart it 2-3 days after surgery when you have secured with any bleeding, The actions can be seen within 2 hours we recommence it. During this time, if needed, the specialist might consider other blood thinners. ‘Also you don’t have any history of stroke or VTE previously and your AF is well controlled, so stroke is less likely to occur within this short period of cessation ‘During surgery, we will keep blood and blood products ready if any bleeding occur. ‘Before surgery, you'll be reviewed by MDT including Haematologist, cardiologist, Anaesthetistand surgeon to make sure you are safe for Sx ‘*During the surgery, the surgeon will cut into the large bowel, remove the damaged pockets or pouches, then reattach the remaining segments of the bowel. Third concern: Golostomiy is dreadful! | am going to have a colostomy bag for the rest of my life ‘*Sometimes, when the reattachment is impossible, the surgeon may create a colostomy which is a small hole that allows stool to exit through the stomach and requires the person to use a colostomy bag, ‘Colostomy —living with colostomy is much easier these days. The patient will just have to follow the instructions about the diet, medications and proper care. They are odor proof and no one will notice if they are not told. Fourth concern: Doctors are saying its elective and safe, but my mother died during elective operation as welll They were operating on her for cancer. ‘Everyone case is different and this procedure will be done by trait equipped hospital where all the facilities is there ‘For other drugs you are taking, you may continue till the evening before surgery. We may need to run blood tests and imaging before surgery. The bowels will be washed out with laxatives and enema. (antibiotics already given), ‘After surgery, the patient will be able to do normal activities within 1-2 weeks. 4 ed specialist and very well 26. respiratory system examination You are in GP, your next patient is 45 year old man with shortness of breath after recent viral URTI. Tasks —Perform respiratory system examination - Teach patient how to do peak flow meter. : Explain what u are testing to pt. 27. Pain in periumbilical plus PR bleeding PE 46Pein ems In the late stage of mesenteric ischaemia + Fever + hypotension + tachycardia + tachypnoea Extra for this case, + heart murmurs + regularity of the pulse Checklist intro GA and vitals Abdominal examination CVS just auscultation PR examination Differential diagnosis + Early/Late Mesenteric ischaemia + Diverticulitis + Intestinal perforation + Intestinal obstruction 28, Trigeminal neuralgia PE You are a GP and about to exai trigeminal neuralgia. Task Do relevant PE and running commentary to examiner 1e a 50 yr old lady who has been recently diagnosed with Feedback - Inspection ~ signs of infection, trauma, injury, muscle wasting, abnormal movement, eye Ptosis, enopth/exopth, - Trigeminal examination Sensory Corneal reflex Jaw jerk Masseter muscle and temporal muscle contraction (teeth clench) and muscle power (disposable wooden stick bite and attempt to withdrawal/ open mouth and try to close it) oo00 47Pein ems - To complete examination CN examination to exclude brain turor SEUSS (tone power reflex examination on both upper limbs and lower limbs 29. Scaphoid fracture PE Q: 25-year-old man works as a chef, he had a fall a few days ago from skateboard and has pain in his right hand. He came to see your colleague. X-ray was done and told it is a sprain. He come back today because of persistent pain Qyoung man fell from bike 2 days ago. X-ray done in ED no fractures seen. Discharged with painkillers now come back to ED with ongoing pain. Tasks: -physical examination of the hands explain x-ray to patient -explain diagno: -further x and Mx Visible # 48.Pein ems pediatrichand adult hand No visible # Positive findings (swelling at snuff box) Wrist jt movement - (painful extension and flex and radial deviation) Examination steps 1-Approach -Introduce and wash hands - lunderstand from the notes that you are complaining of pain in your right hand so how severe is it from 1-10, Would you like me to give you painkillers? All right before that do you have allergy to any medications. | will arrange a stronger painkiller for you. explain examination and consent -position hands on pillow and exposure 2-Look Dorsal aspect “sears -skin colour changes especially bruising -soft tissue/ joints swelling -muscle wasting Palmar aspect -scar (carpal tunnel release scar). 49Pein ems -thenar or hypothenar muscle wasting. -Contracture. Elbow -theumatoid nodules, gouty tophi. 3-Feel -Temperature + pulse (just present or not) tenderness and swelling normal hand then painful hand "wrist (RA) metatarsals MCP (RA) ®PIP (RA&OA) "DIP (RAROA) -palmar: fee for thenar and hypothenar muscle wasting 4-Move (limitation and pain) Active -wrist (4; extension, flexion, ulnar and radial) ‘move your wrists up then down then from side to side like this. -fingers (4; flexion, extension, abduction, adduction) make a fist then open your hand. Splay your fingers and push them together. -thumb (5; extension, flexion, abduction, adduction, opponents) point up to the ceiling, then down then outward then inwards then touch your little finger. Passive (wrist and fingers only) 5-special tests None 6-Function tests -grip power (put your finger and ask him not to let it out) -open jar -key (imagine you open the door) -safety pin or paper clip -writing ‘7-to complete exar ation - examine the joint above and below 50Pein ems Explain X-ray -this is the x-ray of your right hand, showing the bones of your right hand. *Itlooks normal, ‘* however from history and examination you most likely have fractured your scaphoid bone which is one of the small bones of the wrist (show it on the x-ray) ‘itis located on the thumb side of the wrist. Why I have been told no fracture despite severe pain? -that because the nature of this fracture is such that is often missed at first. Management ly may be so vague on x-ray so that it -what | am going to do for you now is to apply scaphoid plaster from below elbow to MCP including the thumb (arm pronation, wrist slight extension and radial deviation, thumb in mid abduction and fingers in can holding position) -{ will give you painkillers and -if the -if the x-ray come back positive then you will keep the (2 months) -avoid heavy lifting, pushing, pulling or any contact sport until fracture heals. -maintain full movement of the fingers through the recovery period to avoid any stiffness. -reading materials 51Geena eng -red flags (pain, numbness, tingling, swelling, colour changes, movement problems) Positive findings Provocative To 4 =o SE rae a ering sanafaune “aaperacar stage ceric atiamenan tes ; ee * Beil | 42 years woman complain of pain at the base of right thumb. Perform Physical ‘examination Explain diagnosis and differential diagnosis Check! 1. WIPEC 2. General appearance and vital signs 3. Look 4. Feel 5. Move 6. Check for each of three nerves (median, radial, ulnar) with specific movement and sensation 7. Special test 1, 2, 3, 4 the same items checked as the previous case but in wrist and thumb and fingers. Movement ~ same as previous case. Do all elbow, wrist, thumb. Power Fingers 52Pein ems 1. Grasp — "Could you please grasp my index finger and don’t let me take it out.” 2. Spread ~ “Could you please spread the fingers and don’t let me put them together” Specific tests and sensation for nerves Median nerve 1, Thumb abduction power “Could you please move your thumb away from index finger against my resistance with this pen torch? 2. Sensation ~ Index finger and thenar muscles Ulnar nerve 1. Froment's test — put a paper between patient’s thumb and index finger tell the patient not to let you take it out (Use the same fingers as patient to take it out) 2. Sensation — Little finger Radial 1. patient will come with wrist drop - Flex the elbow, pronate the forearm and extend the wrist and fingers 2. Sensi n — anatomical snuff box Special tests — 1. Finkielstein test — “make a fist with thumb inside and deviate it to the side of little finger” (reproduction of worsening of pain means positive. It is pathognomonic for aDeQuervain’s tenosynovitis” 2. Tinel test (T for T) Tap on the wrist. Check for the symptoms (Carpal tunnel syndrome) 3. Phalen test (Phalen test) Flexion of the wrist for 1 min and check for symptoms (Carpal tunnel syndrome) Explain -there are two tendons called abductor policies longus and extensor policies brevis pass through a tunnel in the wrist covered by fibrous tissue called extensor retinaculum that hold the tendons in place. When inflamed or swollen, the tendons become compressed against each 53Pein ems other because this retinaculum cannot extend this led to resisted and painful tendons and thumb movements. -possibilities: trauma, ganglion (nerve swelling causing compression) Management PRICE 2-NSAID 3-Physio 4-{f still symptomatic®™ steroid injection” if not improved (surgery release) 31. Rash/ haematological examination Young male with hx of sore that and flu like illness a month back now developed rash on lower limb (pic given _—_ outside) maculopapular, non blanchable rash ,not painful ,no fever joint pains nothing. Task, PE, Provisional Dx and DDS to the etl in It is purely a haematological examination anad before that you have to mention the photo first. Check the rash in the photo for © site, shape, color ~ redness that is Purpura, if purpura present, is that Petichiae (small spots less than 2mm) or Ecchymosis (large purple lesions) ‘© Types of configuration : discrete (which is indivial lesions clearly separated from ‘one another) or confluent (lesions merging together) or linear or discoid (coin shaped) or target © check whether blench on pressure or not (you can ask the examiner for that) Then do the haematological examination. © DRE for any bld loss 54Pein ems 32. Primary dysmenorrhea with simple ovarian cyst on USG You are a GP. You are going to see a 23 years old lady, Karen, coming to you with pain during period. In USG findings : there is a maturing follicle and endometrial thickness of 8mm. There is a cyst in right ovary measuring 2.5 cm. Pelvic examination not done. UPT negative. Your tasks : -Take history “Explain DDx -HOPC: First time? When did this pain begins? -Pain questions (where, when , Is that happening during the whole period or at the start of the period or before the period? how long, radiation, nature, continuous or intermittent, relieving, precipitating factors) -Associated features (differentials)-fever, (PID) discharge(PID), itchiness(infections), mass (Myoma), Dragging sensation down below? ‘Are you sexually active? Any chance that you get pregnant? (miscarriage, ectopic) Other symptoms (to exclude endometriosis)-Dyspareunia ~any pain during sexual intercourse? Dyschesia—Any pain while opening of the bowels? Dysuria ~Any pain while passing urine?(key q) -5 P -periods, Pills, partner, parity, pap test Past medical, surgical, SADMA ‘When did this ultrasound taken? (ans: two weeks after the period) Explanation —in your ultrasound, the endometrial thickness is 8mm, which is the thickness of the lining of the womb. This is the normal thickness in the middle of the cycle. Also, there is a mature follicle which means that this follicle which contains the egg. This follicle will rupture releasing the egg at the time of ovulation, which usually occurs two weeks before the period. ‘We also found an ovarian cyst in right ovary, which is a fluid-filled pocket in the ovary, which is most likely the functioning cyst containing the maturing follicle which is a normal occurrence. Your ovaries normally grows follicles each month which produces female hormones maintain the menstrual cycle. -DDx -the cause of your painful menstruation is most likely a primary dysmenorrhea. It’s the cramping pain that comes before or during the period. This pain is caused by natural chemicals (prostaglandins) released from the lining of the womb. This causes the muscles and blood vessels of the womb to contract causing the pain. When bleeding continues and the lining of the womb is shed, this chemical level falls so the pain lessen. -Other DDx endometriosis which is the wrong location of the inner womb lining on the other organs like ovaries and ligaments, adenomyosis which is the wrong location of inner womb lining on the outer surface of the womb, Myoma or fibroid which is the benign tumor in the womb. But all these are unlikely according to your history and ultrasound result. Or it could be PID which is an infection down below but less likely since you don’t have any discharge and your pain is not consistent. 33, Global developmental delay Mother comes to your GP clinic concerned that her 21 month old child has not started walking yet. Task 55.Pein ems History P/E -Advice on further management Rule out: UGenetic or hereditary cases eg: Downs syndrome. cerebral palsy Trauma Utumor Unfections Ospina bifida congenital hypothyroidism Epilepsy Umetabolic disease Uchild abuse Head lifting 3m, Reach andgrasps ‘Smiles .5m Cooing 3m Rolling 4m things 5m Sit with support 6m ‘Transfer 6m Recognize mum gm Babbling 6m Sit without support —_Pineer grasp 9m Eye contact 6m. 1. word 12m 8m Waves bye, clapping Crawling at 9 months: am Walking 12m Scribbles 18m Imitates 18m Uses 2 words phrase, name objects 24m History: Hil am Tasrifa, one of the drin this GP practice, how r u doing Susan? ‘© how long he is having this problem? © Developmental: + Gross motor: +ls he able to walk? +Is he able to stand by himself? *Can he sit without support/ with support? Can he roll over/ lift his head? Fine motor: *Does he reach and grasp things with his left hand? (usually happens at 5 months) *Can he use his three fingers to grab things? (pincer grasp) (usually happens at 9 months) Social: *Does he maintain eye contact? + Language: 56Pein ems *Does he say at least one meaningful word? (usually at age of 1) = If he is not able to, go backwards. Is he able to speak baba/dada (babbling) Birth: Cpregnancy —infections (TORCH) , medications , complications, smoking * How was your pregnancy with him? * Did you have any infection / any other complication during the pregnancy? delivery —How was the delivery? Term/preterm? Was it a normal vaginal or a caesarean section? Post partum —did he cry immediately after birth? Any resuscitation needed? Heel prick test done or not?(key Q) immunization Nutrition -how about her feeding? Any feeding problems? Drooling? Bowel habit? Waterworks? Rule out CP arching of back? Scissoring of legs? Rule out epilepsy -Any fits or jerky movements of limbs? Rule out Cong. hypothyroidism -high pitched cry, decrease activities, dry skin, umbilical hernias? Sleepy all the time? QHow about her vision and hearing? injury to the head/ back? CiAny headache? Early morning nausea/ vomiting? How is your home situation? Uo you have any family history of similar problem or any other illness? UPast medical / surgical problems CMmedication + allergies COFHxof such problem? Any other sibling having similar condition? P/E General appearance Posture of the child, dysmorphic features of down syndrome, scissoring of legs, spinal deformities, dry coarse skin, macroglossia vital signs + growth charts OThyroid examination (key point) abdomen -umbilical hernias Focused Neurologic examination inspection, Tone, Reflexes (key point) OPositive signs 1 o examine the back for any injury/ spina bifida Positive findings in this case were U-Significant Delay in 2 or more developmental milestones O-Growth chart Weight & height -S0th centile 87Pein ems HC-3rd centile Oxplanation From history and P/E, your child is having GDD, because its not just his walking is delayed, his language and fine motor skills are also delayed Ul'm also concerned about his head circumference which is lower compared to height and weight Quill refer to a pediatrician to do a full developmental assessment and screening tests for Metabolic diseases, Genetic testing, Endocrine studies, neuroimaging, EEG, Lead screening, hearing and vision, CT scans and psychological assessment Oar {showing empathetic to patient} 34, Alzheimer counselling ‘35-year-old lady comes to your GP clinic asking about her father who has recently been diagnosed with Alzheimer's disease. She is very concerned about her father and has many questions from you. The daughter has the father's permission to inquire about his condition. Tasks: Explain the condition -Answer her questions Alzheimer's disease is * an ° ° + that markedly interferes with ° ° itis an In AD, plaques develop in the hippocampus, a structure deep in the brain that helps to encode memories, and in other areas of the cerebral cortex that are used in thinking and making decisions. Causes/Risk factors: The exact EiSETSUARASWA. However, there are certain risk factors like * advancing age, © family history, © obesity * insulin resistance, * vascular factors, © dyslipidaemia, * hypertension, 58‘© inflammatory markers '* Down syndrome © traumatic brain injury ;, we will do some investigations like: Blood: TFT, and LFT CT scan: stroke, tumour PET: frontal lobe dementia EEF: Creutzfeldt-Jakob disease LP: NPH/syphilis, Treatment: Mild to moderate disease - Donepezil Severe disease - Memantine sstigmine, Galantamine Supportive treatment Diognosis of dementia requires evidence cf ‘AL Clear evidence of decline in memory and 59Aate-onset depression hypothyroidism Down ‘A 60 yur old was diagnosed with Alzheimer 3 weeks ago. His son wants discuss about father’s condition. Task Explain dx and possible complication Explain mx plan Exact cause of unknown Can occur at any age but commonly seen over 65 yr Usually present with Loss{of memory of things that’ve happened recently They can clear remember events in the past. Effect on other function 60Pein ems Poor power of reasoning and understanding Diff performing familial tasks Poor decision making and judgement Problem with thinking Some have emotion and behaviour changes ‘Wandering around in familial places Personality changes — being specious, withdrawal, aggressiveness, loss of skill Psychological problem Possible complication Because of poor memory, ‘+ wandering and go out and could not able to remember way back home and get lost ‘* There is always likelihood of accident with house hold items with fire gas knife and hot water * Alot of pt with Alzheimer had ‘+ Without proper supervision, they are likely to have poor self-care, develop infection and skin ulcer ‘* Moreover, poor nutrition, leaking of bowel and water Alzheimer is chronic and lifelong, it is not easy to look after daily. Really appreciate you came today and discuss about your father = - As your GP, will regularly visit = Family meeting if you agree for tender loving care - Will provide contact for special support group (Alzheimer d/s and special support group) Risk factors- Cause is uncertain - But if there family h/o, increase chance of having the same problem = Down $ have also risk 35. Compartment $ PE HIMO at ED, young man in his 20s was here due to a motor vehicle accident. Primary and secondary surveys were done, he swollen left leg and a series of X-rays were done. The X-ray with positive findings is given and a picture showing open wound on the left leg. Tasks: -Perform relevant physical examination on the lower leg of the patient. -Explain to the patient what you are doing, Not to remove the bandage on the patient's leg. -Explain the X ray to the patient -Explain to the patient about further immediate management * Start with WIPE approach = HN stability and = General luvk. - Pt lying down (comfortable/ in distress) In moderate pain no bleeding from any part * Inspection of Leg | can see bandage trom knee to ankle which is blood stained. | would like to remove the bandage and Inspect the leg open / closed wound diffuse bruising and swelling on the shin color change of the foot (Pallor/Cyanosis) - Active bleeding 62Greet: “Temperature (Cool Periphery) CRT (Poor Circulation) Pulse (Circulation) ‘Tenderness ( Skip the tenderness of fractured area as he is in severe pain. check in specific muscles of compartments like 1* webspace for Ant. Comp, Dorsum of foot for Lat., and sole and calf muscle for post. Comp.) Muscles for Ant. Comp=> ‘= = tibialis anterior * extensor hallucis longus * extensor digitorum longus Lateral compartment= * peroneus longus = peroneus brevis CMOVEMENT: Dorsiflexion( ant compartment), plantar flexion( post compartment), eversion ( lateral compartment), inversion breat 1oe movement: passive extension of great toe Patientunable lo move: can you wiggle your oes? If patient permits you can check power in these specific muscles to rule out PARALYSISI! OSENSATION: 14,15 if handaged, if not then 17-81 4 web space ( deep peroneal)="9 ant compartment Dorsum of foot ( Sup peroneal) lateral Sole ( tibial) > posterior Finish with full secondary survey and chest exam to exclude any fat embolism 63QEExplain: + Ihave examined you and your sensations of foot is intact, movements cannot be elicited due to pain + Pulses are good and the CRFT is good + This type of fracture can cause a complication called compartment syndrome where the pressure increase inside the leg with bleeding + However my examination doesn’t show that you have it * Will splint the limb + Call ortho reg * Will rv you and the Xray * Most likely will do an open surgery to fix the bones + Pain medication Olf features of Compartment Syndrome: * Call ortho registrar = Put on IV line, fluid and send for blood = Tetanus immunization + IV antibiotic * Specialist most likely cut the skin to relieve the pressure = Then surgery to fix the broken bone 64Online format QUES: You are a HMO in ED. A 30 years old male had a motor vehicle accident brought in ambulance in emergency department. His x-ray shows left tibia fibula fracture, severely cormminuted. It has been stabilized by orthopedics surgeon but he has been complaining severe pain in the fracture site even after adequate analgesia. You are suspecting compartment syndrome. There is a medical student with you. Task: Explain to medical student how you will examine this patient with anatomical landmarks and what you are looking for in. such a patient of compartment syndrome. Explail " Hi John, | am X, one of the HMO in this hospital. It’s very nice to meet you. *So, which year you are in currently? (4th Year). That's great, it must be so exciting for you. Well, | am very glad to show you one of my patient today. = 50, we have a 30 years old patient presented with severely comminuted fracture of the left tibia and fibula after motor vehicle accident. Although It has been stabilized by orthopedics surgeon but he has been complaining severe pain in the fracture sile even afler adequale analgesia. So we are suspecting the possibility of compartment syndrome. | am going to discuss with you on how to examine a patient like this . If you do not understand at any point, please do not hesitate to ask me again. * So Compartment syndrome is a serious condition that occurs when there's an increased amount of pressure inside a muscle compartment. Compartments are groups of muscle tissue, blood vessels, and nerves in our arms and legs surrounded by a very strong membrane called the fascia, Fascia does not expand, so in case of swelling/ bleeding such as due to lower limb fracture can result in an increased amount of pressure inside the compartment. This results in injury to the muscles, blood vessels, and nerves inside the compartment and most importantly it can cut off blood flow to the compartment. This can result in loss of oxygen going to the tissues. (ischemia) and cellular death (necrosis). *To diagnose this early we look for few signs and symptoms like pain, pallor, Paresthesia, paralysis and pulselessness. So we will be looking for these findings during our examination. Are you with me so far? 65.= Now, before we start examining, we need to wash our hands, introduce ourselves, take a proper consent about the procedure of the examination and request for an adequate exposure of the examining part which is in this case the lower limbs. = Next, we should offer him some painkiller as he is in pain now. (making sure he does not have any allergy to it) = also we should ensure if he is vitally stable by checking fly BP, PR, RR, S202 and Temp. first. "Then we will start with general appearance to see if he is comfortable or in distress, If he is alert or confused, if there is any active bleeding from th site or if there is any other visible injury or sign of trauma anywhere else in the body. "= Then we will do inspection of the inj it and look for whether it is open or closed wound, any diffuse bruising or swelling on the injured site, any change in color like Pallor or Cyanosis that can suggest poor peripheral circulation. Pallor is ‘specially important as it’s a sign of compartment syndrome. + After that we will do palpation, (use previous notes for detailed explanation) co Temperature (Cool Periphery suggests poor peripheral circulation) © CRT (Poor Circulation) © Pulse (Circulation) : lack of pulse or poor pulse isa sign of C.S. o Tenderness: As patient is already in severe pain, we can skip checking for tenderness over the fractured site. But, to check for Compartment Syndrome, we can palpate specific muscles of the compartments like 1st webspace for Ant. Comp, Dorsum of foot for Lat. comp, and sole and calf muscle for post. Comp. We will skip it if patient complains severe pain, We will also feel for any firm swelling of these compartments as it can suggest increased pressure inside. 66= Then we will do movement of the muscles of each compartment. Lower leg has 3 main compartments: anterior, Posterior and Lateral. (if you have time you can discuss the muscles of each compartment here). To check for anterior compartment we will do dorsiflexion of the ankle, for post compartment we will check plantar flexion and for lateral compartment we will check eversion of the foot. If patient is able to do active movement, we will also assess the power of these muscles by asking the patient to do these specific movements against resistance. Pain or weakness during movement also suggests C.S. ® Also, If patient is unable to do active movement, we will da passive extensian af great tae which can be very painful if there is compartment syndrome, so we should inform the pal ask him to wiggle his toes nt before doing this test. If patient is unable to do any movement, then we will just = Then we will check for any paresthesia or loss of sensation In these compartments by cotton wool and pin prick. We will first touch his sternum with the cotton wool so that he can sense it. Then with his eyes closed we will check the deep peroneal nerve sensation on 1 web space for Ant Comp, Sup peroneal nerve sensation on the dorsum of foot for lateral comp and tibial nerve sensation on the sole for Post Compartment, Paresthesia or loss of sensation is also a sign of C.S. "Finally if our PE goes with possible CS, we can confirm it by checking the intercompartmental pressure by a manometer. + We will finish the examination by full secondary and lertiary survey ay well CVS and Respiratory system. = Lastly we will discuss our fin urgent management of the con igs to the patient, thank him and reassure him about the 36. Clavicle fracture Ques: Young male with fall and inability to move the arm and pain in shoulder. TASK: Explain Xray and possible implication QExamine the pt for any possible complication UDo immediate mx 67Pein ems Possible implications: “Injury to vessels “Injury to nerves “injury to lung Examination: Qwire Qvitals arrange painkiller UGA: distressed due to pain LILOOK: “Front: shoulders at the same level No SSRRBMD No step deformity/ skin tenting No discoloration of hand ‘Side: shoulder contour is maintained FEEL: CRT, Pulse, Temperature, Tenderness OMOVE: painful movement Do wiggling of the fingers Osensation: Axillary Nerve (C5) Qduscultation of lung apex How to make triangular sling for pt 68.CMANAGEMENT: Dou have broken your collar bone but its good that your vessels and nerves are intact. We have put you on this sling which u need to use for 7-10 days will give u more painkillers Ury to move your fingers everyday so that stiffness doesn’t occur Dull recovery in 2-4 weeks Review in 24 hours Gar 37. Wrist cut injury PE 30 years old male came with a knife injury at the flexor aspect of the left wrist. Bleeding has stopped with pressure Task Teach medical student about PE with anatomical landmark Dx with reason 69Pein ems Positive findings on movement > Wrist flexion and extension — loss of wrist flexion > Finger flexion and extension, abduction and adduction — loss of finger flexion > Thumb movement ~ flexion, extension, abduction, adduction, opposition (loss of thumb flexion, adduction, abduction and opposition) > Check for tendon injury — FOP and FDS Positive findings on sensation > Loss of sensation in median and ulnar nerve distribution Pen touch test 4ve “> Froment sign +ve Introduce with the med student Will check for vessel (temp, CRT), nerve, muscle, tendon. WIPE Assess vital Arrange painkiller * Palmar ‘© There is a longitudinal cut wound at the wrist about 5 cm in size, no active bleeding, no thenar/ hypothenar wasting, normal finger posture is lost © Dorsal © No swelling, scar, redness, rash, bony deformity, muscle wasting, no sign of trauma, no nail changes Feel (check on normal side first) ‘© Tem (looking for reduced temp in wrist cut injury in case of deprivation of vascular supply) ‘* Pulse (if there is pain, check at no pain area) 70