Professional Documents
Culture Documents
2: Vitamin B 12 Deficiency
3: Visual Disturbance (Amaurosis Fugax)
4: Transient Ischemic Attack (TIA)
5: Weakness in right arm and leg (Subdural Hematoma)
6: Subarachnoid Hemorrhage
7: Acute Vertigo (PICA)
8: Acute Stroke Counseling
9: Seizure And Subdural Hematoma
10: Acute Brain Syndrome/Acute Confusion/Delirium
11: Hyponatremia Delirium HIDEMAP
12: Hyponatremia (Delirium)
13: Acute confusion in a Postoperative Patient (Delirium Tremens)?Post
surgery Delirium
14: Delirium After Burn Injury(Book 134):
15: Delirium (Digoxin Toxicity)
16: Multiple Sclerosis (Optic Retrobulbar Neuritis) Do it later
17: Multiple sclerosis
18: Cervical Spondylosis with C6 or C7 disc Prolapse
19: Encephalitis
21: Assessment of a comatose patient
22: Recurrent Falls/Assessment of Mechanical Falls
1:
Task
History
PEx:
History
Physical examination
Diagnosis
Management
Do you need some painkillers? Since when are you having this
pain? How bad is it?
What type of pain is it? Is it pulsating, throbbing or a dull ache?
Is it one sided of all over your head?
When the pain starts, where does it start first?
How does it progress? is it aggravated by movement, noise or
light?
Do you get any symptoms before the headache starts for
example visual problems, changes in your sense of smell,
nausea or vomiting? Is this the first time?
How many episodes have you had previously? How long does it
last?
What relieves your pain? Is it worse in the morning? did you
have fever recently?
Any infection recently? Do you feel numbness or weakness in
any part of your body? Did you hurt yourself in your head?
Do you think your headache is related to food especially red
wine, cheese, chocolate, bananas, Chinese food, coffee?
How's your general health?
Any history of HPN or DM? What is your occupation?
Any stress at work or home? Any financial problems recently?
How are your periods?
When was your LMP? OCP?
Do you think your headaches are related to your periods?
Any family history of migraines? SADMA?
DDx:
Mx:
2:
o
DDx:
o
o
o
o
o
o
o
o
o
o
o
o
Investigation
Physical examination
Features
o
o
o
o
o
o
o
o
o
o
History
o
Investigations:
o FBE: Hgb low and MCV high
o Vitamin B 12 low and folate level normal
o Iron studies
o Intrinsic factor antibody level + diagnostic
o LFTs, TFTs, RFTs
Dx and Mx:
o From the history and PE, you have anemia caused by
vitamin B 12 deficiency which caused the neurological
symptoms. I will refer you to the hematologist and
neurologist for further evaluation and management.
o The treatment is replacement of vitamin B12 1000mcg
injected intramuscularly every 2-3 days. The body stores
can be recovered after 10-15 injections and maintenance is
1000mcg every third month. If there is poor intake, oral
vitamin B12 may also be given. I will also give you oral
folate 5mg as co-therapy.
o The prognosis depends on how long the person had
symptoms and if it is in the first few weeks of the
symptoms, complete recovery usually occurs and if it is
delayed (>1-2months), it might not recover completely. If
left untreated, it can result in progressive and irreversible
damage to the nervous system
3:
You are an HMO and a 50-year-old woman is in the ED with complaint of loss of
vision. She has past history of bypass surgery 2 years ago. She is hypertensive and
is on ACE inhibitors.
Task
o History
Physical examination
o
Features
o
o
o
o
History
o
Mx:
o
Tx:
o
<60% ASA
60-70% may or may not undergo carotid
endarterectomy
>70% carotid endarterectomy
Symptomatic
<30% ASA
>30% carotid end-arterectomy
Bypass
4:
Variant 1:
Trevor, aged 65 years presents to your GP clinic with his wife Margaret. He tells you
he had funny turn this morning. He has completely recovered and made the
appointment at his wifes insistence. He says he first noticed something was wrong
when he answered the telephone call from his sister and found it difficult to speak.
His wife reports that his words were muddled and he had difficulty making him
understand. She thought he seemed confused at that time.
Task
o
o
o
Variant 2:
You are in ED and a 60-years-old woman comes to you complaining of left arm
weakness.
Task
o History
o Physical examination
o Management
Variant 3:
A 60-year-old female came to the GP clinic with weakness of the right leg. She has
diabetes type I which is well controlled.
Task
o Relevant history
o Physical examination
History
o
CHADS SCORE
o major stroke risk factors in people who have atrial
fibrillation
o CHF (1)
o Hypertension (1)
o Age >75 (1)
o DM (1)
o Stroke/TIA (2)
0 low aspirin (81-325mg)
1 Intermediate aspirin or warfarin
>2 high risk - warfarin
5:
A 60-year-old man is in the ED where youre working as an HMO where he is
complaining of weakness of his right arms and legs.
Task
o History
o Physical Examination
o Diagnosis and management
Risk factors
o Elderly patient brain shrinks (cerebral atrophy)
o Dementia
o Alcoholic
o Warfarin
o Head injury (recurrent falls)
Symptoms
o Weakness or numbness
o Headache bending forward or when coughing or when
changing head direction
o Confusion
o Drowsiness
o Personality changes
o Amnesia
o Seizures
History
o Can you tell me more about what happened? Is it getting
worse or improving? Any change in your vision? Any
problem with speech? Did you have any recent head
injury? How did it happen? Any headache after that? Any
N/V/changes in personality? Drowsiness or confusion?
Episodes of fits? Difficulty in walking or ataxia? Any past
history of heart disease, stroke, DM, increased lipids?
Medications? Do you have enough support?
Physical examination
o General appearance
o Vital signs
o Eyes
o CVS
o CNS examination
o BSL and dipstick
Management
o Subdural hematoma because of the head injury and you
are also taking warfarin.
o Admit. Referral to neurologist and CT scan.
o Baseline laboratory examination including clotting profile
and INR.
Treatment
o Small: careful observation until it heals by itself or
temporary insertion of a small catheter and suctioning the
hematoma
o Large: craniotomy
6:
Variant 1:
A 36-year-old male patient is in the ED with sudden pain on the back of the head
while working in the fields. It is not relieved by Paracetamol.
History
Physical examination
o Management
Variant 2:
Rosemarie aged 27 years presents to your surgery with history of headache for last
couple of month. She describes headache as feeling funny around her mouth then
flashing bright lights, then a pounding headache always on right side of her head.
The headache could last for several hours sometimes relieved by vomiting. For a
few days afterwards, she feels tired and just a bit off. She had tried pain killers like
panadol and ibuprofen with minimal relief. She is otherwise fit and healthy and has
no previous medical problems and is not on any medications.
Task:
o Focused history
o Physical examination
o Diagnosis and management advise
DDx:
o Migraine
o Subarachnoid Hemorrhage:
o
o
o
o
History
o
Trauma
Task
o
(Epidural)
Subdural hemorrhage
Tension headache
Tumors
Can you tell me a bit more about it? When did it occur?
How severe? Where? Does it go anywhere (neck)?
Character? N/V? Is it progressive? Is it the first time? Does
anything make it worse? Photophobia?
7:
You are working in a primary care facility attached to a teaching hospital and a 50year-old man is consulting you about intense dizziness. He is a previous patient who
is overweight, and he is on medications for control of hypertension and
hyperlipidemia. He appears unwell and distressed with slight drooping of left eyelid.
His wife drove him to the hospital.
Task
o History
o
DDx:
o
o
o
o
o
o
o
PEx:
History
o
o
o
8:
A 60-years-old man is brought by his wife to the ED complaining of acute onset of
weakness and numbness of the left side of the body and aphasia/dysphasia 1 hour
ago. The symptoms are still present. He has a history of hypertension and a
pacemaker was inserted a few years ago for heart block. His wife wants to discuss
his condition with you.
Task
Explain the situation to the wife
Explain about management plan and possible outcome
Answer her questions
Counseling
Is my patient hemodynamically stable?
Does the wife have a SPA or consent to discuss her husbands
condition?
I understand that you are quite worried about your husband, but let
me assure that he is in safe hands and we will do our best to help
and treat his condition. Before anything else, do you have any
particular concern that I can address? I will explain the condition,
cause, risks and followup.
Most likely he has a condition called stroke. It is a condition in which
part of our brain stops functioning due to disturbance in the blood
supply to that area of the brain (Draw diagram). The lack of blood
flow can be due to blockage of the vessels by a clot which is a
thrombus or embolus or leakage of blood which is called
hemorrhage. This in turn leads to the symptoms that your husband is
having now.
There are certain risk factors for this to happen: hypertension,
diabetes, smoking, aspirin/warfarin, head injury, peripheral vascular
disease, lifestyle, dyslipidemia
Ask about contraindication to thrombolysis: bleeding disorder or
recent surgery, warfarin/ASA
It is a serious condition and is a medical emergency so he needs to
be admitted to the stroke unit ASAP to stabilize his condition. He will
be assessed by a neurologist who will order some investigations. The
most important is non-contrast CT scan or MRI to see the type of the
stroke and other investigations like FBE, lipid profile, ECG, U&E,
LFTs, RFTs, echocardiography.
If it turns out to be ischemic stroke, he might be put on ASA and if
within 3 hours of onset, a substance called rTPA can be used to
9:
You are a GP in a small rural town and are asked to see a 22-year-old man who
collapsed about an hour ago. He has now fully recovered.
Task:
o Relevant history to try to determine the cause of the
collapse
o Ask examiner for relevant physical findings
o Explain to the patients what you this has likely happened
and what it your immediate plan of action
Differential Diagnosis
o HOCM - rare?
o Vasovagal syncope
o Infection?
o DM (hypoglycemia)
o Trauma?
o Neuro problems?
o Cardiac?
Focused History
o When? Feeling of chest pain? Palpitations? Fever?
Headache? History of trauma? Blurring of vision? Previous
loss of consciousness? Changes in personality? LOC?
Vomiting?
o Ask for patients wife to describe scenario and take
relevant history
o PMHx/SADMA
Physical Findings: all normal: ask for fundoscopic findings
Dx:
o Most likely this is a case of subdural hematoma which may
have resulted from the accident you had. Veins from the
brain bleed out which form a clot which if big enough may
have caused you to have a fit and lose consciousness.
Management:
o Skull x-ray and CT scan
o FBE, UEC,
o Urgent referral to a neurosurgeon/neurologist
Syncopal disorders:
o Common causes: cardiogenic disorders and postural
o hypotension, which are usually drug-induced; vasovagal
o
o
10:
Variant 1:
Your next patient in GP practice is an 85-year-old woman who was brought by her
daughter because her mother was acutely confused over the past few days. (one
case with DM and one with UTI)
Task
History
o (3 days and patient unable to recognize anyone,
wondering around the house and at times became
incontinent, + dark, cloud and smelly urine, on
medications for BP and cholesterol)
Explain plan of management
Vatiant 2:
Your next patient Mrs. Gladys George brought to your surgery by the staff from a
Low level nursing facility. Mrs. George moved to the Nursing home one month ago,
after being discharged from an old aged care psychiatry unit. Before her admission,
she had been living independently at home. The precipitant for her admission was a
fire in her flat. When the fire departments arrived Mrs. George was running around
the premises of the building claiming she was Messiah and the blaze was started by
demons. She was to taken to the hospital and was treated at an old age psychiatry
unit. She had normal blood tests and MRI brain showed generalized atrophy
consistent with age. The nursing staff thinks she had lost some weight. She had
been wandering the halls at night on few occasions. She is agitated and seems
confused. On one occasion she asked the staff are the Russians here yet -. One
of the nurses think Mrs. George has been seeing some things.
o Task
o How will you manage Mrs. George
Variant 3:
(Feb 4, 2012): An elderly whos confused and has SOB is admitted in the rural
hospital where youre working which is 300km away from the city. ECG and CXR
showed right-sided heart failure. In the blood test, no abnormalities were detected.
The daughter wants to talk to you.
Task
o Talk to the daughter
o Counsel accordingly
o (LHF SOB sec. backflow of blood into lungs and patient
cannot breathe properly)
o Sit upright, start furosemide to remove fluids CPAP if
not working
o Start high flow oxygen, explain about heart failure
o Arrange cardiology consultation;
o Investigation: Transthoracic Echocardiography to measure
ventricular function
Advice: Low-salt low fat diet, ideal weight, stop smoking/alcohol,
control HTN, DM and lipids; ACEI, diuretic, beta-blockers when
stabilized
no indications to transfer to hospital
Features
Onset
Duration
Delirium
Rapid
Hours to weeks
Dementia
Slow insidious
Months to years
Course over 24
hours
Consciousness
Perception
Fluctuates worse at
night
Reduced
Misperceptions
common (esp. visual)
Common (visual)
usually or auditory
Distractable
Minimal variation
Acute Psychosis
Rapid
Depends on response to
treatment
Minimal variation
Alert
Misperception rare
Alert
May be misperception
Uncommon
Normal to impaired
Variable, may be
incoherent
One or both present
Difficulty finding
correct words
Often absent
Variable may be
impaired
Variable: normal, rapid or
slow
Usually absent
Hallucinations
Attention
Speech
Organic Illness
or drug toxicity
Causes:
o Depression/Drugs/alcohol
o Ears/Eyes
o Metabolic (hyponatreamia, diabetes, hypothyroidism)
o Emotion/encephalopathy (loneliness)
o Nutrition (Vitamin B12/diet)
o Trauma/tumor
o Infections
o Arteriovascular disease (CVA, MI)
Investigations:
o LFTs, BSL, TSH, FBE, Blood culture, U&E, CXR, CT scan,
urine MCS, ECG
Hx:
o What do you mean confused?
o Did she have any fever?
o Lumps or bumps?
o Any headaches or early morning vomiting?
o Did she lose consciousness at any time? Any weakness in
any part of the body or any problem with speech? Any
chest pain or shortness of breath?
o How about her appetite and weight?
o Has she lost any weight? Any weather preference? Any
swelling all over the body? Any medical illnesses like
diabetes or hypertension? SADMA? Any recent change in
11)
An 83-year-old man developed strange behavior, confusion and disorientation for
the last couple of days. He lives in the nursing home. He is on some drugs:
Indapamide (hyponatremia, hypokalemia, hyperglycemia), statin, imipramine. His
physical examination is unremarkable. BSL is also normal. Blood test has done:
Sodium 120mmol/L, Potassium 4.5mmol, Urea is normal, Creatinine is normal.
Task
o Explain the test results to the daughter, and the possible
causes of his confusion.
Low sodium level (135-145mEq/L)
Pseudo hyponatremia:
o Cause: DM If the sugar is high: Hyperglycemia.
The fluid is high the sodium seems to be low but its
normal.
Osmolality Formula:
o 2 X Na + GGlu/18 + BUN/2.8
If the glucose/sodium is high the osmolality is high. High
osmolality hyponatremia
If the osmolality is normal: True hyponatremia sodium goes
low because of low osmolality.
Causes: look for the extracellular FLUID volume.
If ECF volume: HIGH
o Cardiac failure, nephrotic syndrome, kidney/liver
failure
o Low: external causes: vomiting, diarrhea, blood loss,
burns, sweating.
Renal causes:
Nephropathy, losing water along
with sodium. Anti-diuretic hormone
causes the losing of the sodium.
Drug:
Indapamide: Its not losing salt but it
is losing the water.
Counseling
Patient is having hyponatremic encephalopathy. When people
have hyponatremia, it is going to give symptoms in the CNS.
Symptoms come with sudden drop of the sodium.
Isotonic/hypertonic. If the sodium drops slowly the fluid
becomes hypertonic. Fluid always goes to the higher
concentration thus losing the water which then goes to the
cells especially the brain cells. It causes herniation of the brain.
If we give the sodium too quickly, the cells will shrink quickly
and the brain is going to die which is called central pontine
myelinolysis. Dont replace it too quickly 0.5-1 mEq/hr.
Inx:
o
Mx:
o
CCF:
Patient comes with confusion: If the patient has fever, problem with
urine, Any sepsis, Any edema
12:
Your next patient in GP practice is an elderly man with a long history of
hypertension and diabetes. He has developed tiredness, confusion, and hes
behaving strangely for the last 2 days. Investigations show sodium is 120,
potassium, chloride, bicarbonate, Urea and creatinine are all normal.
Task
At this stage, I will call the ambulance because your father needs
urgent treatment. In the hospital he will be reviewed by a medical
registrar. IV lines will be secured and blood taken for further
investigations. They will start him on IV fluids (PNSS or hypertonic
saline 3% for rapid correction). A cranial CT scan will also be
organized.
13:
You are an orthopedic resident called by the ward NOD to see a 65-year-old man
who had a left knee replacement 2 days ago. He had been quite okay until today
where he seemed to be confused, restless and agitated. He had become verbally
aggressive and wants to pull out his drip and go home. His vital signs are BP
130/90, PR 102 regular, T 38.3, RR: 30. Cardiorespiratory examination is difficult
because patient is not cooperative. Per abdomen examination reveals some lower
abdomen tenderness. CNS examination is normal as far as you can assess. You
found the patient to be slightly confused and disoriented to time, place and person.
You could not do the whole MMSE because of lack of cooperation. ECG is normal
and you have asked the nurse to send the blood for troponin. Reviewing the medical
record, you note that the patient is drinking 6 cans of beer per day. His preoperative
biochemistry was normal except for elevated GGT, Hgb 120, MCV 110 with normal
b12 and folate.
Task
(Condition 149): You are an intern called to the ward to see a patient who became
acutely confused after a left total knee replacement. A few hours earlier, he started
to behave in an irrational manner, became agitated and difficult to manage. Until this
stage he had been making an uneventful postoperative recovery. His confusion has
now culminated in the patient being disoriented, noisy, and difficult to restrain. The
patients wife is with the patient and she has been unable to help.
Task
A 60-years-old man became restless and shouting in the postop ward. He had knee
replacement this morning and was uneventful. Morphine was given to relieve his
pain. Investigations were done are results are pending. Patient has hallucinations
and delusions and MMSE shows that hes disoriented. He has history of drinking 4-6
cans of beer every night.
Task
Assess situation
Is my patient hemodynamically stable? I would like to start with
DRABC and call for help and restrain patient as per hospital
protocol.
Ensure and assess DANGER (physical restraints); DRABC
Institute pulse oximetry and put in high-flow oxygen.
14:
You are a night intern in a general hospital and your next patient is a 25-year-old
male student with 20% partial thickness burn sustained when throwing fuel over fire.
The burns involving all the limbs are being managed conservatively and have been
dressed under IV ketamine. You have been called because the patient is unable to
sleep, restless and distressed and has pulled out the IV line delivering patientcontrolled analgesia which is morphine 1mg/hr.
Task
History
15:
Your next patient in ED is a 70-year-old male brought in by ambulance because his
son found him with worsening confusion and complaining of worsening nausea
during his weekly visit. He is slightly demented but managed to live alone at his
home with some help from meals on wheels and district nurse coming 2x per
week.
Task
Features:
Precautions:
History
o (confusion, unable to recognize him, did not skip
meals, no fever, headache, problem with heart rhythm
and HTN on medications with digoxin, and fluid
tablets/water pill; problem with vision)
Physical examination
o (VS normal except pulse is irregular, CNS
unremarkable, chest, lungs and abdomen normal,
urine dipstick negative, BSL normal)
Investigation
o (FBE normal, urine microscopy and normal, U&E
(potassium increased, sodium normal, ABG), CT scan
normal, RFTs normal, CXR negative, ECG showing
AF), Digoxin level increased!!! HyperkalemiaArrythmia
Diagnosis and management
narrow therapeutic range
indications: CHF & AF
optimum dose with ACEI, loop diuretics and beta-blocker
Contraindications: HOCM, WPW
Cause hyperkalemia cardiac arrhythmias deaths
Elderly patient
Ischemia
Previous MI
Hypothyroidism
Increased calcium, decreased magnesium
16:
Mandy aged 35 years presents to your GP clinic. She tells you that she had
intermittent blurring of vision for the last few weeks. She attributed this to stress at
work and had not asked for help but yesterday evening she had similar episodes.
She is otherwise fit and healthy. Mandy works as secretary in an office and has to
work every day form 8-5.
Task
Focused history
o (2 episodes, 30 pack years, lasting few minutes, no
PMHx)
Physical examination
o (looks well, 130/80, vitals normal, 80 minutes, regular,
BMI 27; VA: R eye 6/12, L 6/6, visual fields normal;
EOM normal; funduscopy blurring of disc margin in
right side, no carotid bruit)
Differential diagnosis and management advise
Differential Diagnosis
Atypical Migraine (without headache)
TIA
Multiple sclerosis
Neurosyphilis
Toxins
Retrobulbar Neuritis
Usually woman with 20-40 years
Loss of vision in one eye over a few days
Retro-ocular discomfort with eye movements
Variable visual acuity
Usual central field loss (central scotoma)
Afferent pupil defect on affected side
Ophthalmoscopy:
Optic disc swollen if inflammation anterior in nerve
Optic atrophy appears later
Disc pallor is invariable sequel
Investigation:
MRI
Lumbar puncture (oligloconal IgG in 80%)
Visual evoked potentials: 80%
Management:
Test visual field of other eye; consider MRI; most recover
spontaneously but with diminished vision
17:
You are an HMO in ED and a 35-year-old woman presented with 2 weeks history of
visual disturbances and pins and needles in the left hand and difficulty walking.
Task
o
History
o
o
Features
o
o
o
o
o
o
o
o
o
o
Treatment: Principles:
o All patients should be referred to neurologist for confirmation of
diagnosis.
o Rule out depression and anxiety.
Acute attacks:
o Corticosteroids (methylprednisolone 1gm over 5 days) and plasma
exchange Disease-modifying therapy
o Severe: immunosuppresants (MTX, AZT, Cladribine, fingolimod)
Prevention of relapse:
o Interferon
o Glatiramer (mimic myelin)
o Natalizumab
o Prednisolone 75mg once a day for 4 day or 50mg for 4 days.
o If severe relapses (optic neuritis , brain stem signs): Hospitalized. IV
therapy: methyl prednisolone 1 g in 200mL of saline daily for 3-5
days
o For long term: methotrexate with folic acid or Cyclophosphamide.
o Refer to neurologist
o Refer to psychologist
o Refer to physiotherapist if with spasticity
o Support groups
o * In classical trigeminal neuralgia only severe pain; but if with
sensory multiple sclerosis
History
o I understand from the notes you have visual problems. What do you
mean by visual disturbances? Doctor theres blur vision, I cannot
identify colors. Sometimes I have double vision as well.
o Is it getting worse? Yes.
o I also understand you have pins and needles in your left arm is it
associated with weakness? Yes.
o Do you have weakness anywhere else in your body? Yes weakness
in my right leg as well. Is it difficult to walk? Yes when I walk I fall to
one side, I had a few falls. Any Headache N/V? No. Any pain
anywhere? Especially your eyes? Yes. Any neck stiffness? No. How
about the water works? I cant control my bladder (urinary urgency).
How about the bowel? Good no problem. Any past medical history?
Same happen 10 years ago. Anything runs in the family? Myasthenia
Gravis. Single, smoker, artist. Drinks alcohol occasionally
Physical Examination
o General appearance: She is distress.
o No facial abnormality. Facial palsy drooping of eye lids
o Eye: Ophthalmoplegia, visual acuity is decreased, visual fields are
normal, theres double vision, pupils are normal. Fundoscopy: Optic
neuritis/atrophy.
o Cranial nerves: Id also like to check 5 to 12. No abnormality for all
other cranial nerve.
o Neurological examination of the upper and lower limbs: Spastic
paraparesis in lower limb, increase reflexes, impaired coordination,
(Heel and the shin test). Lower limbs: Theres impaired sensation.
Gait: ataxic gait.
Diagnosis and Management
o Jane, from history and examination I suspect you have a condition
called MS but to confirm the diagnosis Id like to order some
investigation and refer you to the neurologist for further assessment
investigation: lumbar puncture, Visual evoke potential, MRI.
o If this is MS, it is an autoimmune disorder. Whats happening is
demyelination (Nerve cells covered by sheath and it got destroyed).
Its uncommon. More common in women, this disease has classical
relapse and remission. Typically presents with pins and needles,
bladder dysfunction etc. Depending on where the demyelination is in
the brain. It is a serious condition but dont worry we will help you. It
is not curable but manageable. Our aim is to slow the progression of
the disease and increase the period btw relapses. Most likely the
neurologist will put you on long term immune suppressants. Acute
phases handled by steroid.
o Refer to neurologist. Review frequently. Reading material
o Red flags: Vision and other symptoms come up.
Critical Errors:
o Not referring to neurologist
o Not doing MRI and Fundoscopy
18:
Variant 1:
A middle-aged woman comes to your GP practice complaining of pain in the right
shoulder associated with neck pain.
Task
o
Focused History
After 6 minutes, the examiner will stop you and you need to
explain diagnosis and differential diagnosis and advise
further investigation
Variant 2:
You are a GP and a middle-aged lady came in with shoulder pain for the last few
days.
Task
o History
Physical examination
o
History
o
NR
C5
C6
C7
C8
T1
DDx:
o Disc prolapse due to cervical spondylosis
o Ankylosing spondylitis
o Rheumatoid arthritis
o Traumatic strain or sprain
o Myopathy level C6
Diagnosis and Management
o From my examination finding, its most likely youre
suffering from a degenerative condition with C6
compression due to disc prolapse consistent with cervical
spondylosis
o PRICE/heat/massage/warm hydrotherapy
o Investigation: FBE, ESR, CRP, rheumatoid factor, HLA B27
antigen, CT or MRI cervical spine
o I need to refer you to orthopedic surgeon
o Painkillers (NSAIDs x 2 weeks) and neck collar (especially
at night; limited time)
o Physiotherapy
o Steroids
o Surgery: limited role. Indications are: intractable pain or
with neurologic deficit.
19:
You are working in ED and an 18-year-old male patient is brought in by his friend
because of confusion and agitation since the last 12 hours. He also had an episode
of seizure during this time. On examination, his GCS is 14, temperature is 38.5C,
BP 140/90, PR 90/minute and RR 18. Neck stiffness is negative. Lumbar puncture
has been done and results are as follows: Glucose level normal, protein increased,
Gram stain negative, cell: lymphocytes 90%.
Task:
Explain results of LP to friend
Diagnosis and Differential Diagnosis
Management
Encephalitis: meningitis + brain parenchyma
Altered mental status/confusion/irrational
Focal neurological deficits
Seizures
Predominant in meningitis
Photophobia
Neck stiffness
Vomiting
DDx:
Meningitis
Delirium
Electrolyte Imbalance (Hypo/Hyperglycemia)
Brain abscess
SOL
Substance abuse
Head injury
Organisms: mostly virus especially Herpes Simplex Virus
Investigation:
CT/MRI: cerebral edema
Lumbar puncture: predominantly lymphocytes (90%)
PCR of CSF
EEG
20:
A 30-year-old man is referred to your GP clinic as he is diagnosed with idiopathic
epilepsy by his neurologist. He has been put on sodium valproate for treatment. He
is a courier driver and getting married very soon.
Task
Features
Sodium valproate:
o hair loss, rare but serious liver toxicity (LFTs every 2
months for 6 months after starting), NTD (spina bifida)
Phenytoin:
o ginigival hyperplasia, hirsutism, fetal malformation (cleft lip
and palate), CHD
Carbamazepine:
o anorexia, nausea, vomiting, dizziness, skin rash, tinnitus,
diplopia, ataxia, tiredness and fatigue; safest in pregnancy
21:
Task
o
o
o
DDx:
o
o
o
o
o
Meningitis/encephalitis
CVA (SAH, stroke)
Epilepsy
Trauma
Drug/alcohol overdose (sedative hypnotics, tranquilizer,
alcohol, antipsychotics)
o Diabetic hyper/hypoglycemia, hypothyroidism, uremia,
hepatic coma
o Multiorgan failure (adrenal)
o CO narcosis
o Psychiatric problem
Examination
o Inspection for any bruises, lumps/bumps, bleeding, signs of
trauma (raccoon eyes, battle sign, bleeding from ears,
nose), jaundice, facial asymmetry,
o CHECK PEARL (miosis: pontine lesions, opioid overdose;
dilated: raised ICP; signs of multiorgan failure, funduscopy
for raised ICP and diabetic/HTN changes), neck stiffness,
mouth for tongue bite marks
o Face: breathing pattern (metabolic acidosis DKA,
hypoventilation, drug overdose),
o Smell of the breath
DKA: fruity smell,
22:
A 70-year-old man comes in your GP clinic because of recurrent falls. He had stroke
7 years ago and had weakness of left lower limb.
o
o
Task
o
History
o
o
o
Task 2
o
o
DDx:
o
o
o
o
o
o
o
o
o
o
Hx:
o
o
o
o
o
o
o
o
Physical examination
Provisional and Differential diagnoses
Management
o
o
o
Stroke
Dementia/delirium/Depression
Epilepsy
Hearing (vestibulococchlear)
Vision
CVS (arrhythmia, MI, anemia, BP)
Chest (PE)
GIT(bleeding and diabetes)
Musculoskeletal
PMHx: Medications: Polypharmacy
Can you tell me more about it?
Can you describe these falls for me?
You had a stroke 4 years ago. How is your general health after that?
Did you feel dizzy, lightheadedness or fainting before the fall? Any
LOC in any episode?
Did you injure/hurt yourself? What did you do after you fell down?
Did you notice any weakness or numbness of your body? Any
slurring of speech? Any BOV? Any shaking or jerking of your body?
Did you bite your tongue or wet yourself?
Do you have any problem with your memory?
How is your mood lately? Any problem with hearing or vision?
PEx:
General appearance: anemia, dehydration, jaundice
Vital signs: POSTURAL DROP (drop of 15mmHg systolic or
10mmHg diastolic)
o Neurologic: gait, tone, power, reflexes, coordination, sensation
o Eyes: Visual acuity, eye movements, visual fields fundoscopy
o CVS: Carotid Bruit, Apex Beat, Murmurs
o Abdomen
Management:
o Most common cause of your recurrent falls is postural hypotension
which is sudden change in blood pressure by changing position. In
your case, this is most likely due to polypharmacy. It is important to
change them or reduce the medications.
o I would refer you to the fall clinic where you will be seen by MDT and
assessment team.
o Investigations: FBE, UEC, Ct scan, MSU, LFTs, ECG, etc..
o Your BP will be monitored regularly.
o Refer to ophtha and ENT for vision and hearing tests.
o Occupational therapists
o Physiotherapist (strenghtening exercises)
o Social worker (financial, meals-on-wheels)
o Admit and refer to falls clinic.
o
o
History
Differential diagnosis to Examiner