Discussion in 'AMC Clinical Exam' started by gOOD sAMARITIAN, Sep 28, 2006.

  1. MEDICINE & SURGERY (2001/2002/2003) Stage 1 & 2

    History taking 2 Neck lump 65 Meniscus/Knee 119 3 Post-trauma. SD 67 Conversion dis. 121
    Pneumothorax 5 Ac. Appendicitis 68 Psychiatric Hx 122
    Asthma 6 Renal colic 69 Panic disorder 123
    Break. bad news 9 Meningitis 70 Anxiety 124
    Bronchial ca 10 Perforated PU 72 Mania 125
    PE 11 Peptic ulcer 73 Depression 126
    Cor pulmonale 12 Mumps/Measles 75 HIP pain 128
    Pneumonia 12 Mononucleosis 76 De Quervain 128
    SOB/Lung Ca 13 PMR 77 AML 129
    CVS exam. 14 R. Oesophagitis 77 Hypothyroidism 130
    Mitral regurg.15 Ulc. colitis 79 Thyroid Ca. 132
    Aortic stenosis 16 Addison’s dis. 80 Thyroid gl. exam 133
    Endocarditis 17 Haemorrhoids 81 Tremor 134
    Sy. sclerosis 20 PVD/Claudication 82 Plantar fasciitis 134
    Cranial nerves 21 Diverticular dis. 84 Fluid balance 135
    Neurolog. ex. 24 Thalassemia 85 HIV 136
    Alcoholism 25 Hydrocele 86 Clavicle fracture 138
    Hep. C 27 Epididymo-orch. 87 Coma 138
    Hodgkin ly. 28 Testicular Ca. 88 Post MI Mx 140
    DVT 29 BHP 89 Wrist injury 140
    AF 30 Prostate Ca. 90 Tiredness 141
    Isch. Colitis 32 Migraine 90 GI exam. 142
    Parkinson 33 SAH 92 Cirrhosis 145
    SCH 35 Alopecia areata 93 Ascites 146
    Gout 37 Psoriasis 94 Portal HTN 147
    Alzheimer dis. 38 Mastalgia 95 Hernia 148
    Cholecystitis 40 Breast exam. 95 Epilepsy 149
    Sciatica pain 42 Ac. urin. retention 98 Osgood-Schl. 151
    Disc prolapse 44 Rot. cuff syn. 99 Carpal tunnel 152
    Aortic aneurism 45 Shoulder exam. 99 Varicose veins 152
    Colon Ca 46 Osteoarthritis 101 Venous ulcer 155
    Stoma care 48 Osteoporosis 103 Parotid tumours 156
    Ptosis & Dizz. 50 Dyspepsia 104 Amaurosis/TIA 157
    Cerebellar ex. 52 Hiatus hernia 105 Lower limb ex. 158
    TA 52 GORD 106 Bell’s palsy 161
    Gonorrheae 52 Sterilization 106 Tuberculosis 162
    IBS 53 Diarrhoea 108 Colle’s fracture 163
    Bulimia nervosa 54 Coeliac dis. 109 Neck pain 164
    Anorexia 55 Chest pain 109 H/chromatosis 166
    Hypertension 56 Angina pectoris 111 Genital Herpes 167
    Peanut allergy 59 MI 112
    RA 60 Pyelonephritis 113
    Fe def. anaemia 63 UTI 113
    Sprained ankle 64 DM 114

    Taking a history

    Greet & Introduce yourself first: Good afternoon Mr. Jones? How do you do? My name is Dr. X.Y.
    Presenting complaint: What seems to be trouble Mr Jones?
    History of presenting illness (HPI): When did it start? What was the fist thing noticed? Progress since then. Have you ever had it before?
    “ SOCRATES†questions : Site, Onset (gradual/sudden), Character, Radiation, Associations (eg.nausea, sweating) Timing of pain/duration, Exacerbating /alleviating factors, Severity (on the scale 1-10 where 10 is worst like labour if woman).
    Past medical history (PMH): Have you ever been in hospital? Operations? Ask specifically about DM, asthma, bronchitis, TBC, jaundice, rheumatic fever, high BP, heart disease, stroke, epilepsy?
    Medication/Allergies: Do you taking any tablets or medicine or injection Mr. Jones? COC for Ms. Jones Any OTD medicine like aspirin etc?
    Sexual /menstrual history (LMP): relevant in abdominal pain, vaginal/urethral discharge. Is it possible for you to be pregnant?
    Social and family history (SH/FH):Tell me about things at the home? .Marital status. Tell me about things at the work? Occupation. Who does cooking and shopping? What you cannot do because of illness? eg. unable to use bath, toilet, dress. How do you manage? Are your parents alive? If dead/ what was the cause of death? Any disease in the family? Heart disease, malignancies, TBC,DM?
    Alcohol, recreational drugs, tobacco: How much? How long? When stopped?
    General question: (more significant in TB or cancer): Have your lost any weight recently? Night sweats. Any lumps? How is your appetite? Fever. Itch.
    System review
    CVS/RS: Have you noticed your heart racing or beating irregularly? /palpitations Oedema? Are you ever short of breath? Do you ever have wheezing when you are SOB? Have you had any cough? Do you cough up anything? Sputum, blood
    GI system: Have you had any pain/discomfort in your belly? (Constant or colicky, sharp or dull, site, radiation, duration, onset, severity, relationship to eating and bowel action, alleviating/aggravating or associated factor .Are you troubled by indigestion? How is your bowel habit? Any blood in your motion/stool? colour.
    Genitourinary system: How is your water work? Any difficulty or pain on passing urine? Is urine stream as good as it used to be? Is there are delay B4 you start? or dribbling at the end? (those questions apply mostly to men). Has the urine colour changed? Have you seen blood in urine? Any venereal disease? UTI or kidney stone?
    Musculoskeletal system :Any pain, stiffness, swelling of the joints.
    Endocrine system Have you noticed any swelling in your neck? Hands tremble. Do you prefer cold or hot weather? Sweating, fatigue, voice, and thirst?
    Neurological system :Do you get headache? Do your arms and legs works? /weakness Do you have trouble seeing or hearing ?

    Is there are anything else you think I should know? (or you want to talk about)
    Problem list: S.O.A.P. : S-subjective O-objective A-assessment P -plan

    Respiratory System Examination:

    This is a Mrs. Jones. She came in with an increasing shortness of breath. Please examine her RS.  Hello Mrs. Jones. Thank you for letting me to examine your chest. SMILE ! ☺☼ Look around for sputum mug, IV line, medication, puffers, and flow meters.
    General appearance: SOB at rest, tachypnoea (RR=14 resp/min=N), cachectic, cyanosed.
    Cough: muffled wheeze ineffective cough =airflow limitations, bovine =vocal cord paralysis( recurrent laryngeal nerve palsy ), a very loos, productive = exc. bronchial secretion due to chr. bronchitis, pneumonia, bronchiectasia. Dry, irritating cough = chest inf. asthma, Ca, ACE . Do you coughing? How long?
    Stridor: obstruction of larynx, trachea or large airways due to foreign body, tumour, and infection/epiglottitis. Sudden onset of stridor> anaphylaxis, toxic gas inhalation, acute epiglottitis, inhaled foreign body. Gradual onset: tumour/vocal cord palsy
    NB. Require urgent attention.
    Hoarseness: recurrent laryngeal n. palsy associated with a lung ca /usually left sided, or laryngeal ca. However commonest is laryngitis.). Are you coughing up anything? Sputum or blood? I would like to know if the pt. has been febrile.
    Position & Exposure - Mrs. Jones could you sit on the edge of the bed please and take off your shirt?
    HANDS  Can I have a look at your hands? For signs of clubbing, peripheral cyanosis, nicotine stains (Are you smoker? How much do you smoke?), HPO=lung ca. mesothelioma. Are you sore anywhere here? Could you put your hand out like this? Asterixis /flapping tremor = CO2 retention due chr. airflow limitation/severe COAD. Wasting ,weakness – finger abduction/adduction T1 = lung Ca. involving the brachial plexus C8-T2.
    Pulse ( N= 60-100/min)- Tachycardia + pulsus paradoxus = severe asthma. Pulsus paradoxus = BP fall during inspiration > 10mmHg, occur with constrictive pericarditis, pericardial effusion or severe asthma.
    FACE : for pallor, ptosis, and Horner’s sy, now open your mouth for me. Poke out your tongue. Look for central cyanosis (= pneumonia, COAD, PE,). Thank you, that is fine. Look for dental hygiene.
    TRACHEA : Look for tracheal deviation (significant displacement suggest but is not specific for disease of upper lobe of the lung, towards lesion -collapse/fibrosis, away from lesion – pleural effusion/tension pneumothorax.
    Tracheal tug = trachea move inferiorly with inspiration=gross overexpansion of the chest /airflow obstruction.) : I am going to feel your windpipe. It might be a bit uncomfortable. Tank you. Examine node : I am going to feel glands in your neck.
    CHEST : I am going to examine your chest/back > inspect (scars & deformities of spine/kyphoscoliosis,), percusses, auscultate, test for vocal resonance. Palpate Chest expansion > Can you take a deep breath in and out. Thumbs moved > 5cm .(Reduced chest exp. On one side= plum. Fibrosis, consolidation, collapse, pleural effusion pneumothorax, (bilateral=diffuse abnormality, Chronic Airflow Limitation/diffuse pulm. Fibrosis). Thank you again. Great.
    percuss > I am going to tap your back. Normal lung structure=resonant note, over solid structure /liver or consolidates lung = dull note, over fluid-filled area/pleural effusion=extremely dull (stony dull) note, over hollow area/pneumothorax= hyper resonant note.
    Auscultate > normal = vesicular breath sounds, bronchial breath sounds = occurs where normal lung tissue become firm or solid, eg. lung consolidation/lobar pneumonia or above pleural effusion, reduced  - emphysema, effusion, pneumothorax, pneumonia, large neoplasm.
    Continuous (wheezes/rhonchi) = airway narrowing / asthma.
    Interrupted (crackles/crepitations) = fine/pulmonary oedema, coarse/ bronchiectasis.
    Vocal resonance: Could you say “99†for me? I touch your back. Thank you. Audible over consolidation, over normal lung=muffled. Ask pt. to cough. Could you cough for me? Thanks.
    I would like to examine heart (pulmonary component of P2. If louder – pulmo. hypertension suspected. There may be sign of RVF or hypertension. Pulmonary hypertensive heart disease/ cor pulmonale may be due to CAL, p. fibrosis, p. thromboembolism, marked obesity, sleep apnoea abdomen: > liver ptosis due to emphysema or enlargement from secondaries deposits of tumour. Pemberton sign’s sign > lift arms over head, wait for one min. + if plethora, cyanosis, insp. Stridor = SVC obstruction /mediastinal compression-lung Ca (90%). Also I would like to check lower limbs for oedema, cyanosis (clue to cor pulmonale) etc. Doctor helps pt. get dressed. Can I help you with your top? Thanks Mrs. Jones. All the best.
    Discus with examiner> e.g., I believe this lady has a pulmonary fibrosis based on clubbing, cyanosis, and bill. Fine inspiratory crackles the lung bases.

    Bedside assessment of lung function.
    FET (forced exp. time): exhale forcefully after maximum inspiration. N= 3sec or les. If increased indicate airway obstruction, Combination of smoking history + FET > 6 s indicate CAL. Peak flow meter is more accurate.
    PEFR =depends largely on airways diameter. It is max. forced expiration through peak flow meter. It is used to estimate airway calibre. Should be measured regularly in asthmatics to monitor response to therapy and disease control.
    Normal M=600 ltr/min F=400 ltr/min
    Spirometry measures functional lung volumes : FEV = volume of air expelled from the lungs into spirometer (Vitalograph) after maximum inspiration using maximum forced effort in one second (FEV1).
    FVC = total volume of air expelled from the lung after maximum inspiration using maximum forced effort. The FVC is nearly the same as vital capacity but in airways, obstruction may be reduced because of premature airways closure.
    FEV1/FVC ratio – N= 80 % in young, decline with age (60% in old age) Ratio is reduced in obstructive defect like asthma or COPD (emphysema/pink puffers, chronic bronchitis/blue bloaters). In restrictive defect like pulmonary fibrosis, plural effusion FEV1/FVC is normal (even increased). No lung disease if FEV1/FVC ratio ~ 75 %
    Pulse oximetry: assessment of peripheral O2 saturation. On most pulse, oximeter alarm is set at 90%. A PaO2 < 80% is abnormal and action is required.

    Horner’s sy = pupil constriction /miosis, sunken eyes/enophthalmos, ptosis, ipsilateral loss of sweating /anhidrosis due to interruption of the face’s sympathetic supply - eg. At the brainstem (demyelination, vascular disease), cord (syringomyelia, thoracic outlet tumour (Pancoast’s sy. =apical lung ca + ipsilateral Horner’s)

    1.A 24 y.o. man comes with shortness of breath( dyspnoea). Dx. PNEUMOTHORAX

    Dyspnoea  subjective sensation of shortness of breath (SOB), often exacerbated by exertion. Graded I – IV, I = dyspnoea on heavy exertion, II = on moderate, III = minimal, IV = at rest. (New York Heart ass. classification). Speed of onset helps Dx. ACUTE > FB, pneumothorax, acute asthma, PE, acute pulmonary oedema, SUBACUTE > Asthma, parenchymal disease (alveolitis, effusion, pneumonia,) CHRONIC > COPD and chronic parenchymal disease (pulmonary fibrosis) or non-rep. Causes, e.g. cardiac failure, anaemia. Cardiac causes of dyspnoea: mitral stenosis or LVF of any cause. LVF assoc. with orthopnea (dyspnoea worse on lying, how many pillows?) paroxysmal nocturnal dyspnoea (waking one up) nocturnal cough ( pink frothy sputum); wheeze (cardiac “asthma). Other causes: thyrotoxicosis, ketoacidosis, aspirin poisoning, or psychogenic (look for peripheral  perioral paresthesia).LH/pulmo, RH/venous.

    Pneumothorax air in the pleural cavity (leakage from the lung) or a chest wall puncture. > ½ cases are due to trauma of some kind (rib fracture, penetrating chest injury, during pleural aspiration). The rest are spontaneous –subpleural bullae rupture in tall, young, healthy male (usually < 40), COPD (usually > 40 y.o) TBC, Ca, etc. Presentation: sudden onset of pleuritic chest pain, or increased breathlessness  pallor and tachycardia. Signs; no symptoms if small. Reduced expansion, resonant percussion note, diminished breath sound on affected side. Mx. . Refer to CXR ( ►► not waste time if it tension pneumothorax is suspected!). Small resolve spontaneously. May not require treatment. Pt. may be discharged if no significant dyspnoea, no PH of pneumothorax, no lung disease. Repeat CXR for 7-10 days. Do ABG in dyspnoeic pt. and those with chronic lung disease. Moderate pneumothorax (lung collapsed ½ way towards heart border)- aspirate and check the resolution on the CXR post-aspiration and after 24 hours. Complete pneumothorax (airless lung)- aspirate and check the resolution on the CXR post-aspiration and after 24 hours. needs to be aspirated. Insert cannula 16 G into 4th- 6th intercostal space in the midaxillary line. (Infiltrate with 1% lignocaine B4 that). Connect cannula to 3-way tap and 50 ml syringe. Aspirate up to 2.5 L of air (50ml x50). Stop if resistance is felt or pt. cough excessively. Do CXR to confirm resolution of pneumothorax. Repeat after 24 h and after 7-10 days. If aspiration is unsuccessful, insert standard intercostal drain with connection to underwater seal drainage. Remove IC drainage 12-24 h after cessation of drainage. First clamp for several hours, do CXR and then remove.
    When is drainage of pneumothorax indicated? For larger pneumothorax > 30% pleural area and persistent dyspnoea.
    Tension pneumothorax : can be rapidly fatal. A valvular mechanism develops – air is sucked into the pleural space during inspiration but cannot be expelled during expiration. The pressure within pleural space increase, the lung deflates further, mediastinum shifts to the opposite side, kinking and compressing great veins and reduce venous return. Signs: resp. distress, tachycardia, hypotension, distended neck veins. Mx. Insert a large bore needle 16 G into 2nd intercostal space in the midclavicular line
    ►► Do it B4 requesting a CXR!

    2. A 19-year-old patient coughing for the last 4 weeks. TASK: Do respiratory system physical exam

    3. A 35-year-old men, 3 weeks history of night cough, not respond on antibiotics treatment or cough mixture. Q. What is most probable Dx? ASTHMA . Do relevant examination. RS= N. Q What you will expect on auscultation? Inspiratory & expiratory wheezes, prolonged expiration. Signs of asthma: tachypnoea, wheeze, hyper inflated chest, hyper resonant percussion note, reduced and air entry. Q What else you will do? PEFR (demonstrate that). Discuss spirometry values.

    4.A 60 y.o. Man truck driver, heavy smoker, COPD, wheeze, Task: Explain condition to the pat. Give ASTHMA Mx. Plan.
    Explain: how to use spacer, puffer /MDI, flow meter (Pt. Education) Q. What is PEF ? Can I use O2 at home? Yes, you can. - Stop smoking; see does asthma improves when he is not driving –related air pollutants, gases, and vapours. Change occupation.
    ors, lignocaine etc.

    5. A 24 y.o. man suffers a severe ASTHMA ATTACK. He wants to go home. He is a painter. PFR = 500 L/min. He has H/O atopic eczema when he was child.:

    6. Asbestosis - occupational history, hoarseness, Horner’s sy. mediastinum shifted, right sided pleural effusion, bronchoscopy, lavage, mediastinoscopy, sputum exam, talk to pt.- BREAKING THE BAD NEWS

    7. A 50-55 years old school teacher, new pt. Married, living with spouse, and three teenage children. HPI: Hoarseness ( could be laryngitis, vocal cord tumour or recurrent laryngeal nerve / n. vagus) for 2 –3 weeks. No other problems. Occasional morning cough but not worried about it. He is still teaching student at school, and he thinks they can hear him. He is not taking any medication for hoarseness. From history: thyroidectomy 6 years ago, he is on Thyroxine. No H/O heart disease, Happy family, smoker, 10-15 cig/day. O/E: healthy man, normal BMI, normal vital, no clubbing, wasting face is normal.

    8.A 60-year-old man had a lump as shown in the picture. (Picture showed enlarged supraclavicular LN) The FNAC showed moderately differentiated squamous cell carcinoma. TASK: Talk to patient to clarify any possible causes and perform relevant examination. Explain him your plan. Most likely cause is: BRONCHIAL CARCINOMA (or skin ca, oesophageal ca – very rarely) Asked about: hemoptysis, cough, smoking etc. O/E: Hands: clubbing, nicotine stains, T1 lesion, wrist tenderness (pulmonary osteoarthropathy), Face – Horner’s sy. Lungs – pleural effusion. Test; CXR, bronchoscopy, CT etc

    9. A middle aged fat lady presents with a chest pain. Pain getting worse on deep breathing. H/O previous DVT. O/E: NAD Dx. PULMONARY EMBOLISM

    10 . Mrs. John undergoes laparoscopic cholecystectomy 10 days ago. She was discharged from hospital. On 10th day, she suffered chest pain, dyspnoea, and the lung scan showing Pulmonary Embolism. Her ECG shows sinus tachycardia and RBBB. She is in ICU, improving. Her husband came to you to ask about her condition.
    What medication is for PE? Warfarin. How often? What dose?

    11. Middle aged man presents with a SOB and swelling of the legs. TASK: Examine his RS. DX. COR PULMONALE

    12.A young man with a fever. Examine his RS. O/E:  ask for cough (non-productive), sputum > sputum with blood and mucus (pus like), the rest of examination is unremarkable. Q. What do you think? PNEUMONIA What are clinical futures of pneumonia? What Ix you want to perform? CXR. He showed 2 CXR and asked me to describe the X-Ray. (1 with the consolidation on the left lower lobe and the other normal which is said to be done 2 weeks later). Why there is no other abnormalities detected? Could be due to treatment.

    13. A45 years old with a SHORTNESS OF BREATH for a few weeks. (If female ask for PAP). She has yellow discoloration of fingers and nails, smoker, non-alcoholic. Father had emphysema Occupation, works in the timbre industry.
    O/E: clubbing, nicotine staining of the fingers, reduced expansion, dullness, breath sounds decreased percussion note – dull, vocal resonance reduced. P/E: Liver enlarged 6 cm bellow costal margins, & liver dullness. CXR= obliteration of CPL, Pleural tap. Dx. Pleural effusion due to malignancy (LUNG CARCINOMA) Bronchoscopy,

    14. A 55 y.o. man presents with shortness of breath ( breathlessness) for 3 weeks .Clerk , smoking 20-25 cig/day for a 30 years, no ROH. I read the paper & wrote a few things. From history: SOB started, a 3 weeks ago, gradually increased, now severe, couldn’t walk even short distance, day & night, no PND/ orthopnea, no wheezing. Mild cough. No phlegm, no haemoptysis, rt. Sided chest pain increased with respiration. No intermittent claudication, no other illnesses. Occasional bronchitis, not significant. FH – emphysema not familiar. Father died of gallbladder disease, not on regular medication, no known allergy, SH: smoker O/E: mild clubbing, RR=40/min, O2 sat reduced, HR=120/min, no tracheal tug / IC recession. Trachea slightly deviated to the left. Apex shifted to left anterior axillary line. Reduced movement on the right side, percussion note: dull RMZ, liver dullness 6 cm bellow costal margin, and vocal resonance prominent. Air reduced RMZ + RLZ. Crepitations? rhonchi
    Q. What is Dx? Pleural effusion most probably due to Ca of bronchus. Q. What Ix? Blood, ABG, FBC & blood film, EUC, CXR – immediately I have been told CXR result. Bronchoscopy. Q. What are causes for SOB in this pt? Ca bronchus itself, irritation to the pleura, pleural effusion. Q. What is Mx? Drainage –aspiration or intercostal drain. (4-6th IC space)

    15. A 65-year-old man found to have a heart murmur 2 years ago on routine exam. Now he wants to go abroad. Coming for a review. Task: Examine his CVS system.
    Introduced. Position the patient (45) Routine examination. Dx. MITRAL REGURGITATION with early left heart failure DD: MI with papillary muscle dysfunction / rupture of chordae tendineae .LVH

    16. A middle age lady, examine her CVS. Findings: AF, small volume pulse, JVP =5 cm, displaced apex and volume overloaded. soft S1, soft pansystolic murmur on the apex radiating to the axilla, LL oedema; moderate to severe MITRAL REGURGITATION. Question asked: What are the signs of severity? Small volume pulse enlarged left ventricle (the more severe/the larger the left ventricle), loud S3, soft S1, signs of pulm.hypertension. What are causes? What is investigation? (X-ray was shown)

    17. This patient present with murmur. TASK: Examine his CVS

    Pansystolic murmur = Mitral regurgitation/incompetence, Tricuspid regurgitation
    Midsystolic murmur = Aortic stenosis, pulmonary stenosis
    Late systolic = mitral valve prolapse

    Early diastolic =aortic regurgitation
    Mid-diastolic = mitral stenosis

    Presystolic = mitral stenosis

    Always refer for echocardiographic confirmation.
    Some murmurs are easily heard by bringing the relevant part of the heart closer to the stethoscope, eg. mitral stenosis in left lateral position, aortic regurgitation by leaning forward. The bell is good for hearing low-pitched sound in mitral stenosis. The diaphragm is better for hearing high-pitched murmur of aortic regurgitation.

    18. A middle-aged man with increasing chest pain. TASK: Examine his CVS and present your diagnosis. Dx. AORTIC STENOSIS DD: Mi, Infective endocarditis, TR. Other DD: cardiomyopathy. Usual way of CVS examination (at 45 angle). Asked whether comfortable, or pain in any area. AF- Diagnosis? BP= 150/70 mmHg (wide pulse pr-AR), JVP – pulsation – MR. Which one is reliable to diagnose AF, heart or pulse?

    Aortic stenosis/ aortic valve disease aortic valve is 2cm². Significant narrowing restricts LV output and impose pressure load on the left ventricle. Commonest cause is senile calcifications (particularly in elderly), congenital, rheumatic fever. Symptoms are exertional chest pain/ angina (50% do not have coronary art. disease), exertional dyspnoea, and syncope. Examination: small volume pulse (parvus), low/narrow pulse pressure (difference between systolic and diastolic BP) harsh mydsystolic ejection murmur maximal over aortic area, which radiates to carotids, is characteristic. Test: ECG – P mitrale, Left Ventricular Hypertrophy, Left axis deviation/left anterior hemiblock, CXR: LVH, ECHO (Doppler) is diagnostic and can estimate the gradient over the valve. Severe stenosis is valve area < 1 cm², or valve gradient > 50 mmHg. Mx. Symptomatic pt. have poor prognosis;2-3 years survival if angina /syncope. Refer to cardiologist. Surgery is indicated for those with syncope if systolic gradient across the valve > 50 mmHg (valve replacement or transcutaneous valvuloplasty). DDX: HOCM Avoid treatment with ACE inhibitors. Endocarditis/antibiotic prophylaxis. Symptomatic pt. poor prognosis. 2-3 y. survival if angina/syncope. The triad- angina/dyspnoea/blackout or light-headedness – indicates aortic stenosis particularly if on exertion.

    19. A 57 y.o. man had syncopal attack when he was playing golf. He suddenly felt down, lost his consciousness. He had past history of TA. Dx. Aortic Stenosis, Vasovagal, epilepsy, Adam-stokes syn.

    AS : S.A.D. - S-yncope A-ngina D-yspnoea
    Sign of severity: splitting of S2 (due to delayed aortic valve closure), S4, aortic thrill, valve area < 1 cm2 or valve gradient > 50 mm. Signs of severity of A.S. are less reliable in elderly.

    20. A 25 years old man comes with a WEAKNESS & FATIGUE.
    From history  fever, lethargy, and tiredness. He is pale, PH: hypertension, unmarried, taking antihypertensives, smoker 15 cig/day, he had some dental work recently. Dx. INFECTIVE ENDOCARDITIS. (SBE)

    Fever + new murmur = Infective endocarditis until proven otherwise. General signs: fever, weight loss, pallor/anaemia. Hands: splinter haemorrhage/fingers or toenails, clubbing (within 6 weeks of onset), Osler’s node/painful pulp infarct in fingers or toes-rare. Check arms for IV drug use (right /and left endocarditis can results from this). NB: Inf. endocarditis without cardiac murmur is frequently seen in IV drug user who develop infection on tricuspid /Rt. valve. Splenomegaly Urine analysis: microscopic hematuria/red cell cast on microscopy. Glomerulonephritis/RF may occur. Cardiac lesion: Vegetation may cause valve destruction and cause severe regurgitation. LVF is common cause of death. Causes: any cause of bacteraemia eg. dental work, UTI, urinary catheterisation, cystoscopy, RTI, Colon Ca, gall bladder disease, IV cannulation, surgery, abortion. Quite often, no cause is found. Streptococcus viridans is commonest (35-50%), Staphylococcus aureus (20%, but causes 50% of acute form) Candida/Aspergillus (IV drug users). Other causes; SLE, malignancy
    Ix. Golden rule- blood culture for every pt. that has a fever and heart murmur. Blood culture is positive in ~ 75 %. Take at least 3 sets of samples, aerobic/anaerobic. FBC: normochromic normocytic anaemia, leukocytosis, ESR/CRP increased, Urine: proteinuria and microscopic hematuria. Echocardiography to visualise vegetations/but only if they are > 2mm, CXR: cardiomegaly, ECG: prolonged P-R interval. Mx. Acute medical admission if suspected. Inform cardiologist/microbiologist. Antibiotics IV for at least 2 weeks. Empirical Th: Benzylpeniccilin 1.8g/4 h + Gentamycin 2mg/kg/8hr + Flucloxacillin 2g/4 hr. Further therapy adjust therapy accordingly to culture. Treatment is usually prolonged 4-6 weeks. Surgery/Valve replacement may be required esp. if endocarditis on prosthetic valve.
    Prognosis: mortality from 6% /sensitive streptococcus up to - 30% if staphylococci.
    Prevention: Anyone with congenital, rheumatic valve disease or prosthetic valve is at risk of developing infective endocarditis and should take prophylaxis prior any procedure that might cause bacteraemia. Require prophylaxis: dental work, surgery/excluding skin surgery, and lower GI or GU endoscopy. Give prophylaxis in high-risk group (PH of endocarditis & prosthetic valve) for normal delivery, insertion of IUCD, urethral catheter. NOT requiring prophylaxis  insertion of IV cannula, phlebotomy, and cervical smear. Low risk pt/no prosthetic valve or PH of endocarditis – Amoxicillin 3g orally, 1hour B4 procedure. If hyper sensitive to amoxicillin then vancomycin. In high-risk group Ampicillin 1g. IV or IM + Gentamycin 2mg/kg.

    21. (Option 1) A 58-60 year old man comes with a c/o a bilateral leg oedema (ankle swelling) for couple a weeks. Otherwise, he is in the good health. Personal history= no smoking, FH: mother died from stroke. Further history revealed: Recently from a long bus trip, he developed bilateral leg swelling. Swelling increased at bedtime less in the morning. No breathing problem, no sleep disturbances, no weight gain, happy family. O/E: pulse irregularly irregular pulse (AF), BP=160/90 mmHg. JVP=6cm (Ox 78, increased if > 4 cm) Tricuspid region/ left sternal border- systolic murmur not radiating anywhere. Liver - not enlarged or pulsatile. Basal crepitations are not present (I asked twice) No ascites, spleen is no palpable. Lower limbs=no redness, no tenderness. Oedema above the calf muscle. Peripheral pulses are present. Ix. FBC, Serum urea electrolyte, urinary analysis, CXR – Rt. ventricle enlarged, ECG – irregularly irregular pulse ECHO-not available. Q. What is ECHO? Ultrasound non-invasive technique used to asses heart function and anatomy as well. Used for quantification of global LV function, estimating right heart hemodynamics, valve disease, CHD, endocarditis, pericardial effusion HOCM. Gated pool nuclear scan= not available. Q. What id Dg? Heart failure. Other DD? So, what is a problem? I explained detailed mechanism of heart failure. Then I told – I will refer you to the cardiologist for further assessment and treatment Q. If you are in remote area what do you think? I sad probably the vascular problem. So, what is your concern? AF – patient has irregularly irregular pulse. So clot can arise any time can obstruct blood vessel - mesenteric artery, brain, anywhere. I will consider anticoagulant. Then suddenly pt. asked: OK doc, now tell me what actually is my problem? I said: You have  BP. But, I am fine doc? Some people are asymptomatic

    Option 2. An 56 y.o. man with comes with ankle swelling. He is non – smoker, non-alcoholic. Mother died of stroke. Long bus trip recently. No chest pain. Some abnormality on heart beat. Irregular beat. Played tennis B4, not now. Use two pillows at sleep/orthopnea(-LVF)-. All has been last 3 months. No cough, no fever.
    O/E: Pulse 84/min, BP: 160/94 mm/Hg. , no cyanosis, no pallor. CVP= 3 cm. Apex shift six mid axillar, no tapping, no heavy soft pan, not conduction to axilla, no S3, S4. Basal crepitations. Spleen, liver not palpable., no bruit, PR=NAD. Urine = N. Nutritional problem = no. X- Ray, What are you looking in X-ray.

    Heart failure - occurs when heart is unable to maintain sufficient cardiac output to meet body demands. Dyspnoea is common early symptoms it is helpful clinically to differentiate between the LVF and RVF. They nay occur independently or together as congestive heart failure –CCF. Causes are ischaemia, HTN, valve disorders or increased alcohol use. LVF : failure of the LV causing back pressure into pulmonary system and giving symptoms/signs within the respiratory system  exertional dyspnoea, orthopnea, paroxysmal nocturnal dyspnoea, nocturnal cough ( pink frothy sputum), wheeze (cardiac “asthmaâ€), poor peripheral perfusion. General signs: tachypnoea (due to increased pulmonary pressure) RR increased , left ventricular S3 gallop /sinus tachycardia (a helpful and quite specific signs), sign of pulmonary congestion (bilateral basal crackles). Causes of LVF: myocardial disease/Ischaemic HD, cardiomyopathy, volume overload/aortic regurgitation, mitral regurgitation, pressure overload/hypertension, AS. RVF : failure of the RV causing back pressure into peripheral circulation resulting in symptoms/signs in limbs and abdomen  peripheral oedema/up to tights, sacrum, abdominal wall, ascites, anorexia, nausea, increased JVP, tender hepatomegaly (increased venous pressure transmitted visa the hepatic veins), pulsatile liver (quite specific and useful sign) if tricuspid regurgitation is present. Causes of RVF – LVF (cause increased pulmonary pressure resulting in sec. RVF), primary tricuspid regurgitation, ASD. Systolic HF/ventricular contractile dysfunction  cause most common coronary artery disease, HTN and dilated congestive myocardiopathy. Diastolic HF/resistance to ventricular filling  ass. With  age probably due to myocyte loss and  collagen deposition, HTN advanced AS.
    22. A 40-50 year old lady. Task: Examine her CVS.
    O/E: she has mid sternal scar - CABG done. Murmur of MR (+), apex beat shifted, .See her hands and tell us something. Pt. has features of SYSTEMIC SLEROSIS .

    23. A young man had head injury in the occipital area in motor vehicle accident (MVA). Airway and circulation = OK. TASK: Please examine his cranial nerves especially pay attention to the eye. Cerebellar test? see Q.55.


    This is Mr. Smith. He had head injury in MVA.
    Introduce yourself and shake hands. How do you do Mr. Smith? Thank you for letting me examines you. Smile ☺ (Observe pt’s posture, physical appearance. Ask pt. to sit on the chair or bed, if not already). I am just going to have a look at you. I am just going to have a look at your scalp. Good. Thank you. (Inspect head, face and neck ptosis, proptosis, pupillary inequality, and skew deviation of the eyes, facial asymmetry. Inspect scalp for scars, tumours e.g. neurofibroma and rashes).

    1st cranial nerve /Olfactory: To examiner: Would you like me to test 1st. cranial nerve? To pt: Have you noticed any change in your sense of smell recently? Do you have any trouble smelling perfume or coffee for instance?
    2nd Optic: Asses visual acuity : Do you wear glasses? (If yes: Could you put them on for me). Can you cover your right eye with this card for me? Thanks, good. Now what is the smallest line you can read? Can you read it for me? Thanks, good. Snellen chart, normal 6/6 = line marked 6 / read from 6 meter . If pt. cannot see the chart, ask: How many fingers can you see? Can you see my hand? Can you see this light? Bilateral blindness of sudden onset bilateral occipital lobe infarction, trauma, bill. occ. Optic nerve damage /methyl alcohol poisoning or hysteria. Bilateral blindness of gradual onset /cataract, acute glaucoma, diabetic retinopathy, chiasmal compression, tobacco amblyopia. Sudden blindness in one eye  retinal artery or vein occlusion, TA.
    Asses visual fields - now I want you to look straight into my eyes. Right, OK. Reduced fields/tunnel vision=glaucoma, papilledema, blind spots/papilledema, central scotomata/loss of central vision may be due MS, methyl alcohol or tobacco, bitemporal hemianopia/loss of both temporal halves of visual fields-pituitary tumour/craniopharyngioma, meningioma, homonymous hemianopia/left temporal and right nasal field loss- TIA, cerebral hemisphere infarcts. Observe size and shape of pupils. Now, look at me. Do not move your head. Just say, “Yes as soon as you see my finger moving. Thank you.
    Fundus/Ophthalmoscopy - to examine: At his point I normally check the fundus. If examiner says, go ahead > I am going to shine a light into your eyes. It might be a bit uncomfortable. Do you see that switch over there? I want you to keep staring at it. Do not take your eyes off it. Try not to blink. Look first at the cornea and iris and then lens. I will start with focusing the beam on ophthalmoscope at the pupil at ~ 1m from the eye. Check for lens opacities B4 examine the fundus. Normally will be red reflex (glow for the choroid) Can be absent in cataracts or intraocular haemorrhage. Next, look in the optic disc (follow the large retinal vein back towards the disc). Normally it is a shallow cup with a clearly outlined rim. Loss of normal depression is called papilledema. /indicate increased ICP. If it is associated with demyelination of ant. Part of optic nerve than it is called papillitis. Papillitis visual loss , papilledema = NO visual loss. Colour - normal =rich yellow. Pale=optic atrophy. Next, look at retina for haemorrhage, streaky/signs of hypertensive and diabetic retinopathy. Look for sign retinal detachment, retinitis pigmentosa (common form of retinal dystrophy, cause night blindness), and central retinal artery occlusion. Causes of ptosis: With normal pupils- myasthenia gravis, myotonic dystrophy. With constricted pupils - Horner’s sy, tabes dorsalis
    3rd Oculomotor: Light reflex - I am going to shine my torch near your eyes. I want you to keep looking at me. Normally pupils constrict briskly. Now test accommodation reflex - Please look over there at the window. And now at my finger (30 cm in front of the nose). Causes of absent light reflex (with intact accommodation reflex) include a midbrain lesion (Argyll Robertson –pupils are small irregular, and unequal, react to accommodation not to light – syphilis/rare in DM). Eye movement  Next ask pt to look up and down, left and right) - Now can you see my finger wiggling? Keep your head still. Follow my finger with your eyes and say if double images are seen/diplopia.. How many fingers do you see? (If two/ Diplopia – Are they side by side > lat. or med. recti or one on top of the other > either oblique, or sup. or inf. recti)? Now you can cover your left (right) eye. OK Now which finger disappears? Features of 3rd nerve lesion - complete ptosis/partial may occur with part. lesion), divergent strabismus (eye down and out), dilated pupil unresponsive to light. NB>Exclude 4th n. lesion when 3rd is present. Tilt the head to the same side as the lesion. The affected eye will intort if 4th is intact. SIN= superior oblique intorts the eye. Third nerve lesions are most commonly related to trauma or are idiopathic. Central causes -vascular lesions in the brainstem & tumours. Peripheral causes- aneurism (usually posterior communicating g artery), tumour, nasopharyngeal carcinoma.
    Remember : lat. rectus, 6th nerve move eyes horizontally outwards, and medial rectus 3rd nerve move eyes horizontally inwards. Eye up > sup. rectus & inf. oblique = 3rd. Eye down > inf. rectus 3rd OUT & sup. oblique (4th) IN. Remember :3rd nerve (medial rectus) moves the eyes horizontally INWARDS.
    4th Trochlear test nerve - Could you turn the eye IN and then try to look DOWN, please? Head tilting compensate for this /ocular torticollis. Isolated lesion are rare and usually idiopathic or due to trauma.
    6th Abducens : nerve lesion features - failure of the lateral movement, convergent strabismus ( 20th Century Fox logo ) and diplopia. Bilateral lesion may be due to Wernicke’s encephalopathy (ophthalmoplegia, confusion, ataxia which is often ass. with Korsakoff’s psychosis). Mononeuritis multiplex and increased ICP also may cause 6th n. palsy. Test for nystagmus asking pt. to follow your pin out to 30 from the central gaze position. At the extreme of gaze (when eyes are deviated) fine nystagmus is normal (physiological). Nystagmus may be jerky or pendular. Jerky horizontal due to vestibular/cerebellar lesion, toxic/phenytoin, alcohol, multiple sclerosis (young), and vascular disease in elderly is important cause. Jerky vertical /due to brainstem lesion, increased upbeat-midbrain, reduced downbeat-foramen magnum lesion. Pendular nystagmus (phases are equal in duration). Cause may be retinal or congenital.

    5th Trigeminus: test corneal reflex - I am going to touch your eye with this piece of cottonwool. It might be a bit uncomfortable. Touch cornea with a cotton tip. Reflex blinking of both eyes is normal response (sensory component- ophthalmic division, motor response blink-facialis). Facial sensation (in all three division -ophthalmic, maxillary, mandibular)- sharp pin touch > Now close your eyes and say yes when you feel I touch you. Can you feel this pin? Is it dull or sharp? Area of dull sensation should be mapped. Light touch > Can you feel this piece of cotton wool. 2. Motor - Clench your teeth like this please/Palpate masseter. Now open your mouth wide. Keep it open. Don’t let me close it/pterygoid muscle 3. Jaw jerk - now, let your mouth drop open a bit. Good. I am just going to tap on your chin. Thanks. In UMNL jaw jerk is greatly exaggerated/pseudobulbar palsy.
    7th Facialis: Did you notice difficulty in speaking and keeping liquids in the mouth or have notice facial asymmetry in the mirror. Any dryness of the eye/lacrimation or mouth/salivation. Look for facial asymmetry – unilateral drooping of the corner of the mouth, smoothing the wrinkled forehead. Test muscle power-Could you look up and wrinkle your forehead, please? Look for loss of wrinkling and feel the muscle strength- push down against the corrugation on each side. This movement is relatively preserved on the side of an upper motor neurone lesion UMNL (lesion occur above the level of brainstem nucleus/supranuclear ). Therefore, forehead movement is spared-bilateral innervation. The remaining muscles of facial expression are usually affected on the side of UMNL. In lower motor neurone lesion LMNL (lesion occur at the level of the nucleus or nerve root) all muscles of facial expressions are affected on side of the lesion-lack of forehead muscle tone. Now ask pt. to shut his eyes. Please could you shut your eyes tightly? Try to open force each eye. Next look is it Bell’s phenomenon is evident. NB. The Bells’ phenomenon is present in everyone (although not usually visible unless one has 7th nerve palsy). In this case when pt. attempt to shut the eye on the side of LMN 7th. Nerve palsy, there is upward movement of the eyeball and incomplete closure of the eye. Next, ask pt. to grin and compare nasolabialis grooves /smooth on the weak side. If a LMNL is detected check quickly for ear and palatal vesicle of herpes zoster – Ramsay Hunt sy. Examining the anterior ⅔ of the tongue for the taste is not usually required but ask examiner: Do you want me to examine pt. taste sensation? /sweet, sour, saline, bitter. Unilateral loss of taste without other abnormalities can occur with a middle ear lesion or lingula neve/ it is rare. Causes of 7th. N. palsy: UMNL/vascular lesion or tumours are the common causes. LMNL : Bell’s palsy (is most common cause of facial palsy), Ramsey Hunt sy/herpes zoster oticus, multiple sclerosis, acoustic neuroma, meningitis. Bilateral facial palsy – may be due to Guillain-Barre sy, sarcoidosis, and bilateral parotid disease, Lyme disease.
    8th : Acoustic: two components, cochlear /hearing and vestibular /balance. Look for hearing aid/remove it. Examine the pinna; look for scar behind the ears. Pull on pinna gently /if tender may be external ear TMJ disease. Inspect pt. external auditory meatus B4 insert otoscope. TM is pearly grey and concave. Look for wax or obstruction. Next, test hearing .Say 68 for high tones, 100 for low. Whisper ~ 60 cm from pt. ears. Ask pt. to repeat a whispered number. If deafness is suspected Rinne’s test/256 Hz vibrating tunning fork placed on mastoid, behind the ear and Weber’s test/ fork is placed on the centre of the forehead. Bilateral deafness may be due to environmental exposure to noise, degeneration-presbyacusis, toxicity –aspirin, streptomycin, alcohol, infection-cong. Rubella, Meniere disease. Vestibular function test - Hallpike manoeuvre – explain to pt. what is about to occur. Grasp his head between the hands, and gets him/her to lie quickly so that the head lies 30 degree below the horizontal. If (+) ve, vertigo & nystagmus occur for several seconds, then abate and not reproducible for 10-15 min. This is seen in condition called benign paroxysmal positional vertigo/due to trauma, infecion or vascular disease.
    9th Glossopharyngeal & 10th Vagus : A lesion of glossopharyngeus may cause no symptoms but difficulty in swallowing dry food may have been noticed. Unilateral vagus paralysis may cause difficulty in swallowing solids and liquid and hoarseness. Spasm of the constrictors of the pharynx (eg. From acid reflux) may cause the feeling of constriction in the throat called globus. Ask pt. to open mouth. Say Aaaahhh…!.If uvula is drawn to ones side that indicate unilateral 10th. Nerve palsy (NB>uvula is draw toward normal side!).Test for gag reflex; (9th is sensory component, 10th is motor component) is traditional but not necessary. Touch back of the pharynx on each side with a spatula. Reduced gag reflex is most common in old age/Ask pt. to speak. Assess hoarseness and ask pt. to cough. It is not necessary to test taste on the posterior third of the tongue Causes of 9th & 10th. palsy – Central cause /vascular lesion, eg. lateral medullary infarction due to vertebral or posterior inf. cerebral artery, tumours, , and motor neurone disease. Peripheral causes; aneurysms
    11th Accessory nerve: shrug the shoulders /trapezius and sternocleidomastoideus. Feel the bulk of trapezius and push the shoulders down. Next turn the head to the side against resistance /the examiner hand. Cause s of unilateral 11th. palsy- trauma, poliomyelitis bilateral cause –motor neurone disease, poliomyelitis
    12th Hypoglossal: motor nerve for tongue. Pt with bilateral 12th paresis may have noticed difficulty in swallowing and a sensation of chocking if tongue slips back into the throat. Inspect the tongue for wasting and fasciculation/fine irregular muscle fibre contractions. They indicate LMN lesion. Ask pt. To poke out the tongue (may deviate towards weaker/affected side if LMN lesion. The tongue like face and palate has a bilateral UMN innervation in most people so unilateral UMN lesions often cause NO deviation. Causes of 12th n. palsy: vascular lesion, tumours, metastases to the brain . A clinically obvious UMN lesion of the 12th nerve is bilateral and result in small immobile tongue. The combination of bilateral UMN lesion of the 9th,10th and 12th nerves is called pseudobulbar palsy/gag reflex =normal or , tongue=spastic, jaw jerk  , speech; Donald Duck-spastic dysarthria, labile emotions. Causes: strokes/ bilateral cerebrovascular disease (eg. both internal capsules), multiple sclerosis, motor neurone disease. (If LMN lesion of 9th,10th & 12th = bulbar palsy/gag reflex absent, tongue=fasciculations, jaw jerk=absent or normal, speech = nasal, normal emotions. Causes: Motor neurone disease, Guillain-Barre Sy, poliomyelitis, brainstem infarction)

    24. Difficulty in speech TASK: Examine cranial nerves. (articulation problem) What are causes of pseudobulbar palsy? Causes: strokes/ bilateral cerebrovascular disease (eg. both internal capsules), multiple sclerosis, motor neurone disease.
    The neurological examination : 1.General incl. Examination for neck stiffness, assessment of higher centres, speech and abnormal movement 2.Cranial nerves II-XII 3.Upper limb /Motor/sensory 4.Lower limb/ + gait 5.The skull and spine 6.Carotis arteries for bruits
    Higher centres and speech  handedness, orientation/in person, space and time, Disorientation may be acute and reversible (delirium) or chronic and irreversible (dementia). Mini-mental state examination is useful way to document the progress of a confusional state or dementia over the time.
    Speech:- Is it dysarthria (difficulty with articulation). Ask pt. to say British Constitution. Cause: Parkinson’s, pseudobulbar palsy. Alcohol, cerebellar disease. dysphonia (altered voice,volume-vocal cord disease) may be due to laryngeal disease or aphasia /dysphasia (impairment of language caused by brain damage)  four types. Receptive (posterior) dysphasia (pt. cannot understand spoken or written word/alexia). It occur with a lesion /infarction, haemorrhage or tumour in first temporal gyrus/Wernicke area. Expressive (anterior) dysphasia, pt. understand but cannot answer properly. Speech is non-fluent. It occurs with a lesion in the third gyrus/Broca area. Most commonly due to left middle cerebral artery infarcts. Nominal dysphasia: Difficulties naming objects, but other aspect of speech are normal. Occurs with a lesion in temporoparietal area. Causes: encephalopathy, or  ICP. Conductive dysphagia: pt. repeats statements and name objects poorly but can follow commands.
    Parietal lobe function: reception and analysis of sensory information
    Temporal lobe function: short and long term memory
    Frontal lobe function: frontal lobe damage may cause changes in emotion, memory, and judgement, careless about personal habits.
    Cranial nerves examination: see page 20

    25. A middle-aged man comes to see you after he watched last night on TV about hazards of ALCOHOLISM. His wife is concerned about his excessive drinking. TASK: Take relevant history and counsel the pt. Asses pt. mini mental state.
    Difficulty in substraction. Alcohol affect > cerebellum, mamillary body, cirrhosis, cardiomyopathy, PU.

    I took detailed history, CAGE questions, performance at work, at home, relation ship, withdraw effects, accidents, sexual behaviour, enquired about short and long term of alcohol. O/E: Hands, arms, Face (parotid) normal, Eyes, oral cavity= N. Chest: 5 spider nevi, no gynecomastia. Abdomen: on inspection normal, palpation normal, percussion: no shifting dullness (ascites) NB. Unfortunately, bell rang so I did not have time to auscultate abdomen, examine genitalia, and counsel the patient. Therefore, I failed in this case, only. Alcohol anonymous association= mention it!

    Alcohol problem : for men excessive drinking is more than 4 standard drinks (SD) a day. For woman > 2 standard drinks per day. One standard drink contains 10 grams of alcohol – equivalent to 1 middy or standard beer (285 ml), or one glass of wine (120 ml), 1 nip of spirits (30 ml). One can of beer = 1.3 standard drinks. 750 ml bottle of wine = 6 standard drinks. To keep below 0.05 blood alcohol level (drinking and driving limit) a 7o kg man/women should not exceed: 2 SD in 1 hour, 3SD in 2 h or 4 SD in 3 hours. Start with a When did you last drink alcohol. Do you like alcohol? What is your usual intake a day? Do you take drink in the morning? Do you drink with tour mates or family or at the club? When was last time you were drunk?
    CAGE questionary (for fully cooperative pt). Have you ever felt you should CUT down on your drinking? Have people ANNOYED you by criticising your drinking? Have you ever felt GUILTY about your drinking? Have you ever had a drink first thing in the morning to steady your nerves EYE-OPENER? Two or more “Yes†answers are suggestive of alcohol problem. Lab. Ix: serum GGT increased in chronic drinkers, MCV >96 (macrocytic anaemia), other changes: abnormal LFTs, HDL increased , LDL decreased , serum uric acid increased .
    Do you know anything about harmful effect of alcohol? Heavy drinking damages the body particularly brain/poor memory and cognition, heart/arrhythmia, cardiomegaly, liver/cirrhosis, stomach/gastric erosion, PU, oesophageal varices. It will cause high BP, gout and pancreatitis (inflamed pancreas) sexual dysfunction; as well, it can cause psychological and social effect like loss of self-esteem, irritability, anxiety, relationship breakdown, accident etc.
    We will work together to make you better!
    A six-step Mx: 1.Feed back the results of your assessment, discuss risk and damage from alcohol 2.Listen carefully to their reaction. 3.Outline benefit of reducing drinking (save money, less hassle from family, sleep better, have more energy, less depressed, reduced risk of HD, HTN liver/brain disease, cancer, accident.4. set goals for alcohol consumption which you both agree. It should be for man no more than 3-4 drinks, 32-4 times at week. /for woman 2-3 SD / 2-3 times per week.5. Set strategies to keep bellow the upper safe limits. Quench thirst with non-alcoholic drinks B4 having alcoholic one, alcohol free beers, avoid drinking on empty stomach, and explore new interest fishing, cinema, and sport. Evaluate progress using diary. Give appropriate pamphlets as Alcohol and health. Get in touch with a Alcoholic Anonymous or Alanon /according to pt. wishes and consent. Alcohol –sensiting drugs: Disulfiram 250-500 mg PO /daily, when taken with alcohol will cause unpleasant reaction; the reaction includes nausea, vomiting, flushing. Such treatment has hazards and the pt. require intensive supportive therapy. Advice from expert.
    Follow –up. Review the pt. diary. If appointment is not kept, contact the pt.
    Withdrawal symptoms: pulse increased , BP reduced , tremor, fits, hallucination (delirium tremens -may be visual or tactile eg. animals crawling all over one). The most characteristic of alcoholic hallucinosis = auditory hallucinations such as whispering, cling of glasses Mx. Diazepam 10-20 mg PO every 2 hours, Thiamine 100 mg IM or IV, vitamin B group supplement PO or IM daily.

    26. Diagnostic: HEPATITIS & ALCOHOL

    27. This pt. Has been sent to your surgery by his wife. She thinks that her husband has drinking problem. TASK: Take history and examine pt. Dx. ALCOHOL ABUSE Q. What you will look for in examination? Do not do just tell me (examiner). How you will proceed? I said a basic Ix. Like blood test, urine etc. Examiner: Results not available now. CAGE ques
  2. Guest

    Guest Guest

    thanz a lot good samaritan

    v nice of u to post all this. but wot are those numbers beside the cases? am new to this so dont mind....

  3. samar11

    samar11 Guest

    thank u

    Thanks alot but i couldn't understand theses no. as well!!!!!!!
  4. Guest

    Guest Guest

    however thank you for your effort

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