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Hazardous drinking (Social alcoholism)

Your next patient in general practice is a 47 year old businessman, John Ramm, who wants to discuss his alcohol consumption with you because he got pulled over by the police in the morning on his way to work and he was breathalised with a BAC of 0.04. The police officer warned him that this was close to the legal limit and a sign that he must have had a lot to drink the night before. That gave him a bit of a shock and he wants to find out how much alcohol is safe to drink and general information about the effect of alcohol on a person.

Task: Brief Hx, Perform PE and Ix, explain findings, Dx and Mx to the patient

HOPC: John is a self employed business man who had a business dinner meeting a few days ago with quite a bit of wine and he actually can’t remember when and how he got home, but his car was in the garage and he woke up in the morning with a bit of a headache as it happens after a heavy session. Driving to his office in the morning he got breathalysed and blew 0.04 which surprised the police officer although it was not over the legal limit. The police officer mentioned to him that he must have had a very high blood alcohol level the night before which gave John a shock realizing that if he had been caught last night he would have lost his license which is vital for his business. John has been drinking regularly for many years. As a sales representative for stationery he meets lots of clients and entertains them often for lunch or dinner and usually there is some beer or wine consumed and he also drinks wine if he has dinner at home. Basically he would


5 to 8 standard drinks per day 7/7, often being quite tipsy.


He has never lost his driving license and

he does not feel that the alcohol has done harm to

his physical, mental or social health.

Although he has

put on 12-15 kg over the last two years

and he does not do much physical exercise anymore and he also noticed that his


function had deteriorated over the last few years even though he still has the desire for it.


He quite often is not able to get up in the morning because of

mild to moderate hang-overs

but because he is self employed it has not caused any problems. He does not spend a lot of time with his children and does not feel fit enough to kick the ball

with them or to go surfing like he used to years ago. PHx. + FHx.: unremarkable although his father was quite a solid drinker but died of old age in his eighties. SHx.: married with 3 children (17, 12 and 9 years old), self employed sales man, no financial problems, non smoker, NKA, no medication.

O/E: moderately overweight (BMI 27) but otherwise well looking man, P 72/min +reg.,


RR 18, afebrile.

ALCOHOL & SMOKING Hazardous drinking (Social alcoholism) Your next patient in general practice is a 47

The abdominal examination reveals a mildly enlarged, soft liver pathological findings on PE.


., otherwise there are no


FBE: possible anaemia, macrocytosis and raised mean corpuscular volume(MCV normal 10-96 fL)


elevated gamma glutamyl transaminase (GGT),

but others can be elevated as well.

Serum uric acid often raised

Lipids high



6.5% of Australians have had an alcohol-use disorder in the last 12 months and up to 40% of

emergency department patients have alcohol problems. Alcoholism is a common and socially destructive problem in Australia. The identification of alcohol misuse is often difficult and requires a sensitive history taking. It is important to identify the difference between regular drinking and binge drinking! Certain professional groups are at risk of “drinking”:

Young and middle-aged bachelors Divorced or separated individuals Alcoholic beverage trade: bar trade, hotel staff Professionals: politicians, doctors and others Travelling professions, e.g. seamen, salesmen, truck drivers Armed forces, especially returned servicemen Authors, journalists and related workers Social club patrons, e.g. sporting clubs

There are a couple of useful questionnaires available:



C: thoughts of cutting down drinking A: annoyed at criticism of drinking habits G: guilty about drinking E: “eye opener” drink to get rid of a hangover

  • 2. AUDIT: the alcohol use disorder identification test, a screening test for problem drinking developed by WHO with 10 questions relating to alcohol use.

The risk has been identified by NHMRC :

NH&MRC guidelines: number of standard drinks each day Low risk Hazardous Men 0-4 5-6 Women 0-2
NH&MRC guidelines: number of standard drinks each day
Low risk

One standard drink contains 10 g of alcohol which equals a pot of standard beer, a small glass of wine, 1 glass of sherry (60 mls) or 1 glass of spirits (30 mls). This can be helpful to calculate the amount of drinks before one reaches the 0.05 level BAC, considering that 1 standard drink raises the BAC by 0.01. That means a person reaches 0.05 after 5 standard drinks. On the other hand the liver metabolises about 1 standard drink of alcohol per hour, which means that the same person can than drink 1 standard drink per hour to stay below 0.05.

Alcohol dependence can be physical, psychological or social!:


Physical dependence is characterised by increasing tolerance and withdrawal and relief of withdrawal symptoms by further alcohol consumption. They can be expressed in a wide variety of effects:

Psychological and social effects

Physical effects
Physical effects

• loss of self-esteem • irritability • devious behaviour • anxiety and phobias • depression • paranoia • stress • relationship breakdown • child abuse • poor work performance • memory disturbances • financial problems • accidents • driving offences • crime-violence • personal neglect • attempted suicide • pathological jealousy

• brain damage (if severe) • depression • epilepsy • Wernicke-Korsakoff syndrome • insomnia—nightmares • hypertension • heart disease — arrhythmias — cardiomyopathy — beri-beri heart disease • liver disease • pancreatic disease • dyspepsia (indigestion) • acute gastritis • stomach ulcers • sexual dysfunction • hand tremor • peripheral neuropathy • myopathy • gout • obesity • other metabolic/endocrine effects — hyperlipidaemia — pseudo-Cushing's syndrome — osteoporosis — osteomalacia • haemopoiesis — macrocytosis — leucopenia

— thrombocytopenia

We classify adults according to the amount of alcohol they drink as

  • 1. abstainers

  • 2. social drinkers

  • 3. social alcoholics

  • 4. alcoholics



Period of abstinence

Alcoholics anonymous

Life style changes

Pharmacological options (thiamine, naltrexone, disulfiram/antabuse)


Smoking counselling

A 30 year-old man return to your practice after a recent chest infection. He smoke 20 cigarettes a day. Last visit you advised him to quit smoking and now you want to follow-up his respond to the previous advice. Counsel about quitting smoking.

Task: to assess his motivation to stop smoking. Counsel his approach and to discuss any therapeutic option.


I’m very glad that you have decided to quit and I can help you I’d like to ask you some Qs (To assess how addicted he is) How many cigarettes a day? How long have you been smoking? What is the pattern of your smoking a day? How soon you smoke after you wake up in the morning? Is this one (start early morning) the most difficult to quit? Do you still like to smoke even if you’re very ill and can’t get out of bed? How do you feel when you’re in the area of No Smoking sign? Do you feel you have to smoke in spite of the sign? Have you tried to quit before---failed trial of quitting How many times Why did the attempts fail ---perhaps very bad withdrawal symptoms Apart from smoking, do you drink alcohol---go together drink & smoking Coffee & tea---combination of coffee & smoking


The most important thing to quit is the strong motivation, I’m glad that you have made your

mind/decided to quit It’s not too late, however quitting may not be very easy

Because you’ve been smoking in this pattern, you may get some withdrawal symptoms after quitting and some people may get some :

  • - depression

  • - poor sleep

  • - irritability

  • - anxiety

  • - reduced concentration

  • - sometimes you may feel craving for smoke and sugar

  • - you may also notice an increase in your appetite

  • - Most of the people who quit they put on some weight

These withdrawal symptoms are maximal in the first few weeks (1-3 weeks after quitting) and then they will disappear. The increase appetite may last in 1-2 years. We can help you if you develop anyone of these symptoms.

The psychogenic symptoms (nervousness, anxiety) treat with benzodiazepine short course.

Advise to quit smoking:

  • 1. Set a date by which you will quit totally, it’s good to quit within 2 weeks from now (he may change his mind later)

  • 2. Your aim is total quit, no gradual reduction


  • 3. Tell patient to review his previous attempts to quit and why he smoke again, in order not to repeat the same mistakes again

  • 4. Inform your relatives & friends that you quit smoking

  • 5. Try to reduce alcohol & coffee intake

  • 6. If you develop any of these withdrawal signs, please feel free to visit me or contact me

  • 7. You may put on some weight, you need to watch your diet and exercise more

  • 8. You may need some nicotine replacement

  • 9. Frequent follow-ups, I need to see you every few days, very critical within the first 2 weeks (phone visits)

10. Offer resource materials and some helpful lines like quitting support groups

The aim of nicotine replacement is to help with the withdrawal symptoms in chronic smoker and addictive symptoms To replace 40% of nicotine that the patient was getting from smoking

  • - Nicotine patches

  • - Nicotine gum

  • - Nicotine inhalers


  • - Pregnancy

  • - Ischaemic heart disease

Medication to help:

  • - Bupropion contraindicated in pregnancy, epileptic, relatively contraindicated in diabetics (given for a few weeks)

Assess motivation How bad smoker Explain withdrawal symptoms Advise for quitting lines Quit total not gradual Support group



Alcohol counselling

You’re working in a GP clinic and you see a 45 year-old man consulted you regarding harmful effect of alcohol after watching a program about it on TV.

Task: take relevant history, arrange further investigation & management.


Mr Smith I know that you’re concern about your drinking, it’s a very good start. I’d like to ask you a

few Q s, some of them might be personal, is it OK with you? Drinking habit

  • - Please tell me for how many years have you been drinking?…usually a long time

  • - How much are you drinking per week

  • - What type of alcohol are you drinking…. spirit, wine or beer

  • - Where do you prefer to drink, with your family or friends.

  • - Continuously or binge

  • - Are you aware of the safe level of drinking

  • - Have you noticed any ill effect of alcohol on you

  • - Tolerance – do you think you drink heavily without feeling or appearing drunken

Withdrawal effect

  • - How long can you go without alcohol not more than 1 day

  • - How do you feel in the morning

  • - Any symptoms of agitation, sweating, nausea, shaking

  • - How do you feel after a period of abstinence from alcohol

  • - Do these symptoms disappear if you drink

  • - Do you ever need to drink before going to sleep Social effect

  • - Have you noticed any problem at your work

  • - Any problem at home

  • - How is your relationship with you partner and children

  • - Have you had any financial problems


  • - Have you had any accidents or crimes due to over drinking

  • - Have you ever tried cutting down your drinking habits before

  • - Have you ever visited any detoxification centre

Health problems

  • - Have you noticed any heartburn, gastritis

  • - Hypertension

  • - Heart disease

  • - Liver disease

  • - Anemia

  • - Any problems regarding your memory

  • - Any recent mood change or depression

  • - Any change in your sexual performance? …pt say that he has problems related to this age


  • - Have you ever thought of cutting down with your drinking habits

  • - Do you feel annoyed about people when they talk about your drinking

  • - Have you ever felt guilty due to your drinking habits

  • - Do you need drinking the first thing in the morning as an eye opener SAD

  • - Do you smoke? ----- a lot

  • - Have you tried any illicit or recreational drug

  • - Is there any family history of alcohol dependence or liver disease


Now Mr Smith I’d like to do some investigations to see the effect of alcohol in your body

  • 1. FBE: to look for anemia & macrocytosis,

  • 2. B12 (usually low), folic acid

  • 3. LFT

  • 4. Lipid profile

  • 5. Serum lipase

  • 6. BSLprone to DM

  • 7. Liver US

  • 8. ECG



FLAGS (Feedback, Listen to the patient, set Aims, Goals, Strategies)

Now Mr Smith, from the history & examination, it showed that you’re drinking alcohol more than

normal. You’re very good in coming here to discuss your condition. From the result of your investigation, the results coincide with your alcohol intake.

Mr Smith, the high alcohol intake usually causes:

  • - high BP,

  • - increases your body weight,

  • - and sometimes cause harmful effect on your stomach such as heartburn,

  • - can effect your liver, heart and brain,

  • - can cause gout,

  • - blackouts,

  • - loss of memory,

  • - problems with your social life,

  • - sometimes causes problem in your sexual life, relationship

What do you think Mr Smith, is this affecting you? I’m going to tell you the safe level of drinking, 2 standard glasses everyday for 5 days and 2 days off. (1 SD = 10 grams of alcohol)

S – Strategies:

  • - To cut dow n, don’t drink daily, drink only with food

  • - Have a glass of water between drinks (to dilute, to quinch/satisfy the thirst)

  • - Switch to low alcohol drinks/beer, don’t drink on empty stomach, mix alcoholic drink with non- alcoholic drink, avoid high risk situation

  • - Avoid or limit drinks with alcoholic friends

  • - Avoid going to pub after work

  • - If you’re under pressure, told them that my doctor told me to cut down

  • - When you’re in stress, take a walk, explore new interests, plan other activities or tasks at a time when you usually have a drink

  • - A lways check the level of SD before each drink.

Mr Smith, it will save your money and you will have less family problems. It will decrease your BP and your LFT will come back to normal. A lot of support is available for you such as family, myself and a lot of support groups.

Mr Smith, always aim for period of absence from alcohol. If you develop any tremor, sweating, agitation please report straight away.

I will arrange for the follow-up with you and I can also arrange a family meeting. Here is a flyer about alcoholism, please read it and any concern you can come and see me anytime. You took a very good decision, a lot of support is available for you.


Angina Pectoris (Abnormal Stress Test)

GP setting. A 62 yo male who presented a few days ago with chest discomfort. ECG done at that time was normal. A stress test was done later on showed ST segment change in anterolateral leads. Pt had chest tightness during the test. Pt is a smoker, no Hx of DM.

Task: explain the test result, short and long term management.


A ny chest pain or discomfort presented at the moment? Pain Qs previous episodes HTN ? Cholesterol? FHx of cardiac disease Ask for the cardiac risk assessment


Mr X, the condition that you have is known as angina Angina is the name given to chest pain or discomfort that comes from the heart when it’s short of oxygen. The heart is supplied by vessels known as coronaries and in this condition, the coronaries is narrowed and this is due to disposition of fat-like atheroma. A very common condition. Millions is suffering from it reassuring in an indirect way. The symptoms is dull, heavy pain, discomfort usually in the centre of chest, pressure symptoms, shortness of breath, usually associated with physical activity or effort


  • 1. Start you on some medications: aspirin, (beta blocker, ACE inhibitor), statins and GTN (carry with you all the time)

  • 2. Refer you to cardiologists ASAP for further assessment and Ix. It’s most likely they will do angiogram. A ccording to the angiogram result, next step will be decided. They may put stents to keep the arteries opened after ballooning or may go for an open heart surgery if needed.

Angina action plan

  • 1. If you have any severe or prolonged pain after trying to rest, take this sublingual tablet (or nitroglycerin spray) that I prescribed and wait for 5 min, if not relieve.…

  • 2. Notify a friend or relative that you have the pain

  • 3. If pain persists, repeat the dose and wait for another 5 minutes, if not relieve call ambulance and take a third dose, tell the ambulance that I’m having a heart attack.

Long term management: ABCCDDES

  • 1. Alcohol cut down alcohol to safe level

  • 2. BP <130/80 as a target, BMI between 20-24

  • 3. Cigarette, quit smoking and refer to quitline…counsellor, nicotine patches

  • 4. Cholesterol and lipid profile…start on statins

  • 5. Diet – ideal diet

  • 6. Diabetes for BSL

  • 7. Exercise, once your condition is stabilised have 30 minutes of brisk walking

  • 8. Stress remodel the stress

  • 9. Follow up and reading material

Sexual life: Angina by itself is not affecting your ability to have intercourse, but sexual excitement can lead to anginal pain. I’d advise you to avoid this until we stabilise the case. Driving: carry your medication, for any pain while driving, – stop and don’t continue driving.

Will I have heart attack? The angiogram is to assess the risk of having a heart attack.


AMI with Cardiac arrest

You’re an intern in ED. A 55 yo man, who was brought to the ED by his wife with a severe central chest pain, breathless & sweaty.

Task: further relevant Hx, Dx, discuss DDx with examiner, Mx and answer examiner’s Qs. (Examiner will ask Qs after 3 minutes)


Cardiac causes:

  • - Acute coronary syndrome

  • - Aortic dissection

  • - Pericarditis

  • - AAA Respiratory causes:

    • - Pneumothorax

    • - Pneumonia

    • - PE

  • - Pleurisy Less likely in this case is gastroesophageal causes such as

    • - Oesophagitis

    • - Gastroesophageal reflux

    • - Oesophageal spasm

    • - Peptic ulcer

  • Musculoskeletal causes like:

    • - Costochondritis

    • - Fracture rib

    • - Herpes zoster

    Psychiatric condition:

    • - Anxiety

    • - Panic attack

    Part I Chest pain

    Is my patient haemodynamically stable? Severe chest pain morphine 2.5 mg IV (up to 15 mg); Maxolone 10 mg I’d like to check the vitals, attached pulse oxymeter to check the oxygen saturation and give him oxygen; hook up to ECG machine


    Where is your pain exactly? Central chest When did it start? How long did it last? Did you take anything for it? What were you doing when it happened?

    What kind of pain? Pressing type Does it travel to your neck, arms and hands? to L.arm and hand How bad? Anything make it better or worse? Any similar episodes before? on and off but subside by itself Any pain in deep breathing (pericarditis)? Any problem in digestion? Reflux, black bowel motion? Is the chest sore to touch? Pain in your calf while walking?


    Any PMHx like high blood pressure, DM, high cholesterol, heart problem? Are you on any medication? No Any Hx of stroke or bleeding problem? Any FHx of heart problem? Father died suddenly at 60 years SAD


    GA, BMI, VS, Heart exam (murmur, rhythm, signs of heart failure)


    ECG: Lead II, III, AVF (inferior); V1, V2 anterior; V3, V4 septum Lead I, AVL, V5, V6 lateral Blood tests: cardiac enzymes (troponin, CK), FBE, BSL, lipid profile, uric acid, U & E


    Oxygen high flow 8 liter Aspirin stat if not given by ambulance 300 mg GTN (glyceryl trinitrate) or Anginine 300 microgram sublingual (check systolic BP: if >100, can repeat every 5 minutes, maximum 3 dose of half a tablet 1.5 tablet) Call the senior medical officer

    Part II – Cardiac Arrest

    Basic life support protocol when the examiner tell about the arrest

    While doing ECG, the patient collapsed.

    • - Danger

    • - Shout for help (Code blue)

    • - Shake the patient

    • - Airway Head tilt or chin lift

    • - Breathing chest movement

    • - Circulation feel the carotid pulse

    • - CPR 30 compressions, 2 breaths (5 cycles over 2 minutes) ECG show Ventricular Fibrillation

    • - Defibrillation monophasic: 360 joule 3 shocks every 2 minutes (biphasic: 200-360- 360) (If defibrillator available do Advanced Life Support if not available, I’d like to start the BASIC LIFE SUPPORT until the help arrive.)

    • - Give Adrenalin 1 mg IV every 3 minutes

    • - Check ECG

    Part III - Patient gained consciousness

    Check his BP --- low BP80/60 Patient will go for PCI (percutaneous coronary intervention: catheterization & angioplasty) or fibrinolysis.

    Indication for reperfusion therapy (PCI):

    • - Persistent STEMI of 1 mm in 2 contiguous limb leads or

    • - STEMI of 2 mm in 2 contiguous chest leads or

    • - New bundle branch block


    A patient came to you in ED with a chest pain, typical for acute coronary syndrome

    • - DR ABC secure IV line

    • - Give Oxygen 4-6 L

    • - Aspirin 300 mg (provided not hypersensitive)

    • - Morphine 2.5 – 5 mg IV (30% have nausea and vomiting)

    • - Maxolon (Metoclopramide) 10 mg IV

    • - BP >90 Glyceryl Trinitrate 400-600 microgram sublingual or spray

    • - ECG

    • - Pulse oxymetry

    Patient collapsed DR ABC Call for help Assist airway No breathing CPR 30:2 until defibrillator arrives Assess the rhythm Ventricular fibrillation shock and continue CPR 2 minutes (5 cycles = 200 compressions) Assess the rhythm, if sinus rhythm stop

    Shock respond can be VF or PVT If Pulseless Ventricular Tachycardia (PVT) shock again and continue CPR for 2 minutes Assess rhythm again and shock continue CPR for 2 minutes If still not responding (after 4 minutes) give Adrenalin 1 mg (after the second cycle), continue CPR, shock again If no sinus rhythm after the third cycle give Amiodarone

    Pulseless electrical activity Adrenaline and continue CPR Every 2 minutes assess the rhythm If after 40 minutes no response stop CPR

    Assess the cause, look for 4 H and 4 T and correct the following (if found):

    Hypoxia, Hypothermia, Hypokalemia and/or Hyponatremia, Hypovolemia and Tension pneumothorax, Tamponade, Toxin, Thrombosis

    Monophasic 360 Joule (start with the maximum) Biphasic 200 Joule




    GP setting. 67 yo male came in for check up. You discovered an abdominal mass and sent him for U/S. It revealed AAA 7cm (infra-renal A.).

    Task: counselling and management.


    Mr X, I understand you are here for the U/S result. Here is the result and we found out you have AAA. Do you know anything about it? (Draw a picture.)

    It’s not an uncommon condition. We don’t know exactly what causing it. Some of the cases run in the family. Do you have a family with the same diagnosis? Some may relate to HPT. Do you have high BP? For how long? Are you on any medication for it? Which one are you on? When was the last time you check your BP? Do you smoke? Have ever check your cholesterol level?

    Swelling/ dilation of the aorta is just below the renal arteries. The normal is up to 3 cm. 5 cm is significant and 6 cm is dangerous because it can rupture even with coughing or straining. In your case the swelling is 7cm. Lucky you we have picked it up now. We will fix it as soon as possible. We have many patients like this. The surgeon is fantastic here.

    My advice is to cancel your travel plan. If you go camping, and with a bad luck if the aneurysm ruptures then you need an emergency surgery, the risk motality is high 50%. While the risk of an elective surgery is 5%. I can explain to your wife if you don’t mind.

    The surgeon will speak to you in details. Anaesthetist also will speak to you. They clamp the vessel, stop the circulation and put the stent Dacron graft on the wall of the aneurysm. They stitch it together.

    I will follow up you. We need to control the BP. Because it runs in the family, you can ask them to see their GP, to do imaging (U/S to screen for relatives >50 years of age) if they have the same condition (the first degree relative).

    Now I’d like to (call the ambulance to) send you to the hospital.


    AAA- post operative d/w family

    Hospital setting. You’re about to see the son of a man who had undergone a laparotomy for AAA . He’s now in ICU and kept on assisted ventilation, he will be extubated tomorrow. He gave consent before the operation to talk to his family about his condition.

    Task: Talk to the son and deal with his concerns.


    What’s wrong with my father? Why is he in ICU? Why did he undergo operation when he had no illness? He was sitting on a ticking time bomb which could have exploded anytime without any notice. How long will he be in ICU? Why are all these tubes hanging out from his body? Is he going to die as he is ICU? Am I going to have same problem? AAA is common in older males especially if there’s FHx of AAA. As you know, controlling the risk factors (DM, hypertension, smoking, and hypercholesterolemia) can reduces the chance of getting it.


    Mr X, I know that you’re here to discuss the condition of your father. Before discussion, let me assure you that your father is in a high care place which is the ICU and this is usually a routine place for major operation patient to have 1 to 1 monitoring and to have the most advanced support, medical observation needed for his follow-up. Currently he’s under an artificial breathing by having a machine called the ventilator to control his breathing and heart and lung function with accurate fluid management. As major abdominal operation may affect the vital function which is the need for high care. Your father had an abnormal dilatation in one of the biggest vessel of the body known as the aorta. This condition is known as abdominal aortic aneurysm. To have the aneurysm, the wall of this vessel is weakened by a degenerative process involving all layers of the aorta. The lining which is the endothelium is damaged usually by smoking, HPT or precipitation of high lipids and triglycerides. This causes the release of enzymes weakening the wall and ends up to the dilatation of the wall. The size of the aneurysm can lead to more sequelae. Rupture of the aneurysm specifically if >5 cm can lead to formation of clots known as thrombosis or the bigger the sac the pressure will be on the surrounding structure.

    Because an aneurysm may continue to increase in size, along with progressive weakening of the artery wall, surgical intervention may be needed. Preventing rupture of an aneurysm is one of the goals of therapy.

    I believe the vascular surgeon made the decision after Ix like CT Abdomen. A n elective surgery which carries less risk than to wait for leakage or rupture of the aneurysm and to have an urgent operation to be done. Death in elective surgery is 5% while in rupture 80-90%. Repair of this operation by elective surgery has better outcome and this is why the surgeon went for this operation. Do you understand this situation Mr X?

    There are 2 approaches to AAA repair. The standard surgical procedure for AAA repair is called the open repair. A newer procedure is the endovascular aneurysm repair (EVAR).

    Most likely there is a plan which your father will be extubated or get off the assisted breathing machine in 1-2 days. The specialist will decide the time to be kept in ICU and he will be discharged to the ward. He will be in the care of the allied med. team, occupational therapist will put him back to the normal tract of activity. He will be kept on blood thinning & strong painkiller like opiates to prevent his blood from clotting. If you need to speak to the surgeon, I can arrange a meeting with him .

    Rupturelow BP, shock


    Syncope (Aortic stenosis) (AMC 36)

    GP setting. A 52 year old technician is consulting you b/o recent loss of consciousness. Task: further history, PE, explain Dx and further assessment


    • - Vasovagal

    • - Carotid sinus syncope

    • - Arrhythmias ---brady (heart blocks) or tachy arrhythmias

    • - Structural heart diseases ---valvular lesions, ischemic heart diseases, HOCM

    • - Epilepsy

    • - TIA & CVA (stroke)

    • - Orthostatic (volume depletion due to vomiting, diarrhoea or bleeding)

    • - Drug-induced centrally acting hypertensive, ACE Inhibitors (Posture hypotention)

    • - DM (Hypoglycaemia)


    Before and during

    • - What happen exactly? ---playing tennis suddenly collapsed

    • - Any palpitation, chest pain, SOB, dizziness, vertigo, blurred vision, severe headache, speech problem, N/V, sweating before collapsed?

    • - Did you lose your consciousness?

    • - Was it witnessed?

    • - How long did you lose your consciousness?

    • - Any change in the colour during the attack? (cyanosis)

    • - Did you hurt yourself when you fell? ---head injury, fracture, pain anywhere in arms, legs

    • - Any abnormal movements during the collapse?

    • - Did you wet yourself?

    • - Any previous episodes? After

    • - When did you regain consciousness?

    • - Did you feel sleepy?

    • - Any headaches, visual changes, altered sensation, pins and needles, weakness in any part of your body?

    • - What did you do after you regain consciousness, did you continue the game or went home? Systemic review

    • - How’s your health in general?

    • - Do you usually get chest pain, SOB, palpitations, swelling in your legs, cough, breathing problems, wheezing?

    • - Change in your appetite, vomiting, diarrhoea, urine

    Risk assessment

    • - Hx of high BP, any heart attacks, diabetes, high cholesterol, stroke, cramps in the leg,

    • - FHx of cardiovascular problems or heart attack, epilepsy

    • - SADMA

    • - Stress level, Mood conversion disorder


    GA, VS (posture hypotension), JVP, Carotid bruit Heart exam ejection systolic murmur (3/6), best heard over aortic area Neurological examination Cranial nerves, motor, sensory

    It’s most likely due to narrowing of one of your heart valves. Ix: ECG & echocardiogram. (ASSyncope, chest pain and exertional dyspnoea)


    Syncope (Wolff-Parkinson-White Syndrome)

    David, 24 yo presented to the ED complaining of loss of consciousness and fainting attack 1 hour ago while playing sports with his friends. His friend drove him to the ED and left.

    Task: take history, PE, investigation, explain diagnosis & management plan.

    Everything is normal, sorry I can’t find anything wrong with you. It could be anything.

    Further Ix FBE, BSL, ECG, U & E, carotid Doppler studies, Echo

    You have a condition called WPW Syndrome. Do you know anything about it? It’s something related to the conductivity of your heart which give you the fainting episode. It’s not a common condition but sometimes it runs in the family. It can be treated with medication. Our plan is to refer you to a cardiologist, maybe he will order some investigations & start you on some medication.

    Asymptomatic observation Medical treatment amiodarone, disopyramide (Avoid digoxin, beta blocker, CCB) carotid sinus massage if the patient is at high risk of AF Tx radio frequency ablation of the accessory pathway, implantable defibrillator Surgical surgical division of bundle of Kent

    Ablation of the abnormal band causing pre-excitation syndrome ECG-short PR interval, wide QRS complex. Delta wave or slurred wave


    Atrial Flutter (AMC 66)

    ED setting. A 50 yo man c/o palpitation & dizziness over the past 3 days. He has not seen a doctor for the past 10 years. At the last assessment, he was told his BP was elevated. His current BP is 150/96, symptoms still presented. He’s now lying down in the trolley.

    Task: relevant focus Hx. Present a summary to examiner then he will give you the exam findings. Tell your DDx. Interpret the ECG.


    Atrial flutter Atrial fibrillation Supraventricular tachycardia Ventricular tachycardia Thyroid

    Hx: Patient STABLE or not Palpitation (LOTS RADIO)

    • - Fast beating of my heart going into my neck

    • - How fast? Around 150/minute

    • - Duration

    • - Sudden or not

    • - Offset ---stop suddenly

    • - How many times

    • - Were you doing anything particular when you get it

    • - Associated symptoms: SOB, loss of consciousness ---mild SOB, sweating, no nausea or vomiting

    • - Anything makes it better or worse


    • - What do you mean by dizziness near fainting experience like lightheadednesswhy heart not contracting well

    • - Do you have it together with the palpitation

    System review

    • - Thyroid hot or cold—weather preference

    • - Weight changes

    Past medical history

    • - Hypertension, DM, Ischaemic heart disease, thyroid disease (risk factors)

    Social history

    • - SADMA 20 cigarettes/day, 5 glasses of wine/day, coffee 5 cups/day

    • - Job? Sedentary life style

    Family history

    Summary: (Case presentation AMC P131) The pt is a 50 yo company secretary who presented with his 4th attack of palpitation & dizziness over the past 3 days. He had 3 attacks after dinner & 1 whilst driving. Each attach


    lasts approximately 2 hours, they come on suddenly & stopped suddenly. The nature of the palpitations is that they appear to be rapid, approximately 150/min and regular. The dizziness always accompanies the palpitation. Associated with mild shortness of breath & sweating. No chest pain, no N/V. He has a history of high blood pressure but no knows cardiac disease. He has a high alcohol intake and has recently been under stress at work. Conclusion: He is at risk of ischemic heart disease because of hypertension, smoking, obesity, and sedentary life style. No evidence on Hx to suggest thyrotoxicosis.


    GA: Overweight, distressed VS: P 150, regular Heart exam: heart sounds show dual rhythm with no bruits, no signs of heart failure

    Dx: Paroxysmal atrial arrhythmia, probably atrial flutter (sudden onset and offset, the rapid, regular palpitation and the rate)

    Causes: hypertensive heart disease, alcoholic cardiomyopathy, ischemic heart disease, occult thyrotoxicosis

    Treatment Tx of arrhythmia + prophylaxis against thromboembolic complications

    • - A – rhythm control Amiodarone

    • - B C D – rate beta blocker, ca channel blocker, digoxin

    • - Complication aspirin or warfarin

    • - Lifestyle modification

    Atrial flutter is usually insensitive to antiarrhythmic drugs cardioversion (direct current shock) or pace cardioversion


    Infective Endocarditis

    GP setting. A middle age lady c/o extreme tiredness and fatigue for the last 3 weeks. (Fever and hand pain)

    Task: take history, ask examiner for examination finding, diagnosis and management.


    Infection: HIV, Haemochromatosis-addison








    How long have you had the tiredness? Any fever? Any change in appetite, weight loss, fever? How is your sleep? How is your mood? Any liver disease? Any change in skin color? How is your diet? Have you had any blood loss? Bleeding anywhere? How is your period? Do you have any weather preference? Hoarseness of voice? Any increase frequency of urine? Do you feel thirsty? Any FHx of DM, tumor? Are you sexually active? Do you practice safe sex? Any STD before? Stable partner? Any recent surgical procedure? Any dental procedure done? Any antibiotic taken prior to the procedure? Did you have heart problem in the past? Have you been diagnosed with any rheumatic fever?

    Positive findings for this case:

    • - History of dental procedure

    • - Heart murmur

    • - Haematuria on urine dipstick

    • - Splenomegaly


    GA: pallor, jaundice, petechial haemorrhage VS: Fever, BP, PR, RR

    Signs of Infective Endocarditis:

    • - Conjunctiva pallor, petechial haemorrhage

    • - Red, painless skins spots on the palms and soles (Janeways lesion)

    • - Palmar erythema


    Hand Examination: no clubbing, Osler node Lungs: bilateral crepitation CVS: S1 S2, any murmur, pericardial rub, any signs of heart failure – JVP, leg oedema Abdomen: Hepatosplenomegaly? Splenomegaly? LN Urine dipstick: blood (+++)


    From history and examination, Ms Smith, you have a condition called infective endocarditis

    (fever + new murmur). Because of your dental procedure, the bacteria mainly Streptococcal (Strep viridians) entered

    the blood stream and into your heart. We need to do some more Ix to confirm the diagnosis.




    3 sets of blood culture taken 20 minutes apart from 3 different sites and time.


    While doing blood test I will also do the serology for complement level C3, C4, ASO.


    ECG and Echo

    I will refer you to the hospital and a cardiologist will assess you


    They will admit you and start antibiotic (Do you have any medication allergy?)


    They will start with IV Benzyl Penicillin + Flucloxacillin + Gentamycin until the blood culture is available


    You will need to stay in hospital until afebrile then discharge home, the nurse will come and give the IV antibiotics (total course of IV 2 wks, oral till 6 wks)

    Dukes criteria:



    Blood culture positive on 2 separate sets


    Echo: any mobile vegetation or new valvular regurgitation



    Fever > 38


    Predisposing heart disease


    Positive serology test for C3, C4, ASO


    Echo not normal but not meeting the major criteria


    Vascular phenomenon due to vasculitis

    To diagnose :


    2 major


    Or 1 major + 3 minor


    Or all 5 minor



    GP setting. A male pt came back for blood test result: cholesterol 7.3 (N 5.5). HDL is normal, LDL high, BSL normal. He is a manager in a supermarket. He does minimal exercise, eats junk food, BMI 31, fat in abdomen. He hasn’t had any symptoms but he’s concerned b/o FHx of AMI. His BP is 134/80.

    Task: explain the result, management


    I’ve got your blood test result and it showed your cholesterol is higher and LDL is also a bit high. It’s good that you don’t have the symptoms. But I know both of your parents had heart attack & you’re a bit overweight which means you’re at risk I appreciate you’re concerned about your health. It’s the right time because with lifestyle modification & with medication, if needed we can lower the risk Before I talked about weight & cholesterol, I’d like to ask you some questions to know if there are other risk factors

    • - I know you’re a manager & you don’t do a lot of exercise

    • - Is your job stressful?

    • - SAD

    • - Any family history of DM?

    • - The age of parents died with heart attack

    Now I’ll talk about the risk of high cholesterol & overweight. Risk of heart attack, stroke, DM, joint pain, back pain, gallbladder problem, kidney problem, psychological problem SNAP I’ll give advice regarding healthy diet and increase fibre diet, more vegetable & fruit, less fatty or take away and fried foods Try to cook by yourself if you can Do not take biscuits or chocolates or fried sacks in between meals. Take wholemeal bread, instead of white bread Take water instead of soft drink Reduce chocolate & salt Exercise of 15-30 minutes brisk walking bring change in your health If you don’t have time, park you car away from your job & just walk to the office You can use public transport and get off one station before It’s good that you don’t smoke/drink Try to reduce your stress at work by giving some responsibilities to others Don’t try to reduce your weight suddenly, 5-10 kg/year is acceptable

    Follow-up In the first 2-3 weeks, you need follow-up to see whether you need support for diet advice – refer to dietician In 6-8 weeks, we’ll do blood tests again for checking cholesterol again and whether you need medication or not Give pamphlet


    Cardiovascular Risk Assessment

    A 43 year-old female came for a routine check-up to your GP clinic. Her father died one year ago of heart attack. Her result showed total cholesterol 7.5, HDL 1.5, LDL 1.7.

    Task: cardiovascular risk assessment and basic management.


    Your cholesterol level is a bit high and you have positive FHx, we need to assess your personal risk of heart disease and discuss management plan.

    There’s a special chart to estimate the risk, the New Zealand guideline (ask examiner for the chart). Before assessing the risk, I need to ask you a few questions

    • - Do you smoke?

    • - Do you have hypertension? We need to check your BP now (ask examiner for the BP)

    • - Are you diabetic?

    Mary, here is the chart, there are some criteria:

    • - Gender Different chart for male & female

    • - Diabetic or non-diabetic

    • - Smoker or non smoker

    • - Age you’re 43 it means you’re here

    • - Your BP is 125/75

    • - Ratio of cholesterol total cholesterol/HDL = 7.5/1.5 = 5

    Mary, you’re in the blue quadrant, which means mild risk (<2.5%) to develop cardiovascular disease in the next 5 years

    Mx: Your personal risk is mild, but because you have a FHx & high cholesterol, we need to talk about the management plan

    • - You need regular follow up for lipid level, BSL

    • - Diet is important to control you lipid No junk food, no fish & chips, seafood, cheese

    • - Keep your body weight normal

    • - Regular exercise

    • - Quit smoking

    • - Control your alcohol intake

    • - Try to reduce your stress

    • - ?Start Lipitor (total cholesterol > 5.5)

    • - Written material

    • - Follow up

    Before starting Lipitor, test:

    • - LFT

    • - CK (because of rhabdomyolysis)


    Hypertension with OCP

    GP setting. A 25 yo female had BP reading of 150/108 on 3 occasions in the last 3 months. She’s on OCP. She had no other symptom. PE normal. Her BP was normal 2 yrs ago.

    Task: take relevant history, explain management, explain the effects of hypertension.




    Grade I

    • 140 90 - 99

    - 159


    Grade II

    • 160 100 - 109

    - 179


    Grade III



    Check BP 3 times within 3 months.


    When I checked your BP, it was high in 3 readings in 3 separate occasions. So we need to find out the

    possible cause How are you feeling these days? Have you noticed any chest pain, headache, SOB, heart racing? Did you have any problem with your kidney or thyroid previously? Have you noticed any recent weight changes? How’s your waterworks/bowel habit? Have you ever check your blood glucose/lipid level? Do you feel thirsty or do you need to go to the toilet frequently? Any family history of stroke, DM, hypertension? Are you on any medication such as painkillers? How long have you been using OCP? Any complications? After using OCP, did you go for a follow-up? When was your LMP? What’s your occupation? Any stress at work/home? SADMA Do you think you eat a healthy balance diet? Do you do regular exercise?


    I couldn’t find any abnormality except the OCP . OCP can cause hypertension. So I’d like to advise you to stop it and use other kind of contraception like condoms. I’ll check your BP after 2 we eks. If BP goes down, the cause is OCP. Meanwhile I’ll do

    some investigations such as FBE, BSL, Lipid profile, U & E, LFT, TFT, Urine analysis. If the BP doesn’t go down, the result shows abnormal, we need to start treatment. At the moment, we don’t need any treatment. First of all, you need to start a healthy diet. Do exercise 30 minutes/day for 5 days.

    Now, I’d like to explain about the effects of hypertension. Hypertension can cause hardening of blood vessels called atherosclerosis which can lead to dilatation or narrowing of blood vessels. H eart enlargement of heart, heart failure, heart attack Brain stroke Eye blurring of vision Kidney renal failure, damage to kidneys

    To prevent these complications, you need to control your BP I hope you’ll be fine if you stop the OCP



    GP setting. A 35 yo man was found to have a blood pressure of 165/95 on two occasions.

    Task: take further history, ask for physical examination finding, and advise management.


    • - Evidence of end-organ damage or complication of hypertension (heart, brain, kidney, eyes) indication to start medication from the start

    • - Primary or secondary

    • - Risk factors for other cardiovascular diseases

    Have you experienced any chest pain, SOB, palpitations, leg oedema Any pains or cramps in the legs Headaches, weakness or numbness in the body Any visual changes or impairments


    Any attacks of funny turns or pallor, chest tightness, throbbing headaches and palpitations


    Have you noticed any change in your weight Any increase hair growth Any skin changes like

    Risk factor

    Any PHx of renal problems, kidney diseases, heart attacks, DM Abnormal cholesterol level Any FHx of cardiac problems SADMA

    O/E: (To see evidence of organ damage and look for secondary cause) GA: BMI VS Radiofemoral delays Eyes : any abnormality, funduscopy Face : plethoric (red face in Cushing) or moon face Neck: any carotid bruit, JVP Thyroid Chest, heart, lungs Signs of cardiac failure Abdomen : auscultate for renal bruit, enlargement of kidney sizes (polycystic kidney) Legs : Vascular examination (peripheral) – pulse, color Urine dipstick


    After I have examined you, I couldn’t find any evidence of secondary causes, your high BP is most likely not secondary to any other problem. It’s a primary or essential hypertension which accounts for up to 95% of hypertension cases. However, we have to do some blood tests (to check for end-organ involvement and secondary causes).

    First line investigation

    • - FBE

    • - BSL

    • - LFT

    • - RFT

    • - TFT

    • - Cholesterol

    • - Uric acid level

    • - Urine analysis

    • - ECG with or without chest X-ray

    Second line investigation

    • - Echocardiography

    • - Renal US

    • - Doppler US

    • - 24-hour urine VMA (for phaeochromocytoma)

    • - Serum renin-aldosterone ratio

    Secondary causes (5-10%)


    • - Kidney 3-4% include glomerulonephritis, reflux nephropathy, renal artery stenosis, polycystic disease of the kidneys

    • - Endocrine : DM, Conn, Cushing, Phaeochromocytoma,thyrotoxicosis

    • - Coarctation of the aorta

    • - Drugs

    • - Pregnancy


    Starting medication if there is:

    1) Evidence of end-organ damage

    • - LVH detected by ECG, chest X-ray

    • - Hypertensive retinopathy

    • - Hypertensive nephropathy

    2) If initial diastolic is >110; systolic is >180 3) Failure of non pharmacologic such as lifestyle, etc

    Lifestyle modification for 3 months – weight reduction, reduce alcohol, reduces sodium, increase exercise and stop smoking Monitor BP on daily basis Measure BP at the same time

    If fails, start medication according to the age & other medical issue of patient ACE inhibitor (because can improve renal function too)

    Aim of treatment: Monotherapy

    ACE Inhibitor – Diuretic – Beta blocker – Calcium channel blocker For asthmatic patient, start with Calcium channel blocker Diabetic ACE inhibitor


    Hypertension: Examination

    GP setting. A 30 yo man had 3 high BP reading of 160/90 mmHg recently. He’s generally well and no other medical problem. He’s asymptomatic at the moment. He smokes 20 cigarettes / d for years. Task: do relevant PE while giving running commentary to the examiner and management.

    Secondary causes of hypertension:TRACK PADS

    T – Thyroid disease – signs of hyperthyroidism R – Renovascular (renal artery stenosis) – bruit

    A – Aorta (Coarctation of aorta)

    • C – Cushing syndrome – look for stigmata (moon face)

    K – Chronic kidney disease (eg glomerulonephritis, nephropathy, polycystic kidney)

    P – Phaeochromocytoma A – Aldosteronism

    • D – Drugs (OCP, NSAID, Steroids)

    S – Sleep apnoea


    • - I’m looking for stigmata of Cushing (moon face, buffalo hump) / hyperthyroidism

    • - Feel the pulse for coarctation of aorta – rate, volume, radiofemoral delay

    • - Measure the blood pressure – sitting/lying and standing in both arms

    • - Exam of eye – look for any redness (polycythaemia)

    • - Funduscopy – any change in the retina, disc, papillary oedema

    • - Thyroid – look for signs of hyperthyroidism

    • - Cardiovascular system – locate apex beat, listen to the heart sound for any murmur

    • - Jugular Venous Pressure, carotid bruits

    • - Respiratory system examination – any added sound, bilateral basal crackles (congestive cardiac failure)

    • - Abdomen – listen for the bruit, any distension, mass, ascites, organomegaly, dilated veins

    • - Palpate renal angle (for polycystic kidney) and auscultate for bruit (for renal artery stenosis)

    • - Pedal oedema


    • - FBE

    • - U, C & E (for kidney disease)

    • - BSL

    • - Lipid profile

    • - Serum cortisol

    • - Renin & angiotensin ratio

    • - 24-hour urine catecholamine

    • - Plasma renin, plasma aldosterone

    • - LFT

    • - TFT

    • - Renal ultrasound

    • - Doppler ultrasound for renal artery

    • - Chest X -ray

    • - ECG

    • - ECHO

    • - Renal arteriography

      • M x:

    Further investigation, may refer

    Follow -up Lifestyle modification



    Scenario 1: GP setting. A 55 yo female who was attended ED with BP 150/90 in 2 separate occasions. Apart from pharmacological treatment, you advised her to lose some weight. She wants to talk to you about weight management. Her BMI is 41. Task: take history, explain health risk of being overweight, counsel regarding obesity.

    Scenario 2: A 20 yo female university student, her BMI is 35. FHx of DM. All Ix normal. Task: explore the risk of obesity and management.

    Scenario 3: A middle-aged lady, BMI 45, saw you 1 year ago for joint problem. X -ray showed degenerative changes. Advised her to lose weight by lifestyle & dietary changes but it didn’t work. She’s here to find out if there are any other options for her. Task: take relevant history & management.

    Normal BMI 20-25; 26-30 Overweight; >30 Obesity

    Critical errors:

    • 1. Show no basic knowledge of pharmacological and/or surgical methods of Mx obesity

    • 2. Tell the pt that she’s not a candidate for pharmacological or surgical Tx.

    • 3. Talk only pharmacological or surgical methods without emphasising that lifestyle intervention is very important.


    When pt gained wt Reason for the gain Duration of being overweight Previous attempts of loss wt Number of times, whether successful, what methods used, what was helpful, reasons behind gaining wt again FHx of obesity, related disease and risk factors Dietary information, physical activity, social background, support and medication MHx: complications of obesity, assess CVS risk factors, r/o endocrine reasons

    What do you eat, please describe your one day diet Do you prepare the food at home or buy fast food Any snacks in between Work, what do you do for a living Are you actively exercise Habits – SADMA MHx: apart from hypertension, do you have diabetes, hypercholesterolemia FHx: anyone in your family have any medical condition ---Mother has a stroke, Father also stroke & in nursing home Have you ever tried to lose weight? What did you try? Did you try exercise? How much? Diet…what kind of diet Have you check your sugar level or lipid level before

    Health risks of obesity:

    • 1. Cardiovascular system

      • a. Stroke

      • b. IHD , heart attach

      • c. Hypertension

    • 2. Metabolic


    High cholesterol level


    Type 2 DM



    • 3. Mechanical




    Obstructive Sleep Apnoea


    Back aches

    • 4. Others


    Cancers (endometrial Ca, bowel Ca)


    Gallbladder disease (stones)


    Psychological problems



    It’s a very common condition. I’m very glad that you come back & decided to take action.

    Lifestyle modification

    You’re putting weight as a result of energy intake more than required. There is no simple effective way to treat this condition. Our aim to decrease energy intake, increase physical activities Energy in (food) = energy out (physical activity) + energy stored (weight) This management should be done by multidisciplinary team, GP, dietician, physiotherapist. You should set goals for yourself. 1) you should tell yourself no further weight gain. 2) lose wt slowly wt loss of 5-10% of body wt health risk. Make a graph to monitor the progress. 3) increase the activity, sport, tennis, golf, cycling, swimming, walking. You should limit your alcohol intake to 1-2 standard drink per day. For diet, fat food (the portion is important), fibre and vegetables. No sugar in tea or coffee. No snack between meals. Eat slowly, chew more (15 times) before you swallow.

    Medication (BMI >30, or BMI>27 with complication, failure to lose wt on a program of diet, exercise and behaviour therapy)

    • 1. fat absorption in the bowel Orlistat (Xenical) lipase inhibitor (SE: GIT disturbance) Mythyl cellulose (bulking agent)

    • 2. hunger (dopamine agonistsuppress appetite & energy expenditure) Phentemine (caution: allergy, palpitation, glaucoma, HPT, pregnant and breastfeeding, high cholesterol, IHD) Diethylpropion

    • 3. Enhance satiety (Serotonin agonists) Sibutramine Fluoxetin and other SSRI

    Surgery Laparoscopic adjustable gastric bands (LAGB), can be covered by medicare

    • - Last resort, BMI>35, Age 15-45, affect the quality of life, esp. with HPT and DM

    • - Pt should have commitment for diet after surgery: low fat+sugar, high fibre+protein, no snacks

    • - 2 weeks recovery period, first start with liquid diet, then soft diet, annual check-up

    • - >90% effective

    • - It’s adjustable and can be kept for many years Risk

    • - General: infection, clots, organ or tissue damage

    • - Specific: reflux, vomiting, heartburn


    Congestive Cardiac Failure (AMC 43)

    GP setting. A 53 yo clerical worker presented with bilateral swollen ankles. (Picture given)

    Task: relevant Hx, provisional Dx, ask relevant PE findings to confirm the diagnosis.

    Left ventricle failure:

    • - Blood is not coming out to the aorta

    • - Bilateral basal crackles because the blood flow goes back to left atrium and pulmonary veins pulmonary oedema in the alveoli

    • - More blood to the lung dyspnea (shortness of breath) on exertion or at rest

    • - Finally will lead to orthopnea and nocturnal dyspnea

    • - Will develop to RVF

    Right ventricle failure

    • - Any problem in lung – COPD – pulmonary artery pressure increase go to right ventricle – right atrium - cause elevated JVP

    • - SVC – to the liver hepatomegaly

    • - IVC drain from the abdomen ascites

    • - Pedal oedema


    What brings you here today? (I’ve come to see you doctor because I have had swelling in my ankles for about 2m and usually gets worse in the end of the day.) Is it started gradually or suddenly? (gradually) Both legs? (yes) Any pain? Any skin colour changes? (no) Swelling anywhere else apart from your legs ? (no) Do you get SOB? (become breathless when walk up stairs/ walk fast and this pass when rest) How much exercise can you do before you get SOB? How many pillows do you use? (only one) What about at night, do you get up from sleep and fell SOB? (no) Do you fell your heart is racing than usual or you fell palpitation? (Yes, for the last few yrs) Have you had any dizziness or black out ? (no) Do you have any cough, sputum, blood in the sputum or fever? (no) Have you had any chest pain, or chest pain on exertion? (not now) Did you have any chest pain in the past? (yes, I had in the central of my chest but it was 4 years ago, lasted for 2 h, and I felt unwell for a few days afterwards.) Any black bowel motion? Weight changes? (no changes, normal weight and has healthy diet) Skin and urine colour changes, tiredness, wt change, itchiness and bruising. (r/o liver disease) PHx of hypertension (no) PHx of rheumatic fever, IHD, DM, hypercholesterolemia, kidney or liver problems? (no) Medication (no) Do you smoke? (smoked for 20 years and stopped smoking last year) Drinking (3 glass of wine/ day ) Job (has to stand for long hours) FHx of IHD, MI, diabetes (mother died of stroke at age of 77, father died at the age of 90)



    From the Hx it seems that the swelling of your legs are due to heart condition which is called

    cardiac failure. Congestive heart failure is present when the

    blood to satisfy the needs of the body

    heart and nearby veins. This triggers

    heart cannot pump enough

    . Weakened chambers allow blood to pool inside the

    Explanation: CAR DIOVASCULAR SYSTEM From the Hx it seems that the swelling of your legs are

    fluid retention, particularly in the lungs, legs and

    abdomen. In your case most likely due to the IHD, MI (the chest pain which you had 4 yrs

    ago). O/E: (You need to ask what are you looking for, but no result will be given)

    I am looking for signs of cardiac failure and underlying causes, kidney and liver disease as well as other causes of swelling like venous thrombosis , bilateral DVT,cellulitis. (Bilateral basal crackles; Hepatomegaly; Ascites; Bilateral pitting pedal oedema) GA: face swelling, dyspnoea (SOB), Mouth cyanosis VS: BP, T, RR, Pulse rate and rhythm JVP distension, pulse and pressure, carotid bruits CVS:

    • - Inspection: apex beat displaced or not

    • - Palpation: apex beat, heave thrill

    • - Auscultation: cardiac sounds ,murmur, rub

    RS: crackles at the base of the lungs, and look for signs o effusion. Abd: hepatomegaly, hepatojugular reflex, splenomegaly and signs of ascites, Check inguinal area for enlarged lymph nodes (enlarged LN cause pressure to the veins) Palpate kidneys Lower limbes exam: Oedema (pitting), symmetry, how match, Discoloration, Tenderness (r/o DVT), Temperature, Varices Urine dipstick


    ECG, echocardiography, CXR Blood tests: cholesterol, FBE, BSL, U & E,BNP


    • - Diuretics (frusemide)

    • - Spironolactone

    • - Beta blocker

    • - ACEI

    • - Digoxin



    You’re a GP. A 50 year-old tram driver came with chest pain radiating to the back and shoulder. He had flu few days ago.

    Task: take history, examination, diagnosis, management.

    Hx: Ask examiner if the patient is stable or not. Are you in severe pain? Do you want a pain killer before we proceed? Could you please tell me where exactly the pain is? How severe is it? Does it go anywhere else? Is it related to any activity or effort? Could you please describe the pain? How does it feel like? Sharp? Pressing in nature? Dull? Any relieving factor? Anything which makes the pain worse?

    Does it change with posture?

    Any associated factors: fever, N/V, sweating, dizziness, heart racing, cough, SOB

    Any previous chest infection, night sweat?

    Have you ever been diagnosed with TB? Any contact with people with TB? Any trauma to the chest? Any loss of weight and loss of appetite? Any history of tumor or cancer, kidney problem? Clotting problem? Any heart attack in the past? Are you on any medication? Any recent long trip? Any recent operation? DM, HTN, high cholesterol?


    started 2 days


    Increase by

    deep breathing

    & cough,



    ago had flu-like




    GA VS Chest exam Heart exam: the only finding is noise on auscultation of heart. Ask examiner is that rub?

    ECG - ST elevation with upwards concavity in all leads.


    You are having a condition called pericarditis which is inflammation of the covering of the heart probably due to viral infection as you had flu a few days back.


    I’d like to send you to the hospital and they will do further Ix:

    • - FBE, ESR, CRP

    • - U & E, creatinine

    • - TFT - hypothyroidism can cause pericarditis

    • - LFT

    • - Connective tissue disease screening like ANA, Ds DNA (double stranded DNA), rheumatoid factors

    • - ECG, Cardiac enzymes, Echo (pericardio-centersis)

    • - Blood culture if fever


    Simple analgesic first If severe, colchicine Steroid and immunosupressant as last resort

    I will refer you to the hospital for investigation and you will be assessed by cardiologist and decide whether you need admission or not.



    A 45 yo woman came to your GP clinic complaining of something wrong with her nerves.

    Task: take history, PE, Investigation, Management


    What do you mean by something wrong with your nerves? Since when? Do you know any reason or precipitating factor? Is it the first time? Any associated symptoms such as tremor, headache, heart racing, weather preference? How’s your appetite, any weight loss or weight gain? Waterworks, bowel habit Any lumps in your body? Any eye problem, skin problem, hair problem? Menstrual history, LMP, cycle, any change in pattern (maybe due to menopause, thyroid) What’s your occupation? Any stress at home or at work? General health Any family history of thyroid problem or cardiac disease SADMA


    GA: BMI; Tremor, sweaty hands; Eye signs: lid lag, exophthalmos; Hair thinning VS: P, rhythm, BP (sitting and standing), T Lymph nodes Thyroid – enlarge – smooth, nodular, thyroid bruit CVS: widespread systolic murmur Abdomen: mass, organomegaly

    Oedema in lower limbs Urine dipstick


    • I believe your condition is probably due to hyperthyroidism.

    There is a major gland in your neck which produce the thyroid hormones. Sometimes the gland becomes overactive and secretes more hormones which is causing your symptoms


    FBE, U & E, LFT

    TFT: T3, T4, TSH US of thyroid ECG (Cardiovascular monitoring is important)

    Radio isotope scan if needed

    • I will refer you to an endocrinologist, who will discuss the management options with you:

      • - Medical : Thiouracil, Beta blocker, carbimazole (agranulocytosis)

      • - Surgery: Partial or Total Thyroidectomy


    Hypothyroidism (AMC 35)

    A 50 year old patient named Jenny, she did some blood test last week and came back to discuss with you. Hb 110 (N 120-160), blood film showed macrocytosis, triglyceride 5 (Normal <1.7), cholesterol 8 (Normal 5.5), TSH 25 (0.5 – 5), slow heart rate. Constipation, lethargic. Anemia macrocytosis deficiency of B12 & folic acid (MCH >100)

    Task: explain result, diagnosis, outline management.

    Critical Error: Failure to interpret the result.

    Anemia macrocytosis deficiency of B12 & folic acid (MCH >100) Increase demand or not enough absorption. Intrinsic factor attached to B12 & absorbed in the gut. Anemia pernicious There are parietal cells in the stomach. Intrinsic factor will attach to the B12 and absorbed. For autoimmune disease, the intrinsic factor will be deficient. Give folic acid and B12. B12 is given with injection, with oral it won’t be absorbed.


    Most of the time is autoimmune disease, associated with each other. Most likely to have another autoimmune disease. It might be 2 things, might be B12 or Folic acid, and see which one is deficient.


    Look Jenny, I’m sorry to tell you that I don’t have a good news for you. As I told you that we

    were suspicious for hypothyroidism. The result showed unfortunately hypothyroidism. Not an uncommon condition Thyroid is the gland in front of your neck, butterfly like, very small. This gland produces hormone called thyroxin. This hormone is very important to our body, it affects almost each & every cell in our body. It makes your heart slow down. It slows down your gut too, so that you have constipation. It affects your metabolism, it increases the fat in your blood, as you can see, high cholesterol & triglycerides.

    This condition is an autoimmune disease which means that our body secretes some antibody that normally attack the bugs. But sometimes, it also attack our own cells and this is what happen in your situation.

    The good thing is that it can be treated easily. Under production of this hormone, you don’t have sufficient of this hormone and have to be replaced. I will refer you to the specialist. The specialist will give you this hormone from outside. He will monitor the TSH level, they will monitor the ECG as well. As you don’t have any heart disease and you’re still young, the specialist probably will start from low dose. Thyroxine will be given 50 microgram increase until get normal TSH. elderly and IHD- start fr 25 ug


    What about my cholesterol? Because you have under production of the hormone, you have increase fat in your blood. However, with the treatment, the fat levels in your blood will return to normal. But it’s also very important that you do regular exercise. Also I’d like to refer you to a dietician.

    Do I need to take any medication for it? Because you don’t have any other risk factors, do exercise and take healthy diet. If afterwards, the results are still high then we’ll start with medication.

    Jenny, other thing that I’d like to discuss with you is your blood result. It showed that you have anaemia. I think the cause of your anaemia is B12 deficiency. I believe the condition is called pernicious anaemia which is associated with hypothyroidism. It tends to come together with hypothyroidism. Are you a vegetarian? I have to check your B12 level. Every 2 weeks, IM injection of vit B12. Normal level, increase the period.

    What will happen if untreated? Stroke, peripheral vascular disease, heart disease, slow heart rate, constipation….

    How long do I need to be on medication? It’s a life-long treatment

    the thyroid will function again? No

    What are the SE of the hormone treatment? We might give you more hormone than necessary, you can have diarrhoea, fast heart rate, palpitation (atrial fibrillation/arrhythmia), sweating.




    Non Toxic Multinodular Goiter

    A 30 yo lady presented to your GP clinic b/o 2 yrs Hx of a lump in the neck Task: take further history, take focus exam & advise investigation & management.



    • - Where is the lump

    • - Onset when did you first notice the lump

    • - Progression Over this time, have you notice any change in the lump?

    • - Quick enlargement or gradually increase in size

    • - Is it painful or sore, any temperature (---thyroiditis)

    • - Have you noticed any other lumps in your body Hypo or hyper functioning of the thyroid

    • - Appetite – (cancer)

    • - Any recent change in your weight

    • - Any change in bowel motions

    • - Are you becoming intolerant to heat or cold

    • - Any recent mood changes

    • - Any palpitations

    Local compression symptoms

    • - Cough, any SOB, any hoarseness of voice, any noisy breathing (stridor)

    • - Any difficulty in swallowing

    • - Function of the thyroid – any shakes, tremor, any recent nervousness (thyroid toxicosis) Possible metastasis Headaches; Bone pain; SOB; Chest pain

    Female – menstrual history How’s your health in general Any past medical history Any previous operation Any family history especially thyroid diseases or cancers Any radiation SADMA lithium might cause thyroid problems; amiodarone Diet: Goitrogenic diet ---cabbage family, turnips, broccoli, Brussels sprout, fish


    GA: BMI, hand tremor, skin (hypothyroid---dry), eye signs: exophthalmus, lid retraction, lid lag, ophthalmoplegia (sign of Graves disease) VS: P, rhythm, T Examine the lump

    • - Inspect from the front

    • - Give a glass of water, 2 sips, to see if it’s moving with swallowing

    • - Is it one side, move or not

    • - Examine thyroid from the back

    • - Drink 2 sips of water if the gland move upwards with the swallow

    • - Palpate each lobe, push by hand and feel the lobe with the other hand

    • - Palpate the surface, consistency ---soft, firm, hard, any tenderness, any skin temperature change, possible thrill

    • - Palpate cervical lymph node

    • - Percussion ---over the sternum for retrosternal extension

    • - Auscultation


    • - Pemberton sign, ask patient to extend the hands and see if there is any change in the face CVS heart sound, murmur Neurological exam: ankle jerk ---delayed relaxation in hypothyroid


    After examination, it seems that it’s an enlargement of your thyroid gland, a gland situated on the top of the voice box. An important gland, secretes the thyroid hormone that controls a lot

    of functions in your body. There are a lot of reasons for the thyroid gland to be enlarged. To know the cause I have to do some tests:

    • - TFT ---in this case it’s euthyroid

    • - Thyroid ultrasound ---multinodular or 1 nodule, solid or cystic

    • - FNAC from the biggest nodule or from the 2-3 biggest nodules

    • - (The radio iodine uptake is important in solitary thyroid nodule)

    • - For retrosternal extension check with chest CT scan

    The result is back. I have good news that it’s non malignant. There is also investigation which showed that there is no malignancy. It’s called Non Toxic Multinodular Goiter, it’s a very common condition especially in ladies around this age. Possibly it’s related to a reduced intake of iodine. Some food stuffs may cause it. Sometimes it runs in families, because of abnormalities in TSH, called familial endemic goiter.

    The treatment actually is just watching the gland, involving frequent visits. There’s a small chance that it may grow to a toxic goiter.

    If symptomatic, the treatment is by surgery:

    • - If developed any pressure symptoms, or

    • - Become thyrotoxicosis or

    • - If the FNAC showed a suspicious lesion, or

    • - If you want to move it for cosmetic reason

    Advised also increase iodine in the diet.

    Pemberton's sign is the development of facial flushing, distended neck and head superficial veins, inspiratory stridor and elevation of the jugular venous pressure (JVP) upon raising of the patient's both arms above his/her head simultaneously, as high as possible. A positive Pemberton's sign is a sign of superior vena cava syndrome, possibly from a mass in the mediastinum, such as a tumor or goiter (thoracic inlet obstruction due to retrosternal goitre or mass).Apical lung cancers often cause a positive Pemberton's sign and a high index of suspicion should be maintained in patients with symptoms of dyspnea and facial plethora with an extensive smoking history.


    Thyroid Nodule

    A 50 year-old lady came to your GP clinic because she noticed a swelling on her left neck for the last 3 weeks. This lump moves with swallowing.

    Task: manage the case.


    Multi nodular goiter Cyst



    Most likely you have a thyroid nodule. Thyroid is a butterfly shaped gland in front of our neck. It is a small gland with two lobes. The gland is important for our body because it secrets some hormones which regulates some functions of cells in the body. It could be a single nodule, multiple nodule, cyst or in some case could be cancer. Management depends on the type of nodule.

    MNG- multi-nodular goiter

    • - Toxic T3 and T4 increase, TSH decrease

    • - Non-toxic T3, T4, TSH normal

    For confirmation I’d like to do some tests.


    TFT – hypo/hyperthyroid (T3, T4, TSH)



    • - cystic, solid

    • - single, multiple

    • - any suspicious features presents or


    • - only lymph node FNAC cystic

    FNAB solid

    • - we will take tissue from the nodule for sample


    • - we will check this tissue under microscope to get an idea what kind of tissue it is Isotope scan - function of thyroid nodule. Three types :

    • - cold means non functioning could be cancer

    • - hot means hyperfunctioning - could be adenoma and

    • - warm means over functioning, Graves disease


    CT scan of head, neck and chest to detect metastasis

    MANAGEMENT Management depends on the test results and the size of the nodule.

    If cyst aspiration can be done If adenoma total thyroidectomy/hemothyroidectomy

    If overfunctioning give medication such as:

    • - carbimazole

    • - propylthiouracil

    • - B blocker

    • - radioactive Iodine131 or

    • - total thyroidectomy + thyroxin replacement


    For cancer total thyroidectomy + thyroxin replacement

    Complications of surgery General bleeding, infection, anesthetic risks Specific 1) Nerve damage (recurrent laryneal nerve) - hoarseness of voice

    • To prevent this, use laryngoscope before and after surgery.

    2) Tension hematoma - as thyroid gland is highly vascular. Haematoma is common. When bleeding accumulate it compress the wind pipe and patient can die because of this. Take out the suture at bedside, call for help, move to the theatre and open all the layers.

    3) Hypoparathyroidism Hypocalcemia need calcium replacement 4) Hypothyroidism (thyroxin replacement) 5) Thyroid storm

    I will see you when your test results come back. Offer reading material


    Papillary Thyroid Carcinoma

    A 20 yo female came to your clinic c/o neck lump in the thyroid gland. You examined her and did all Ix. FNAB came back confirming the diagnosis of papillary thyroid carcinoma.

    Task: Talk to the patient about her Dx, give appropriate reassurance, Mx


    I’m sorry to tell you that you have a nasty growth in your thyroid gland and the result came in telling that there is a papillary thyroid carcinoma

    This is the most common type of cancer in the thyroid Unfortunately it can affect all ages especially the young people It’s a slow growing malignancy but it can spread to LN. The good news is in your case, there’s no LN involvement. You came early and the prognosis is good

    Would you like me to continue or shall we make another appointment? Mrs Smith, I’d like to ask you some questions Did you experience any difficulty in breathing or swallowing? Have you noticed any change in your voice? Have you noticed any lumps in your body other than this? Does anyone in the family have the same problem? Did you have a previous exposure to radiation

    I will refer you to the surgeon There are 2 types of operation

    • 1. Conservative surgery – take off the lobe related to the lump, isthmus and leave 40% of the other lobe

    • 2. Radical surgery – take all the whole gland and lymph nodes

    Complication of the operation

    • - Anaesthesia

    • - Bleeding

    • - Infection

    • - Injury of recurrent laryngeal nerve and will affect your voice

    • - Hypocalcemia (from the parathyroid gland)

    Radiotherapy: Iodine 131 if the tumour invade the underlying structure (laryngs, trachea).

    Maintenance treatment:

    Thyroxin tablet to compensate This tumor is TSH dependent, when the thyroxin level is normal, TSH will be kept low (if

    TSH is high, there is a chance of recurrence of this papillary ca because this is a hormonal dependent cancer). Prognosis- better in young female


    • - CT scan on the neck, chest and bone (bone scan) for metastasis

    • - Blood test (serum thyroglobulin)

    • - Yearly check-up for 2 years


    Type 2 DM Counseling (AMC 73)

    A 35 year-old lady with BMI 35 came to your GP clinic for the result of her random blood sugar which is 15 mmol/l. She is on ACE inhibitor and thiazide diuretic. She had not had any signs and symptoms of DM.

    Task: explain diagnosis and management.

    Critical errors:

    Not stopping medication No telling to monitor BSL for 3 times a day

    Your blood test result showed that your blood sugar level is higher than normal.

    • I suspect you may have DM.

    • I will explain to you what is DM, what is the cause, risk factors, how to manage it, how to control it, how to prevent the complication. During my explanation, if you have any questions, please feel free to stop and ask me. At the end of the consultation I will give you the reading materials.

    There are 2 types of DM, type I and type II Type I usually happens in childhood/early age. Type II is due to insensitivity of body cells to insulin hormone, to vegetate blood sugar in our body which means insulin resistance, we called this “insulin resistant DM”.

    Why do I have diabetes?

    Causes could be familial, diet, lack of exercise. In your case, medication could be the cause.

    It is not a curable disease, but controllable. Don't worry we can control diabetes very effectively and prevent complication with your cooperation and specialist help. Many people are living their normal life with DM. People might have some symptoms like polyuria which means frequent waterworks and thirsty (polydipsia).

    It could affect many parts of our body or could be asymptomatic that means no sign or symptoms.

    • I need to arrange some tests to confirm the diagnosis

      • - OGTT Fasting blood sugar + 2 hour after meal

      • - Fasting Blood Suger Baseline test:

        • - FBE

        • - RFT

        • - Lipid profile

        • - HbA1C

        • - Urine microscopy and culture


    • 1. Stop diuretic

    • 2. Control blood sugar

    • 3. Regular monitoring of blood sugar 3-4 times a day by glucometer and HbA1C every 3 months by doctor. RFT, urine dipstick

    • 4. Lifestyle modification


    • - smoking, nutrition, alcohol, physical activity (BMI)

    • - BP control

    • - cholesterol control

    • - reduce stress

    • - small cut


    we will control your

    multidisciplinary team.

    blood sugar, next

    we will aim to prevent complication by

    You need to take healthy diet, avoid junk food. I can see your weight is above normal. You need to reduce your weight by exercise and diet. If you want, I can refer you to a dietitian for healthy diet advice.

    If you have a dog, take the dog for a walk

    If you have a car, park the car in the station and use public transport.

    I’m going to refer you to a specialist to assess your condition. You need to stop diuretic and switch to another medication.

    You need to visit your GP regularly You need to check your BP, lipid level regularly.

    If you want I will refer you to a support group.

    To prevent complication, you need to check regularly:

    • - Eye refer to ophthalmologist

    • - Foot care podiatrist

    • - Kidney nephrologist

    • - Skin care skin specialist

    Regular follow up Reading material Red flags hypoglycemia

    If you are not able to control your blood sugar with lifestyle modification in 2-3 months, you might need to start on medication. After that, you might need to take medication to control your blood sugar level.

    My friend is using insulin; do I need to use insulin?

    Very unlikely because your diabetes is type II. But sometimes to prevent complications you might need to take insulin. For you, lifestyle modification and medication are first.

    Diabetes is diagnosed as follows

    • 1. If symptomatic (at least two of polydipsia, polyuria, frequent skin infections or

    frequent genital thrush).

    fasting venous plasma glucose (VPG) ³ 7.0 mmol/L random VPG (at least 2 hours after last eating) ³ 11.1 mmol/L

    • 2. If asymptomatic:

    At least 2 separate elevated values, either fasting, 2 or more hours postprandial, or the 2

    values from an oral glucose tolerance test (OGTT).



    GP setting. A 57 yo man with type 2 DM recently commenced on insulin and you have booked an appointment for him to a diabetic educator next week. He’s on protaphane (long acting insulin) 20 unit bid. This morning he had a pre episode of being dizziness with nausea, sweating and light headedness. His friend brought him to your clinic urgently.

    Task: relevant Hx, what tests you’d do in your clinic and how would you manage your pt.

    Diabetic patient has to check 3 things:

    • - Check Blood Sugar

    • - Check insulin dose

    • - Meals


    Mr Smith, could you tell me this morning what’s your symptoms and signs exactly? (compared between the symptoms previously and now) Have you check your blood sugar regularly like 3-4 times a day? D id you check your blood sugar this morning ?---No Did you take your insulin today?---Yes Have you had your breakfast today?----No, I wasn’t hungry Have you had your dinner last night? D o you do exercise?---Yes, at least 2 days and yesterday I had a good walking for 1 hour Any headache, vomiting? Did you lose your consciousness? Any weakness any part of your body? Any speech problem, visual disturbance, difficulty swallowing? Any recent trauma to the head or falls? SADMA

    Ix: Random Blood Sugar (<3mmol/L is hypoglycaemia)


    You have hypoglycaemia, that means your blood sugar level is lower than the normal level. The cause of your condition is you haven’t checked your blood sugar & you took insulin and you didn’t have a good & proper breakfast.

    I’ll give you glucose drink now and recheck your BSL in 10 mintues.

    Y ou need to check your BSL 3-4 times/d, if you find the level is too low or too high most of the time, let me know and we may need to adjust your insulin dose. Eating good food regularly, don’t skip meals especially when you are on insulinRefer to dietician to give an idea of the suitable food. How he can avoid some kinds of food. Do not smoke. Cutting out alcohol or drinking only a little. Exercise is important, but do not over stress yourself.

    Hypoglycaemia action plan

    Keep some Jellybeans in your pocket, if you have any symptoms like dizziness, sweating , tremor, palpitations, take 6. Don’t repeat unless still unwell after 10 mintues. Follow either a complex carbohydrate meal.

    Glucagon 1ml IM 10-25 ml 50% dextrose


    Diabetic Ketoacidosis

    In a countryside hospital. A male 20 year-old came to see you complaining of tiredness.

    Task: history, physical examination investigation & management.


    When did it start How did it start Is there anything else you feel at the same time? Any fever, pain, lump Any skin changes color, skin rash Any weather preference Any visual problem Any problem with bowel Any problem with urination – increase frequency, color – light Any thirsty feeling Is your mouth dry Are you generally healthy Any chronic condition, asthma, diabetes, any renal problem, liver problem Any history of STD How’s your mood, appetite, sleep, sexual problem Social Hx: Occupation; SAD ; Family support Any family history of diabetes, thyroid problem


    GA: acidotic breathing, Ketone smell, signs of dehydration VS: RR increase hyperventilation, BP postural drop, PR, T Systemic review – normal Urine dipstick : sugar +++, ketones +++

    BSL 16.4


    ABG to check pH, bicarbonate, potassium Metabolic acidosis with compensatory respiratory alkalosis PH 7.2 (normal 7.35-7.45) pO2 - 96

    pCO2 - 28 HCO3 – 14 K+ - increases


    I highly suspect you have diabetes based on history, physical examination First episode with DKA , medical emergency admit to ICU Start IV line 15-30 ml/kg/hour, first 2 hours 7.5 ml/kg/hour after that Short acting insulin IV 0.1 unit/kg/hour infusion Monitor urine output NaHCO3, sodium bicarbonate 8.4% 70-100 ml only if pH<7 (risk of arrhythmia)

    If K>4 no need If K 3-4 30 mmol/L If K <3 40 mmol/L When glucose level <12, we can add 5% dextrose 100 ml/hour


    Addison’s Disease

    A 30 yo woman is complaining that her skin has become darkening over her body. She recently loss weight and feels lethargic.

    Task: take history, PE, Investigation and Management.

    Causes of Addison’s disease


    Autoimmune (80% in UK)


    TB (most common worldwide)




    Cancer (primary or secondary)








    Drug – heparin



    Addison’s disease

















    Main Symptoms


    Skin darkening




    Abdominal pain




    Postural drop of blood pressure – dizziness


    Weight loss, nausea, vomiting


    Myalgia, arthralgia


    Later – depression


    When did you notice the skin pigmentation Could you tell me the distribution of the pigmentation Is the pigmentation getting darker When did you start to feel lethargic Do you have any headache, dizziness When did you notice weight loss, how much Any change of your appetite, any nausea, vomiting, diarrhoea or constipation Do you feel anxious Sweating, palpitation, tremor, weather preference (to rule out hyperthyroid, phaeochromocytoma) Do you feel thirsty, do you need to go to toilet ferquently (DM) Do you have any cough, chest pain, night sweating (Chest infection) Any contact with TB patient Any abdominal pain Period – how’s your period Are you sexually active, stable partner (HIV) How’s your general health, any autoimmune disease

    Are you taking any medication (Drug induced) SAD



    GA: pigmentation all over the body, darker on palm and mucous membrane of mouth, BMI VS: BP always fluctuate, sometimes postural drop Thyroid, lymph node Systemic Abdomen – organomegaly Urine dipstick


    FBE, HB low BSL low Urea & Electrolytes – Na low, K high, Mg high, Ca high LFT high ACTH stimulation test (not for pregnancy, OCP)Serum cortisol level low CT scan abdomen Chest X -ray (to exclude TB, Pneumonia) – no need in this case Abdominal X-ray for calcification


    From the history & examination, you’ve got a condition called Addison’s disease, which is not uncommon. There is a problem in one gland of our body called adrenal gland which is responsible for secretion of some hormones (cortisol, aldosterone) (Destruction of adrenal cortex leads to cortisol, aldosteron e deficiency) It has effect on the cells of our body

    I need to admit you to the hospital to have a replacement of the hydrocortisone by the endocrinologist, 20 mg IV in the morning, 10 mg at midnight If postural hypotension is not controlled, they will give you mineralocorticoid (fluorocortisone) Hydrocortisone bid lifelong (not given late in the day)

    Advice You need to wear bracelet in your hand You should carry a cortisol card in your bag You need to keep a cortisol injection at home for emergency Do not stop medication by yourself You need to be followed-up by your GP regularly You need to visit your GP for any kind of condition (infection, stress) If you need to do a surgery, you need to consult w ith your endocrinologist

    RED FLAG (Addison crisis)

    • - Severe abdominal pain

    • - Dizziness, sweating, palpitation

    • you need to go to ED directly


    • - No skin pigmentation

    • - BP very high, PR high

    • - Headache, sweating

    • - Investigation Adrenalin high


    Phaeochromocytoma (Incidetalomas) (AMC p 303)

    A 66 year-old male presented to you with right upper quadrant pain for possible gall stones and USG was ordered which showed a focal round mass of 5 cm at the position of right adrenal gland.

    Task: take history, Examination, Investigation, Management.



    10% rule

    10% malignant 10% extra adrenal

    10% bilateral

    10% familial

    Symptoms: sweating, headache, pallor, flushing, pyrexia, seizure, visual disturbance, palpitation, chest tightness, pulmonary oedema, abdominal pain, constipation, high BP

    How do you feel right now, any pain How is your tummy pain In addition to gall stones, the US result showed a mass on the top of your kidney at the area of adrenal gland For this reason, I’d like to ask you a few more questions and I’d like to do a few more Ix

    Is it cancer?

    Well, it’s not clear yet, it just showed a mass Have you ever felt dizzy, nauseated, heart racing, any funny turns (seizure), any kind of headache, sweating, weather preference

    Have you ever checked your BP, normal or high Do you have easy bruising Have you noticed any change in your body weight, appetite Abdominal pain Do you feel weak or tired Have you noticed any increase of abnormal hair growth (Cushing) Any sexual problem, cramping sensation in your legs Polyuria, polydypsia (DM) --- more thirsty than before, passing water more frequently Any family history of thyroid problem, hypertension MEN syndrome thyroid, parathyroid, pituitary, adrenal Past medical history SAD


    GA: skin pigmentation Symptoms of Cushing: Cushinoid face, truncal obesity, abdominal striae, hirsutism, easy bruising BMI (body fat distribution)

    VS: BP (episodic HPT), PR, Temp CVS, Chest, Abdomen




    After history & examination, I couldn’t find any abnormalities, but you have a history of

    funny turn. For that reason, I’d like to do some tests:




    U & E: normal (Sodium high, K low when has episodes)


    Aldosterone level high


    BSL high


    Serum calcium high


    RFT – urea, creatinine


    ECG, echo


    24 hour VMA level


    Urine catecholamine level


    Serum cortisol level


    MIBG scan (nuclear scan radioiodine labelled agent)


    CT/MRI of adrenal gland

    From the blood test & US report, I suspect you have phaeochromocytoma (a catecholamine producing tumor). Normally a part of the gland secretes a hormone called adrenalin but in your case, a large amount of hormone has been secreted which is responsible for your symptoms I’d like to refer you to a surgeon who will arrange an operation for you Before the operation, you need to be prepared with some medications for 1-2 weeks : first you will be given alpha blocker then beta blocker (to avoid crisis from unopposed alpha adrenergic stimulation) Laparoscopic key hole operation After the operation you need to stay in the hospital for a few more days to monitor your blood pressure


    Massive Weight Loss

    A 45 year-old female came to GP clinic complained that she lost 7 kg of weight over the last 6 months. Appetite is good, no other abnormalities.

    Task: take history, examination, DDx, Investigation.


    • - Malignancy (lung, GIT, lymphoma, leukaemia, melanoma)

    • - Autoimmune

    • - Endocrine/metabolic (DM, thyroid)

    • - Infection (TB, HIV, atypical pneumonia, infective endocarditis)

    • - Psychological (Anorexia, eating disorder)

    • - Decrease intake

    • - Malabsorption (Coeliac, IBD)

    • - Menopause

    Hx: (head to toe) When exactly did you notice that you’re losing weight Did you notice any recent change in appetite since then Any change in your mood Any change in your bowel habit Any abdominal pain Any blood in stool Any lump in the body Any fever, night sweat Any vomiting Any recent travel Have you noticed any excessive drinking of water or passing more water Did you eat more than you usual Any irritability or tremors in the hands (thyroid) Any hair loss (thyroid) Did you find it difficult to flush your stool (Coeliac) Any change in your period Any chronic medical illness How’s your waterworks Any skin rash Are you sexually active Are you in a stable relationship Any recent diagnosis with STD Any family history of malignancy Any other GIT problems like ulcerative colitis, Crohn’s disease Do you drink alcohol, how much, how long Smoking, how much, how long (bronchial carcinoma) Are you on any medication Any longstanding use of any medication Pap smear and mammogoaphy


    GA: ask everything


    • - Alert, anemia, jaundice, any rash, any lymph nodes, any clubbing, BMI

    • - I’d like to check for any skin mole or any new mole in the body and scalp

    • - Examination of the throat – any lump or swelling under the tongue, any malignancy Thyroid Breast Full respiratory system: equal breath sounds, any wheezing CVS Abdomen PV PR

    Any office test available – random BSL


    • - FBE

    • - U & E

    • - CRP

    • - TFT, LFT, RFT

    • - Chest X-ray

    • - ECG

    • - US abdomen

    • - Gastroscopy

    • - Colonoscopy

    • - Fecal Occult Blood

    • - Tumor markers

    • - Calcium (osteoporosis)

    • - Magnesium

    • - CT abd,pelvis


    Pleomorphic Parotid Adenoma

    A picture of swelling over the left cheek, the patient said that the swelling is already there for 5 years. Not painful. Firm on palpation, not lobulated.

    Task: examine the patient and tell DD, manage the case.

    Causes: Alcohol intake (parotid enlargement); Nutritional


    GA: looks healthy, active, not drowsy VS

    Clinched teeth masseter muscle will contract localization of the swelling (behind the masseter muscle, in front of the ear)


    Size: 5x5 cm


    Shape: rounded


    Consistency: firm, not lobulated


    Margin: well defined


    Mobility: mobile, not attached with underlying structures



    Bimanual exam of the parotid gland check the opening next to the second upper molar tooth or middle third of the line from trigus to the middle of the upper lip Lymph node enlargement Check facial nerve (sit in front of the patient) No sign of facial nerve involvement



    Rise eyebrow to check forehead, push it down


    Close eyes and try to open


    Show teeth nasolabial fold compared for 2 sides


    Blow and whisper

    DD x:




    Mixed parotid tumour


    Tumour infiltration


    Duct blocking by stone







    Alcohol intake




    Severe dehydration


    Mikulicz syndrome (all 3 salivary glands enlarged together)

    Lump or enlargement of the whole gland

    Parotid swelling can be lump (malignant or benign) to differentiate look for facial nerve involvement, consistency, wt loss, rapid growth, LN involvement, painful or painless

    • Course, pain, lobulation, involvement of facial nerve

    Diffuse swelling

    • - viral (parotitis)

    • - blockage (stone) suppurative or not


    US (?no fine needle spreading) Surgeon parotidectomy


    Consent For Below Knee Amputation (AMC 120)

    A 30 yo man has open crush injury to his L leg in a motor vehicle accident. He’s conscious, no injury in other area. The orthopaedic registrar has assessed him and immediate below knee amputation has been recommended. He’s now stable and has been given painkillers.

    Task: no need for Hx and exam. Obtain consent from p t and answer examiner’s questions.

    How do you feel at the moment?

    Before we discuss what should be done, I’d like to ask you a few questions Do you want me to call your friend or family?

    Assess patient’s competency

    Do you know what’s today date, month, and year? (time, place, person) Do you think you can concentrate well, any drowsiness, dizziness? Are you using any drugs apart from painkillers? How much damage do you think your leg has?

    I’m sorry to tell you that you have a massive w ound on your left leg, we call it a crushing type where some of the vessels, nerves and tissues are completely crushed and not viable . After discussing with the surgical team & my registrar, it seems that you need an urgent operation You will be managed by a multidisciplinary effort with a team of specialists The aim will be to save your leg by all possible means. Broken bones, tendons, bleeding vessels, nerves can be repaired, even a completely amputated leg can be replaced. But I’m sorry in your case, the blood vessels, nerves and tissues were crushed, nearly dead . Some are irreparable and may be too graved to be salvaged. In such a situation, the team may need to take a decision in the operation theatre to amputate your leg which may be necessary to save your life. Before going to the theatre, we need your agreement and sign the consent to do so Do you want me to explain again or is it clear? The operation if needed is below knee amputation With recent advances, this operation is combined with fitting of a prosthesis which is very effective Most patients with them is fully functioning You can still follow your compassion with sports

    Brian, there are some hazards of not doing the amputation . The dead tissue will release some toxins and some other products which can have a serious effect on your body like sudden cardiac death, gas gangrene which is a major cause of death. The infection spread so quickly that is it difficult to control with antibiotics or medicines.

    I’m asking you to give consent as a last resort, that is if everything else fail to save your leg, only then it will be done. If you still insist to refuse, then the surgeon will not do the amputation, but I want to confirm again that my explanation is very clear and you are aware how serious it is. If you need further discussion with the surgeon, it can be arranged. I’ll tell them about your final decision.

    I have some concern about the validity of patient’s consent. I would like to discuss with my supervisor. VALID CONSENT

    • 1. Competency of patient – Patient must be mentally competent

      • - Patient’s ability to comprehend and retain relevant information

      • - Patient needs to weigh risk and benefit before making a final decision

        • 2. Patient’s understanding

          • - Consequences of having and not having the operation

          • - Different treatment options

            • 3. Making decision free of coercion


    Brain Death (AMC 59)

    A 38 year-old school principal came to your GP clinic requesting information of brain death because he needs to make a discussion on it with someone at a seminar. He has already printed out information about it from the internet.

    Brain death

    Brain death occurs when a critically ill patient die after being put to a life support. It may be due to an

    accident, stroke, or MI. The heart continues to beat but the pt cannot breath anymore. The brain is no longer functioning. The heart doesn’t need the brain to beat because it has its own system to trigger or initiates impulse. In Brain death the person is not alive, not going to recover.

    • C oma

    Coma is similar to a deep sleep with exception external stimuli can trigger the brain to react, either less or no. No external stimuli can trigger the patient to wake. The patient in coma is still alive. The recovery is possible.

    Vegetative state

    vegetative state in which the person has lost higher brain function or cortical function. But the lower brain function is not damaged. The patient may not be able to swallow by themselves but can still breath spontaneously. Therefore the heart can beat, respiratory function is still good. Eyes can open on stimulation but the patient can’t wake up or talk. The limbs can move. HR, RR, BP maintained. They can cry, get upset, randomly laugh or pull faces. Motor reflexes are present.

    Tests: CONDITION 059. TABLE 1. Brain death protocol.

    Predetermined criteria before test (make sure to check) Body temperature more than 35 °C after resolving the temperature with blankets for 20 minutes No drugs which depress the central nervous system (CNS) given for the last 48 hours (longer if CNS depressants given in large amount or for a long time) No neuromuscular relaxants given for the last 12 hours No endocrine problems eg hypothyroidism, hypopituitarism PaC02 > 50 mmHg check ventilator No hypoglycaemia

    TESTS to confirm :

    1. Pupils fixed and unresponsive to light - CN - 2, 3 2. Absent corneal reflexes CN - 5, 7 3. Absent pain response in cranial nerve distribution CN- 5 4. Absent gag reflex on endotracheal tube movement CN- 9, 10 5. Oculocephalic reflexes absent (no 'dolls' eyes' response) 6. Vestibulo-ocular reflexes absent (no nystagmus) -CN - 8 COWS

    7. No spontaneous respiratory response after 10 minutes (patient ventilated on 100% oxygen at a rate of 4 breaths/min with a tidal volume of 7 ml/kg). Arterial blood gases taken at 5 and 10 minutes.

    Diagnosis to be made by 2 doctors independently including the intensive care consultant. Neither will be a member of the transplant team where organ donation is considered. 2 groups of tests, preferably separated by 24 hours. The results of examination must be recorded in the case notes or a suitable devised form.

    Organ donation: it should be mentioned in driving license.


    End-of-Life Request From a Terminally Ill Patient (AMC 124)


    • 1. Refuse to do saying by law in Australia we are not allowed to do it.

    • 2. Empathy

    • 3. Solve the problem- eg pain, palliative care team, make the pt comfortable

    • 4. Palliative support group

    • 5. Tell them the truth


    • 1. Suicide Self-killing by means such as hanging, drug overdose or carbon monoxide poisoning. No involvement of others.

    • 2. Physician-Assisted Suicide Provision of means for patient to kill themselves, such as a prescription for self-poisoning, or insertion of an intravenous line for a patient to inject lethal drugs. Requires involvement of doctor.

    • 3. Passive Euthanasia I Refusal of treatment by competent person Refusal of antibiotics in advanced malignant disease, or advance directive refusing resuscitation. No direct involvement of others.

    • 4. Passive Euthanasia II Withdrawing or withholding life-sustaining treatment from incompetent patient . May require involvement of others.

    • 5. Active voluntary euthanasia doctor involves voluntarily, active participation, assisting patient to die

    • 6. Active non-voluntary euthanasia

    • 7. Doctrine of double effect give lethal dose of one drug

    PASSIVE Euthanasia

    • - Refuse to take medication

    • - DNR do not resuscitate

    • - Stopping life support

    The doctor has to respect the wish of the competent patient. The best interest of the patient dying with dignity. Stop resuscitation if there is no improvement. Take consent from family.


    Domestic Violence

    Your next patient in general practice is Fiona Cresp, a 25 year old mother of 2, well known to you. She has visited you 4 times in the last 6 months. First time she came with 5% burn on the left hand, second time she came with some injury on the right hand. The other two times she came with a complaint of tiredness for which you investigated her thoroughly and everything was normal. At the time you counselled her accordingly and advised about life style changes and stress management.

    This time she has come with a complaint of an injury to her head. Task: focused Hx, examine the pt, discuss Dx and Mx the pt.


    “Two days ago Fiona accidentally hit her head on a door frame when she was rushing around the house chasing her son. She did not think much about it and thought it was not bad, however, today the area appeared quite swollen and painful. She thought it might be better to have it checked out and to have some antibiotics”. If the candidate asks more detailed questions Fiona will admit that she actually was hit by a

    kitchen plate which her husband had thrown in an anger tantrum and she was in the wrong spot and got hit. She assures you that her husband did not mean to hit her with it but that he

    just became angry because he was told on that day that

    he lost his job

    as a personal care

    assistant. He

    got drunk when he came home, became very angry and started to throw things

    in the kitchen,

    when Fiona got hit by a plate he was throwing. Fiona believes he did not want

    to hurt her, but he has had a history of being short tempered and often has arguments with her

    and also with people at work and in other situations.

    If the candidate shows empathy and asks further questions

    you can tell her/him that he

    actually often becomes aggressive towards you, especially when he drinks alcohol and over the last 6 months he gets regularly drunk at least twice a week and on a number of occasions

    he has hit you, causing bruising at several sites of the body.

    The beating started shortly after

    the birth of the last child when the family faced financial problems because you couldn’t go

    back to work but had to care for your child.

    Your husband also lost several jobs because of

    his aggressive behaviour and most of your friends have withdrawn from your family and you are very lonely. Even his and your parents have become disenchanted because of his argumentative and aggressive behaviour. You haven’t spoken to anybody about the situation because you had hoped that it would rectify itself and be only short lived, because when your husband is sober he promises regularly that he will change and improve. PHx. + FHx.: unremarkable SHx.: You live with your husband and 2 children, 3years and 8 months respectively. Your younger child has got cerebral palsy following premature birth and some hypoxic event during delivery. You are aware that the prognosis is not very good and hence stopped taking him to the hospital. You take care of him at home though you are very busy with his care but you can save some money. He has not developed any complication yet, but his limbs are very stiff. You feed him by spoon and he takes that and he has settled in at home quite well. You used to work as a PCA but stopped working since your delivery. Your husband does house keeping job but has lost that too 2 days back (the same day you got injury). He is short tempered and had argument with his supervisor and hence was sacked. He drinks alcohol and sometimes excessively.


    You don’t drink alcohol, don’t smoke and you are not on any medication.

    suicidal thoughts though you feel depressed

    . You have


    You don’t have any

    lost interest in sex

    as your husband is

    very aggressive in that too. No loss of appetite, weight or sleep. No loss of energy.

    Examination : distressed looking lady, vitals stable. There is a 2 x 2 cms laceration present on the head, looks 2 days old, red, tender and swollen. Multiple unexplained scars on the head and multiple bruised in different areas of her body are present.

    Take photographs of the injuries!

    Management :

    • 1. Cleaning and dressing of the wound, pain relief if necessary.

    • 2. Explain to the patient that

    it looks like domestic violence and that she needs some help.

    If patient refuses tell her that she is unsafe in her situation now and there are various resources available with which this can be stopped and a crisis management plan can be instituted:

    Offer to organise admission to a refuge


    ensure informed consent for all actions

    consider notifying police (if she agrees)

    show empathy

    build the victim’s coping skills and self esteem


    mention about community sevices


    support services

    women’s support group

    domestic violence resource centre.

    social services/ police/ social workers.

    Don’t forget to see her child with child protection services (CPS) and fix an appointment once this issue get solved.

    Possible questions to be asked if suspect domestic violence


    has your patner ever physically threatened or hurt you?

    is there a lot of tension in your relationship


    sometimes partners react strongly in arguments and use physical force. Is this happening

    to you?


    Have you ever been afraid of any partner?


    other approach – HELP H – hear what the woman has to say about her History – what effect has the violence and abuse had onset and pattern of abuse worse case of abuse and greatest fear E – assess women’s self ESTEEM L – assess her life situation does she have regular partner any supportive people what is the financial situation P – PRAISE her efforts so far for whatever she has done


    Domestic Violence

    A 13 year-old girl, Sarah, with her Mother came to your GP clinic for certificate because she has missed school for a couple of days. You noticed the girl has poor eye contact. Physical examination you found bruise on arms & legs.

    Task: take further relevant history, manage the case.

    Hx: (confidentiality)

    • I understand Julia, Sarah does not want to talk to me.

    I’d like to talk with Sarah individually---No, I’d like to stay (If yes I’ll ask my nurse to be the chaperone while you wait outside and I talk to Sarah) I’d like to ask why you want a medical certificate for Sarah---she missed her school Why did she miss her school?---she had flu Any other reason?---no During the PE I noticed some bruises on Sarah’s arms & legs. Is this the first time---no How did she get the bruises?---maybe she hit somewhere Does she have any blood clotting problem?---no Any family history of clotting problem?---no Is she on any medication?---no How about her general health?---everything is all right

    OK Julia, everything we talk here is confidential, except if it cause harm to you or others

    Are you living with Sarah’s Father?---no with my new partner Do you have other kids---Yes, I have a 9-month old boy Any problem at home, how is your relation with your partner and Sarah? How does your partner cope with Sarah?---very badly How is your relation with your partner?---he hit me and Sarah Does he hit your other kid?---no

    Does anyone at home smoke?---yes Does anyone drink alcohol at home?---yes, my partner Anyone taking illicit drugs?---yes, my partner, he’s taking marijuana How about Sarah?---no, she does not smoke, drink alcohol nor take any illicit drugs How is Sarah doing at school, how is her progress?---not good recently, since the new partner came Anything happen recently?---yes, he hit me and Sarah wanted to help me


    You’re not the only one who’s suffering from domestic violence. Do you want me to inform police?

    It’s OK Doctor, my partner will change

    OK, we’ll see what will happen. If you change your mind, I’m here to help. But for Sarah, she is still minor, it’s my medical obligation to inform the DHS.

    They will organise some tests and they will do some service what is good for Sarah We need to work in a multidisciplinary team, GP, DHS, and Police at a later stage

    • I don’t want to inform anyone Doctor


    DHS will provide safety for Sarah and a counsellor for you & Sarah

    Julia, I understand you do not agree to inform the Police If you change your mind, when you agree to inform the Police, I will help you If baby admit the baby to the hospital


    Arguments Build up Violence Repentance Honeymoon