Escolar Documentos
Profissional Documentos
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II.
I.
II.
The Clinical and Oral Examination, which also consist of three components:
1.
2.
3.
I.
Simulated Clinics.
Data and slides Interpretation.
Oral Examination.
This paper consists of around 100 questions in the best answer format, 75 questions
are in the form of patient management questions (PMQ) and 25 questions are
traditional factual knowledge questions.
2.
19
8
12
13
11
9
7
8
5
4
4
3.
The guidelines for appraisal of scientific papers recommended by the EvidenceBased Medicine working group published in JAMA are adopted
II.
MCQ..40 marks
MEQ 35 marks
CRQ...25 marks
Only those who pass the written examination will be allowed to set for the clinical
examination.
1.
Simulated Clinics:
The main objective is assessment of adequate consultation skills, which include the
following:
History-taking skills.
Communication skills
Health education and health promotion
Patient management skills
Prescribing.
Effective use of resources: the primary health care team, referral system and use of
investigations
Evidence of being a competent and safe doctor.
Categories of Cases:
The cases or the their themes may include all or many of the following:
Acute cases.
Chronic disease management.
Difficult patient
Difficult situation, e.g.: breaking bad news or patient with multiple problem
Clinical examination.
Telephone consultation / Referral.
Patient education.
2.
EBC
Biochemistry
Serology
Urine/Stool
Hormonal assay
Growth Chart
Pulmonary function test
Audiogram
X-ray
ECG
Etc.
B)
The slides may cover some or all of the following board areas:
General Medicine
Dermatology
Ophthalmology
Other relevant topics
3.
Each candidate will be examined by two panels, spending around 25-30 minute at
each one
Each panel consist of two examiners
One of the panels will have a specialist in community medicine as examiner.
The areas covered in one panel will not be repeated in the other one.
Simulated clinic
40%
Data and slide interpretation 30%
Oral examination
30%
According to the Saudi Council for Health Specialties Examination Regulation, the grading
of the candidates at the clinical and oral examination will be in the following categories:
1.
2.
3.
4.
Clear pass
Pass
Borderline Pass
Fail
(For more details see General Examination Rules and Regulations Revised, November
1999; Page 9-11 Saudi Council for Health Specialties)
(For more details about the contents, format and instructions see The Final Examination
of the Saudi Board for Family Medicine / Contents and Instruction For Candidate
September 2000, by Dr. Eiad Al Faris and Dr. Hamza Abdul Ghani)
II.
Oral Exam
I.
What is OSCE?
The objective structured clinical examination (OSCE) is an approach to the assessment of
clinical competence in which the components of competence are assessed in a planned or
structured way with attention being paid to the objectivity of the examination.
The student is assessed at a series of stations with one or two aspects of competence being
tested at each station. The examination can be described as a focused examination with
each station focusing on one or two aspects of competence. In a typical examination there
may be 20 such stations and students rotate round the stations at a predetermined time
interval. A 20-stations examination with 5 minutes at each station will occupy 100
minutes.
Objective
OSCE
Subjective bias is removed as possible
Structured
Clinical
Examination
Objective:
Traditional clinical examinations have been criticized on the grounds that they lack
objectivity. In the OSCE, subjective bias is removed as far as possible.
In any clinical examination there are three variables. The patient, the examiners and the
candidate. In the OSCE attempts are made to minimize any examiner subjective bias and to
minimize any bias and to minimize any bias introduced by candidates seeing different
patients. The following contribute to the objectivity of the examination.
Structured
The examination is structured in such a way that the content of the examination and the
competences to be tested are planned carefully in advance. Thus the examination can
sample different subject areas, e.g. cardiovascular system, dermatology, accident and
emergency medicine, geriatrics, etc. and different skills, e.g. history-taking, physical
examination, problem-solving, patient education including attitudes.
In this way the examination is designed to reflect adequately the objectives of the
course and to make the maximum use of the time available for the exam. It is structured so
that competencies in history-taking, physical examination, patient education, problemsolving, etc. are tested in a range of areas and not in one or two areas of medicine, e.g. a
patient with a myocardial infarction or a patient with chronic bronchitis
Clinical
The OSCE is a clinical or practical examination. It is a performance assessment and is
concerned with what students can do rather than with what they know. Here are some
examples of competencies assessed at stations in an OSCE.
History taking from a patient who presents with a problem, e.g. abdominal pain.
History taking to elucidate a diagnosis, e.g. hypothyroidism.
Educating a patient about management, e.g. use of inhaler for asthma.
General advice to a patient, e.g. on discharge from hospital with a myocardial
infarction.
Explanation to patient about tests and procedures, e.g. endoscopies.
Communication with other members of health care teams, e.g. brief to nurse with
regard to a terminally ill patient.
Communication with relatives, e.g. informing a wife that her husband has bronchial
carcinomas.
Physical examination of system or part of body, e.g. examination of hands.
Physical examination to follow up a problem, e.g. CCF.
Physical examination to help confirm or refute a diagnosis, e.g. thyrotoxicosis.
A diagnostic procedure, e.g. ophthalmoscopy.
Written communication, e.g. writing referral letter or discharge letter.
Interpretation of findings, e.g. charts, laboratory reports or findings documented in
patients records.
Management, e.g. writing a prescription.
Critical appraisal, e.g. review of
published article or pharmaceutical
advertisement.
Problem solving, e.g. approach adopted in a case where a patient complains that her
weight as recorded in out-patients was not her correct weight.
In the examination it is what the examinee does, when confronted with a patient or a
situation, that is assessed not what he knows and the answers he writes to a theoretical
question on the subject. A range of techniques can be employed in the OSCE to emphasize
the practical nature of the examination. These include simulated patients, videotape and
simulators: of these, simulated patients have the greatest to contribute to the OSCE. In
traditional clinical examinations all too often history-taking ability is assessed by the
examiner scoring the candidates written or verbal report of the history and no attempt is
made to watch the candidate taking the history. In the OSCE the process as well as the
product, is measured in the examination. The technique he uses taking the history and the
questions he asks are assessed as well as his findings and his conclusions based on the
findings.
Take history
Examine a patient
Interpret x-rays or other clinical materials
Describe management etc.
2)
Two (2) of the 17 stations are rest station where you will do no task.
3)
All stations have an equal value from the total mark allocated for the OSCE.
II
OSCE
Oral Exam.
60%
40%
To pass the Clinical examination, it is essential to score a minimum of 60% of the total
mark for the clinical examination. (By adding the marks obtained in the OSCE & the Oral).
1.
Doctor-patient relationship
Encouragement of patient contribution
Patients cues
Well-being and psychosocial context of the problem
Physical complaints:
E.g. Any recent exacerbations
Current level of treatment
Problems with medication
Smoking habits
Restrictions on lifestyle:
o E.g. Exercise tolerance
o Time off work
Examination:
Chest examination
Inhaler technique
Establish rapport
Encourage patients contribution:
Active listening and use of open-ended questions
Explore the social & psychological context of the problem
(Is he a student? Is he a smoker? Any association with sport?)
Exploration of patients Ideas, Concerns & Expectations
Examples (Afraid to be addicted to the inhalers
Afraid from corticosteroids
Frequent absence from collage
Drop out from sport team
Expect to change to tablets)
Health education:
o Explanation of asthma
o Explanation of asthma drugs: bronchodilator , anti-inflammatory
o Stress on the importance of correct technique
o Discuss The possible triggering factors & how to avoid them:
E.g. house dust mites, animal dander and house pets, cockroaches, respiratory
infections, environmental irretant, tobacco smoke, cold air, exercise, air pollution,
chemical gases or fumes
Drugs (aspirin, NSAID, beta-blockers, food preservative (sulfates)
o Action plan: recognize deterioration, what action to take,
o Importance of PEFR
Respond to patient cues (his understanding ability, his anxiety)
Provide patient with health education material
Arrange for follow up
Demonstrate to patient
10
=
=
=
=
Mild attack
Moderate attack
Sever attack
Life threatening attack
Patient Education:
What is asthma?
Asthma is a chronic breathing problem, its symptoms varies from cough, (which usually
more at night and increase after exercise) shortness of breath, wheezing.
These symptoms are caused by decrease air entry to the lung due to inflammation (
narrowing) of the air way.
If the patient take care of the disease and follow proper medical advice he can have
normal activity, but asthma can be a life threatening if the case neglected & did not receive
the proper management.
The illness may start in childhood which may improve when child is getting older
or may continue to adulthood. Also it can start at adulthood in previously healthy child.
It can vary from case to case, so the patient try his best to avoid the precipitating
factor. But for exercise it is recommended to continue activity and exercise and to take one
inhalation of the Bronchodilator (Ventolin) 20 minutes before start the exercise to prevent
the attack
11
Smoking:
Both active and passive smoking must be avoided if family member
smoke and not ready yet to quit he should not smoke at home, in the car or other closed
places where patient may stay in.
Wood smoke, household sprays, bakhoor, cooking oil, detergent, some strong small
should be avoided.
Green zone: Indicates all is clear, PEF is at 80-100% with less then 15%
variability. There are minimal symptoms (ideally none) related to asthma. The patient is to
continue maintenance therapy as previously instructed by the physician. Inhaled 2
agonists may be used if needed prior to exercise or for occasional mild symptoms.
Yellow zone: Indicates caution, PEF is 60-80% predicted with 15-25% variability.
Asthma symptoms such as nocturnal cough, shortness of breath or wheezing may occur.
This would indicate:
Either an acute exacerbation in which case guidelines in following section should be
followed,
Or a gradual deterioration in the severity of asthma where intensification or
stepping up of maintenance therapy is required, this should be done in consultation
with the physician. A doctor ought to be consulted within 48 hours.
Red zone:
This signals a medical alert. PEF is less than 60% and asthma
symptoms are present at rest and interfere with activity. Inhaled 2 agonist should be taken
immediately, if PEF remains below 60% immediate medical attention at an acute care
facility is recommended, if PEF improves to above 60% instructions for the yellow zone
should be followed. Physician has to be consulted within 4 hours or less.
These are broad guidelines. Instructions given to each patient should be individualized
taking into account factors such as reliability, level of understanding, availability of
medical care and the doctor patient relationship. In some patients instructions on when to
start sustained release theophylline or prednisolone could also be given.
Doctor-patient relationship
Encouragement of patient contribution
Patients cues
Well-being and psychosocial component of patient problem
Physical complaints
Dietary problems
Medication problems
Examination & investigation:
Blood pressure
Visual acuity
Management & education:
Smoking habit
Pruritus
Pain and/or paraesthesia in legs
Sexual problems
Visual problems
Angina
Claudication
Examination:
Fundoscopy
Inspection of feet:
o Circulation
o Reflexes
Blood creatinine
Blood cholesterol
Education:
o Check self-care & lifestyle
o Self-monitoring
o Foot and eye care
o Smoking habit
o Diet
o Exercise Smoking habit
12
13
Doctor-patient relationship
Encouragement of patient contribution
Patients cues
Exploration of patient ideas, worries and concerns
(What do you know about diabetes?)
It is two types:
o The first type: Represent 10% of diabetic patients, they are called IDDM (they
always take insulin).
o The second type: Consisted 90% of cases and they are called NIDDM their body
secretes either too little insulin which is not enough or large amount but not
effective.
When the body secretes no insulin sugar level will increase.
So diet and exercise are important to control diabetes.
By some modification in patients life style he can live a normal life.
Diet:
o Eat three meals a day at regular times.
o Eat nothing between meals except a snack (specify hours).
o Eat no sweet for now (sugar, dates, honey)
Exercise:
Start by increasing your daily physical activity, like walking.
Other exercises may by added when you are feeling better.
Glucose Monitoring
o This will help you feel that you have more control over your health.
o Specify time: e.g. before breakfast & supper.
Medication:
Insulin:
o There is no insulin in tablets form.
o They must be taken as subcutaneous injections.
o They are usually taken twice per day: 30 min. before breakfast & 30 min. before
supper.
o Schedule may be changed till we find the best for you.
o The nurse will show you the technique for injecting your self & how to store and
take care of your insulin.
Tablets:
o They are not insulin
o Given to patient whose bodies make insulin.
o They help your insulin to work better.
Driving:
It is advisable to stop driving until your sugar is well controlled if you are taking
medication, because risk or low sugar.
Traveling:
Talk with your doctor before you travel to help you to fit your diet and medication into
your travel schedule.
14
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Doctor-patient relationship
Encouragement of patient contribution
Patients cues
Well-being and psychosocial component of patient problem
Date of onset of hypertension, duration
Levels at time of onset
Specific question to rule-out secondary hypertension:
Hairsutism
Easy bruising
Palpitation, sweating
Muscle cramps
Leg claudication
Symptoms suggestive end organ damage:
Chest pain
Breathlessness
Orthopnia
claudication
Transient visual loss
Past medical history :
Renal disease
Obstetric history (pre eclampsia)
Cardiovascular risk factors:
Smoking
Obesity
Hyperlipidemia
Diabetes mellitus
Family history (Assessment of degree of risk) :
Hypertension
Ischemic heart disease
Stroke
Hyperlipidemia
Premature cardiovascular death
Renal disease as autosomal dominant polycystic kidney
Drug history :
For hypertension : efficacy and side effects
Other drugs : OCP, Steroids, Thyroid hormone, NSAID
Over the counter medications
Alternative medicine products
Substance abuse
Social history :
Smoking and alcohol
Diet : salt, fat, weight gain
Caffeine
Leisure activity & exercise
Work environment and stresses
Family and home situation
Education level
15
16
General examination:
o Height and weight (BMI), waist circumference
o Skin for signs of : mainly secondary causes
o Chronic renal failure
o Xanthelasmata
o Stigmata of cushing, Neurofibromatosis
o Yellowish finger staining
o Fundoscopy : for hypertensive retinopathy
Neck examination :
o thyroid enlargement
o distended vessels
o carotid bruits
Lungs :
o signs of heart failure (basal crepitations)
o sings of bronchospasm (to avoid b-blockers)
Heart :
o left ventricular lift, S3,S4 ( heart failure end organ damage)
o loud AS2, loud systolic murmur in chest and back , delayed femoral pulses
(coarctation of aorta)
o high pitched end diastolic murmur (aortic regurgitation apparent isolated systolic
hypertension)
Abdomen:
o masses or enlarged kidneys
o signs of chronic liver disease
o bruits lateral to midline (renal artery stenosis)
o aortic pulsation
Extremities :
o pulses for radiofemoral delay, diminished or absent
o edema, bruits and neurological assessment
CNS :
o focal deficit (old stroke)
o For elderly patients: nuro-psychiatric assessment ( multi infarct dementia )
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
The following items may need to be considered in every visit and annually:
Well-being
Physical complaints
Any side-effects
Examination in every visit:
Blood pressure
Chest examination
Examination and investigation annually:
o Fundoscopy
o Urinary protein
o Blood creatinine
o Blood cholesterol
Also consider:
o Chest X-ray
o ECG
o Ambulatory blood pressure
Education:
Complications of BP.
Appropriate prescribing
Follow-up arrangement
17
18
Poor Compliance
Poor compliance is a common problem inpatient with a symptomatic chronic disease, e.g.
patient may not respond to doctors advices and he may not take his medication.
The following approach may need to be considered in dealing with poor compliant
patient:
o
o
o
o
o
o
o
o
o
o
Assessment of degree of risk (if it is not clearly documented in the patients file)
and use the information to improve patients compliance
o Family history of BP., IHD.CVA.
o Complication of BP / DM.
o Or other significant systemic disease
o
o
o
o
o
o
o
o
o
o
19
Doctor-patient relationship
Encouragement of patient contribution
Patients cues
Explore patient believes, ideas, concerns and expectations about his complain
Details of the complain:
o Pain: Onset, duration, severity, distribution, aggravating factors and
relieving factors
o Stiffness: Onset, severity, duration
o Weakness: Degree?
o Swelling
o Deformity: Malalignment, subluxation or dislocation
Occupational history:
o Repetitive overuse
o Biomechanical
o Positioning
Family history: Osteoarthritis (OA), ruematoid arthritis (RA) or gout
Systemic illness: Systemic upset in RA, gout, sepsis
Sleep disturbance or depressed mood
Specific extra-articular feature:
o Alopecia: SLE
o Rash: SLE or Reiters syndrome
o Ocular symptom: Reiters syndrome
o Oral symptom: SLE, Reiters
o Paraesthesias
o GIT or urinary symptom: May indicate inflammatory bowel disease, drug,
or fibromyalgia.
Effect on daily functioning
Shared understanding of the problem with the patient.
Exploration of any relevant continuous problem if any
The following items may need to be considered in examination of patient with joint
pain in the first visit:
Inspection:
Skin Changes:
o Scars of skin disease
o Erythema: periarticular inflammation
o Red joint or bursa: sepsis or crystals
Deformity:
o Correctable: soft tissue abnormalities
o Non-correctable: capsular restriction or joint damage
o Muscle wasting
Palmer erythema: RA
Nail changes:
o Clubbing (arthritis with COAD)
o Pitting (psoriasis, Reiters syndrome)
o Splinter: Vasculitis
Vasculitis
Eye changes:
o Episcleritis (RA)
o Iritis: Ankylosing spondylitis chronic Reiters disease
o Iridocyclitis: juvenile chronic arthritis
o Conjunctivitis: Acute Reiters disease
Assimilation of findings:
Distribution
Extra-articular features
20
Very painful.
Signs of intense
inflammation.
Definitive diagnosis :
urate crystals in
synovial fluid.
Management:
- Colchicine dramatic
improvement NSAID
(indomethacin).
Migratory arthritis
Synovitis
Conococcemia : fever,
polyarthralgias & skin
eruption prior to arthitis
compare to other septic
arthritis.
Management:
- Hospitalization
Ceftriaxime 1 g IV
TDS.
21
Fibromyalgia
Common in middle age
More in female
- Chronic aching
Clinical features:
- Pain : cervical,
shoulders, pectoral
lumbosacral areas.
- Headache sleep
disturbance & fatigue
- Swelling numbness &
morning stiffness
No evidence of joint
swelling
Multiple tender areas
Nongonococcal Septic
Arthritis
- Both genders
- Swelling, pain, warmth
With severe constitutional
symptoms
- Monoarticular synovitis
particularly knee rarely
small joints.
-
Management:
- Hospitalization
- Drainage & rest
- Antibiotic guided by
culture
22
Preliminary Investigations:
o Erythrocyte Sedimentation Rate (ESR)
o Complete Blood Count (CBC)
o Rheumatoid Factor (RA)
o X-Ray of the affected joint
5% of healthy persons
10-20% individual over 65 years old
SLE
Sjogrens syndrome
Chronic liver disease
Sarcoidosis
Interstitial pulmonary fibrosis
Hepatitis B
TB
Leprosy
Sub-acute bacterial endocarditis
Syphilis
Malaria
Visceral leishmania
Bilharziasis
23
Doctor-patient relationship
Encouragement of patient contribution
Patients cues
Duration of pain, onset, quality, characteristic, location, radiation, concurrent
infection.
Risk Assessment:
Symptoms potentially indicative of serious underlying pathology; e.g. fever, progressive
severe neurologic deficits bilateral deficits, bladder dysfunction saddle anesthesia
Inspection:
o Gait (patient without shoes)
o Back for scoliosis, lordosis, swelling, masses, color, & scars.
Palpation:
o Spine land marks: C7, T3 (scapular spine), T7 (inferior angle of
scapula) & L4 (iliac bone).
o Skin for hotness, tenderness (infection, fracture, ) & masses.
o Muscle spasm.
o Sacroiliac joints.
Percussion: for deep tenderness.
Movement:
o Toe-walk S1
o Heal - walk L5
o Squat & rise L4
o Movement: flexion, extenuation, lateral flexion.
Patient Sitting:
Movement:
o Rotation
o Extend knees role out disc prolapse.
o Knee reflex.
24
Patient Supine:
Examine free side first.
o
o
o
o
Movement:
Straight leg raising test (S L R) Active, passive & crossed SLR
Bragard test.
Lasegue test.
Figure of four (sacro-iliac joint)
Power:
o Hip flexion. L1 - L2
o Knee flexion; L5 S1
o Knee extension: L3 L4
o Foot planter flexion. S1
o Foot dorsi flexion. L4 L5
o Big toe dorsi flexion
o Foot inversion: L4 L5
o Foot eversion: L5 S1
Reflexes:
o knee reflex: L3 L4 (if not done while patient is sitting)
o Ankle reflex: S1
Sensation.
o Medial side of foot. L4
o Dorsum of foot. L5
o Lateral side of foot: S1
Patient Prone:
o Femoral nerve stretch. L4
o Compress midline as in CPR
Examination of the abdomen
Mechanical disturbance
Poor muscle tone / Poor posture / Unstable vertebrae / Severe Scoliosis
Extrinsic disease such as aortic aneurysm, uterine fibroids, prostate disease, hip
disease
Degenerative disc or facet disease
Psychological, this includes hysteria, malingering, and acute remunerative spinal
pain (Green-Poulitice disease).
Inflammatory arthritis - rheumatoid and Marie-Strumpell's disease
Infections, acute and chronic
Trauma: Acute sprain or strain / Chronic sprain or strain / Fractures / Subluxated
facet (facet syndrome) / Spondyfolisthesis with strain.
Toxicities from heavy metals
Congenital asymmetries of facets or transitional vertebrae
Metabolic disorders - osteoporosis or transitional vertebrae
Tumors:
o Benign (such as meningiomas, neuromas, osteoid osteomas, Paget's disease)
o Malignant - primary bone or neural tumors and metastases
Prevention:
o Lifting technique
o Standing
o Posture
o Seating
o Demonstrate to the patient
o Bed
o Work: chairs + desks
o Exercise
o Wt. Reduction
o Smoking, personal habits
o
o
o
o
o
25
26
Preliminary Investigations:
The routine ordering of plan lumbosaeral spine feature is neither cost- effective nor useful
for decision making. Finding normal disc spaces does not rule out disc herniation.
Specific investigation for abdominal or pelvic causes: e.g. urine examination, renal
or pelvic ultrasound
Major trauma
2.
27
History Taking
N. Dashash, A. Assaggaf, A. Al Harthy & H. Al Hajjar
In history taking stations some time patient presents with typical story, the candidate may
reach the final diagnosis from the first impression and ignore to ask relevant and specific
questions to prove it objectively. Candidates are advised to think loudly to give the
examiner the chance to understand how he think, in order to give him the desirable
evaluation mark
(For more advices see simulated clinic exam)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Differential Hypotheses:
o
o
o
o
o
o
Alcohol
Medications
Cerebellar disease
Hyperthyroidism
Anxiety
Parkinsons
28
29
o
o
o
o
o
o
o
o
o
o
o
o
o
Cholestasis:
o Primarily biliary cirrhosis,
pregnancy
o Extrahepatic obstruction, drugs e.g.
Contraception
Endocrine:
o Thyrotoxiosis, myxoedema
o Hyperparathyroidism, DM
Investigation of Pruritus:
With no overt skin disease
o Urine: Glucose, protein, and urine
microscopy
o Stool: Occult blood & parasites
o CBC, differential white blood count &
blood film
o ESR, U & E, serum iron and uric acid
o TFT & LFT
o Chest-X Ray
Haematological / myeloproliferative:
o Iron deficiency, polycythemia
o Hodgkins disease, multiple
myeloma
Malignency
o Miscellaneous e.g. gout,
psychological, old age.
Management of Pruritus
o Elimenation of underlying cause
o Emollients as dry skin the most
common cause of itching.
o Calamine lotion
o Crotamiton (Eurax) cream 0.5%
o Systemic antihistamines e.g. Benadry
QID, Atrax, Hisenanal.
o Topical corticosteroid ointment
o Unidazole combination.
30
Past History:
o Similar problems, or any psychiatric problem
o Medical or surgical problem (hypertension, DM, hyperthyrodism or asthma.)
Family history of similar problem or any psychiatric problems
31
32
Prescribing of Antidepressants
Fayza Rayes
Associated problems
Depression
Depression with
Psychosocial stress
Depression with
Anxiety symptoms
Depression with
insomnia
Suggested
Treatment
1) SSRIs
2)Tricyclic antidepressants
1) SSRIs
2)Tricyclic antidepressants
1) Imipramine (Tofranil)
2) SSRIs (Prozac)
3) (Tofranil) + Alprazolam
Benzodiazepin (Xanax)
Amitryptylin (Tryptezol)
Dothiapin (Prothadin)
Maprotiline (Ludiomil)
Trazodone(Trazolan)
Depression with DM
Depression with CHF
or IHD
Depression with
Arrhythmia
Depression with
Hypertension
Depression with
Hypotension
SSRIs
SSRIs
Depression with
Urologic disease
Depression with
Parkinson 's Disease
Depression with Stroke
Trazodon (Trazolan)
SSRIs
Nortriptylin (Nortrilen)
Trazodon (Trazolan)
SSRIs
Nortriptylin (Nortrilen)
Amitryptylin (Tryptezol)
Imipramin (Tofranil)
SSRIs
Trazodon (Trazolan)
SSRIs
Trazodon (Trazolan)
Nortriptylin (Nortrilen)
SSRIs
Comments
Consider the cost
Social support
Psychotherapy
(75-150 mg)
(20-60 mg)
(250-500 microgram) TDS for 6Ws
then tapered slowly over 4 Ws
(25-300mg)Strong sedative, dizziness
anticholinirgiceffects:wt.gain,constipa
tion hypotension, cardiotoxic,
tachycardia
(25 250 mg)Less cardiotoxic, less wt
gain, not in pregnancy
(75 150 mg) not in eplipsy
(150-400mg in deveded dose)
hypotension
No Wt. gain
Less cardiotoxic
Less cardiotoxic
(see insomnia)
(see insomnia)
(10-150mg in devided dose)
no hypotension, no sedation,
less anticholinigic, safe in elderly
(see insomnia)
(see Hypotension)
(see insomnia)
(see Hypotension)
Depression with
(see Insomnia)
Migraine headache
(25-300 mg in devided dose) not
sedative constipation, nausea,
headache, sexual disfunction
Nortriptylin (Nortrilen)
(see Hypotension)
Depression with
Amitryptylin (Tryptezol)
(see Insomnia)
Chronic urticarea ,
Imipramine (Tofranil)
(see Migraine)
allergic disease
Nortriptylin (Nortrilen)
(see Hypotension)
Effect after 2 weeks and diagnosis of medication failure after 2 months
Acute treatment for 6-12 months while continuation treatment for 4-6 months
And maintenance for chronic relapsing patients for years
33
Choices of Antidepressants
Fayza Rayes
Drug & Dose
Amitriptylin
(Tryptyzol)
25-300 mg
in devided dose
Imepramine
(Tofranil) 25-300 mg
in devided dose
Clomipramine
(Anafranil)
10-250 mg
Nortriptylin
(Nortrialen)
10-200 mg / day
Maprotiline
(Loduomil)
25- 150 mg
Trazodone
(Trazodam)
150- 400 mg / day
No hypotension, no sedation
Less Anticholinergic effect
Sertralin
(Zoloft)or (Lustral)
25-100 mg
Fluoxetine
(Prozac)
10- 80 mg / day
Citalopram
(Cipram)
20-60mg
Fluvoxamine
(Faverin)
100-300 mg
in devided doses
Parooxetine
(Seroxat)
20-60 mg
Indication
Depression with insomnia
Migraine
Not for hypotensive patient
Depression
GAD
Panic attacks
OCD (Drug of first choice)
Phopias
Panic attacks (Drug of first
choice)
Elderly
Minimum effects
Hypotenssion
Priapism (1/6000 cases)
Depression 50-200 mg
Maintenance 50 mg
Depression 20 mg
Bulimia 60 mg
OCD 20- 60 mg
GAD & Panic attacks
Depression 20-60 mg
Panic disorder 10mg increase
evrey week by 10mg / mux 60
mg
Depression 100-300 mg
OCD (the drug of first choice)
Insomnia
Doctor-patient relationship
Encouragement of patient contribution
Respond to patients cues
Clarify what patient means exactly by dizziness
(Is it true vertigo or light headedness or disequillibrium)
Severity of symptom: e.g. associated nausea and/or vomiting.
Effect of problem on patient's life, his ideas, worries & expectations.
Course: constant or attacks (duration & frequency)
Onset and timing.
Precipitating factors:
o Change in head position
o Valsalva maneuver
o Standing
o Viral infection
o Auricle manipulation,
o Hyperventilation
o Fatigue
o Explosion
History of pervious attacks.
Ear disease:
o Hearing loss / tinnitus.
o Fullness or stuffiness
o Otalgia / discharge.
o Pervious ear surgery.
Rule out associated brain stem symptoms:
o Double vision.
o Numbness and/or weakness in arm face and leg.
o Difficulty in speech.
o Confusion or loss of consciousness.
o Swallowing problems.
Associated symptoms:
o Valvular disease.
o Palpitation.
o Syncope on exertion.
o Prolonged bed ridden.
o Head & neck trauma
o Seizure
o Symptoms of DM, hypertension, anxiety, depression or panic attacks.
Drugs history
34
35
Menieres disease.
o Sudden onset. Common in adults
o Recurrent similer attack with Adults long free intervals.
o Lasting hours to days
o Associated with tinnituss, hearing loss, ear fullness and
naauseaa+vomiting.nystagmuss presented by menstruation, emotional
stress
Acoustic Neuroma
o Gradual onset. Onset in adult
o Persistent
o Progressive. Unilateral hearing deficit. Tinnitus.
o Facial numbers, weakness
o Diplopia, dysarthria, dysphagia, Dysporiea
o Uncordination, Paraesthsias
Multiple Sclerosis
o Sudden or transient, persistent as or Recurrent
o Lasting days pr wks.
o Other discrete CNS symptoms.
Acoustic Neuroma.
Gradual/ onset in adult:
o Persistent
o Progressive, unibateral hearing deficit, tinnitus.
o Numbness, weakness, diplopia, dysanthria, dysphagia, dysphonia
o Uncordination and paraesthsias.
Acute/ onset in elderly:
o Recurrent
o Brain Stem Symptoms: No Nausea OR vomiting
o Vertebro Basillar insufficiency: Nystagmus
Drugs:
o Antibiotics
o amino glycosides
o Quinines
o Anticonvulsants,
Hypnotics
Disappear when Drug Discontinued.
o
o
o
o
Antidepressent
Diuretics & antihypertensive
Hydrocarbons exposure
Organic -Carbon Monoxide.
Exposure
36
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
37
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Symptom
o Dysuria
o Altered bleeding patternd
contraception-
o Abdominal pain
Alternative Diagnosis
Urinary tract infection
Side-effect of hormonal method of
combined and progesterone-only contraceptive pills,
injectable contraception (Depo-Provera), implants n)
or intrauterine system (Mirena)
Irritable bowel syndrome, constipation,
endometriosis
38
o
o
o
o
o
o
Infection
Candidiasis, bacterial vaginosis,
Trichomonas vaginalis
o Cervical swab
Gonorrhea
Chlamydia trachomatis
Investigation
o Urinalysis/blood glucose
Cause
Diabetes
o Midstream urine
Urine infection
o Serum follicle-stimulating
Hormone and oestradiol
Oestrogen deficiency
-perimenoausal
-Inadequate hormone replacement
Treatment
Candidiasis
39
40
Introduce yourself
Specific information:
o Age, Job, Travel history
o Marital status and sexual contact,
Main complaint; (e.g. detail of urethral discharge, type, color, associated irritation,
blood staining, odor, duration).
Rash: how it progress. Ulcers: how and where the lesions first appear, any
prodromal symptoms suggestive of herpetic infection, any rash involving other parts of the
body (i.e. palms & soles for syphilis, axillae and wrists for scabies).
Associated symptoms: e.g. fever, swelling, joint pain, abdominal pain, pelvic pain,
conjunctivitis, weight loss, cough, diarrhea, fatigue, headache).
Exploration of patient s ideas, concerns and expectations and the effect of the
problem in patients life.
41
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
3.
Physical Examination
H. Al Hajjar, A. Al Harthy & A. H. Hassan
General Instructions:
In joint examination lists, each list is comprehensive and cover all areas
Special tests are not necessary to be done in all patients according to the case
Always great patient and introduce your self by name and specialty
Gentle approach
Be systematic
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
42
43
o Phalen test: flexing the wrist 90 for one minute causes numbness and parasthesia.
o Flick test: move hands similar to shaking thermometer will relief the pain.
o Abductor pollices breves examination: resisted thumb abduction. -opposition.
o
o
o
o
o
o
Surgical
Simple decompression
44
o
o
o
o
o
Special tests:
Cross over test (acromioclavicular joint)
Anterior drawing test / apprehension test (dislocation)
Posterior drawer test (dislocation)
Clunk test (labral tear)
Impingement test
45
Patient Standing:
Look.
o Gait (observe patient walking)
o Bone deformity. Genovarum / genovulgus.
Patient Supine:
Look:
o Size and shape of patella.
o Quadriceps wasting
o Skin: color, scars & swelling
o
o
o
o
o
o
o
o
Palpate:
Temperature: all sides & compare.
Tenderness: slight flexion.
Attachment of collateral ligaments.
Joint line: menisci.
Tibial tubercle.
Anterior surface of patella.
Synovial membrane thickening.
Effusion:
- Patellar tap.
- Fluid displacement test (most reliable)
- Fluctuation test.
Move:
flexion & extension
o Active
o Passive.
o Against resistance
o
o
o
o
o
Special tests:
Varus & vulgus stress instability (for collateral ligaments)
Anterior & posterior drawer tests for cruciate ligaments.
McMurray manuver for menisci.
Friction test. (For patello-femoral joint.)
Apprehension test. ( For patello-femoral joint.)
46
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Inspection:
Gate
Deformity
Skin
Swelling
Compare with other foot
From behind
Palpation:
Site of pain
Tenderness at ligaments sites, anterior capsule, lateral malleolus and base of 5th
metatarsal
Skin temperature
Movements:
Active planter and dorsiflexion
Passive planter and dorsiflexion and inversion and eversion
Compare both sides
Special movements:
Anterior drawer test
Talar tilt test (inversion stress test)
Comparing two sides
Quick knee examination
Arrangement
47
48
Funduscopy:
o Dilate / darken the room
o Check the machine, proper power.
o Red reflex.
Important diagnosis not to be messed
Acute angle closure glaucoma:
It is an emergency, rare to occur, but the patient can lose vision if not managed early.
Symptoms:
o Red painful eye
o Nausea and vomiting
o Blurred vision
o The patient may give a history of similar attack in the past that were aborted by
going to sleep
Signs:
o Red and tender eye
o Hazy cornea
o Fixed, semi dilated pupil to light
Management:
o Emergency treatment is needed and documents the level of vision in each eye.
o Acetazolamide (Diamox) 500 mg oral or I.V.
o Timolal 0.25 0.5% drops
o Rilocarpine 0.5 4% drops
o Then patient referred to the emergency ophthalmology care for
- Continue medical treatment to I.O.P.
- Surgery (iridectomy) or lazer
49
Signs:
o Loss of temporal quadrant (visual field).
o Cupping and pallor of the optic disc.
Investigations:
o tonometry: Raised intraocular pressure.
In 3% pressure is in the normal range
o Ophthalmoscopy to determined cup/disc ratio)
o Ccomputerized perimetry.
Treatment,
o Topical beta-blocker, as timolol eye drops 0.25 twice daily.
(Conttraindicated in heart failure and asthma).
o Surgery: if medical treatment fails.
Visual Acuity:
o Far vision:
Chart + 6 m., cover the other eye.
o Near vision
o
o
o
o
o
o
Field:
Confrontation method.
One meter apart, cover one eye, Eye fixed, bring the object into the field.
Color Vision
lshibara plates.
Funduscopy:
Dilatation, Check the machine, darken the room, and fix a target.
Right hand for right eye, from the tight side.
Red reflexes
Optic disc.
50
4.
51
In counseling stations usually patient comes with questions and inquiries, therefore
candidates are advised to give patient chance to ask questions, and it is also advisable when
you give some information to ask for feedback from the patient from time to time, and let
the simulated patient guide you during this station. Candidates who conduct completely
doctor-centered consultation (does not look to patients agenda) may perform badly in
counseling stations.
(1) Epilepsy Counseling
H. Al Hajjar
Topics:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
52
Home environment:
Don't be in potentially dangerous state alone (kitchen, fire, bath drain, door locking).
Medications:
o Don't stop suddenly by your self
o Don't miss doses (compliance). Don't or dose by your self.
o Side effects.
o Interaction with other medication
Status epileptics.
o Major attack does not stop as anticipated
o Duration > 20 minutes
o Recurrent attacks with no consciousness in between
o Call ambulance
o Keep rectal valium at home
Follow up:
o Shared with hospital
o Drug serum levels. Unnecessary when the patient is well controlled.
Driving:
According to local driving regulations in different countries. Ranges from one to ten years
free from seizure also according to type of driven vehicle.
Pregnancy:
o Risk of fetal abnormalities with medications
o Uncontrolled seizures affect the fetus. Balance risk / benefits.
53
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Annual Review:
Evaluate patients life style and coronary risk
Simple assessment for anxiety and depression
Review of drug treatment
Assess patients ability to continue with normal activity and work
Assessment of functional status, .g.: angina, breathlessness, presence of heart
failure
o Identify patients requiring referral for further investigations for possible
revasculization
o Consider ECG
o
o
o
o
o
54
55
56
57
Rehydration solutions:
o Use of ORS, Pedilyte, WHO Packet, Ricelyte
o Home made solution: (One letter water + one tea spoon salt + 8 tea spoon sugar
+ few drops of lemon juice)
o How do you know that ORS is working?
o Breast feeding should continue and extra fluid is given
Educate mother about medications that should be used only for special indications:
o Anti-vomiting medicine: if vomiting is very severe and prevent oral
rehydration
o Anti-diarrhea medicine: not effective and may be harmful
o Antibiotic are not usually indicated
Reassurance
o GE is a self limiting
o If properly treated it rarely gives complications
58
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
59
Classification of Obesity:
o Mild obesity is a relative weight of 120-140 % (BMI 27.5-30 kg/ m2).
o Moderate obesity is a relative weight of 140-200 % (BMI 30-40 kg/ m2).
o Severe or morbid obesity is a relative weight over 200% (BMI > 40 kg/ m2).
o Obese patients with high waist-hip ratios (>1.0 in men; > 0.8 in women) greater
risk of diabetes mellitus, stroke, coronary artery disease, and early death.
60
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
61
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
62
Accidental
Percutaneous or permucosal
Household contact
Chronic carrier
Household contact
Acute case with identifiable
Blood exposure
Prenatal
Sexual acute infection
Sexual, chronic carrier
Vaccination + HBIG
Vaccination
Vaccination + HBIG
Vaccination + HBIG
Vaccination + HBIG
Vaccination
63
64
o
o
o
o
o
o
o
o
o
Causes of Insomnia
Psychiatric disorder
Drug & Alcohol abuse
Medical /Surgical problem
Primary sleep disorder
50 %
10-15 %
10 %
10-20 %
65
Pain
Prescribing Of BZDs
Short acting
Insomnia
Long acting
66
Explain to the patient the information needed to help her to make informed choice
of appropriate method:
o Effectiveness of each method.
o Risk & benefits of the various methods (Advantages & Disadvantages).
o The best methods for specific case.
o Instructions for their use.
o The follow-up policy for various methods.
67
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
68
Medico-legal certificates
Take feedback frequently and insure that you are answering all his queries
Important information for travelers:
General advices
o Avoid swimming in lakes or rivers
o Use safe traffic and transportations
o Use recognized air lines
o Carry enough of your regular medicines in their original containers along with extra
prescriptions for them.
o Wear a medical bracelet if needed.
69
Travelers diarrhea:
Prophylaxis:
o Bactrim double strength tab once/day from the day of arrival.
o Or bismuth subsalicylate 2 tablets or 2 oz of liquid 4 times a day while traveling
Treatment regimens
o Ciprofloxacin 500mg orally 2 times daily for 1 to 3 days. or
o Ofloxacin 400mg orally 2 times daily for 1 to 3 days. or
o Single-does ofloxacin plus loperamide 400mg or
o Ofloxacin and Loperamide (Imodium) 2 mg tab. 2 tablet stat then one tablet after each
losse stool.
Or Diphenoxylate with atropin (Lomotil) 2.5 mg - 2 tab. QID
Malaria: Chloroquine one tab. once a week. 2 ws prior to entering, 4-6 ws after
leaving.
5.
70
The main objective of the simulated clinic is to evaluate the candidates skills in
consultation. Accordingly, in preparation for simulated clinic exam, the candidate needs to
improve his/her knowledge and skills in consultation.
Some Important Consultation Models:
Byrne & Long (1976)
Doctor-centered consultation: the doctor was more likely to make decision for the
patient and instruct him to seek some service.
Patient-centered consultation: the doctor was more likely to seek the patients
views and permit him to make his own decision concerning the outcome.
Failure to explore the real reason of patient problem is the main reason of
consultation failure
Patient-Centered
Consultation
Use of patients
Knowledge and experience
Silence
Facilitation
Doctor-Centered
Consultation
Use of doctors
Special knowledge and experience
Clarification
Analyzing
Gathering
Interpretation
Probing Information
Skills used by physician in patient-centered against
Doctor-centered consultation
71
72
Patient with hidden agenda: e.g. patient requesting vitamin or cough syrup or
patient showing certain non verbal cues
Aggressive and demanding patients e.g. patient may till you: give me this
medication now! or he may say: Your colleague Dr. X is very rude
Passive aggressive patient: e.g. patient may say: yes, but!
Poor compliant patient: e.g. patient refusing your medication or investigation or
advice
Common pitfalls:
Common pitfalls:
Reaching final diagnosis from the first impression and ignorance to ask specific
questions to prove this diagnosis objectively
Disorganization and non-directive interview
No clear objectives
Failure to make use of preliminary information from the patient file
Repeating same questions in the same way
Wasting long time sticking to one issue
Ignorance of patient cues
Doctor-centered consultation
Thinking of one and only one possible diagnosis
Forgetting to ask about patient health beliefs
Forgetting to ask specific questions to rule out the possible differential diagnoses
Ignorance to ask specific questions for risk assessment and continues problem
No summarization of the history and no feedback from the patient.
Forgetting to conduct physical examination
Wasting long time in discussing irrelevant physical examination
73
Common Pitfalls:
Speculate possible objectives from the given scenario, and at the same time be open
minded and ready to conceder patients objectives
2)
o
o
o
o
o
3)
Remember the basic skills to obtain information and try to avoid habits which
block communication:
Basic skills to obtain information
General Attitude:
Respect
Empathy.
Touch (if appropriate)
Eye contact.
Body language
Social smile.
Encouraging.
Questioning:
Open-ended questions
Facilitating verbal & non verbal
Reflecting questions.
74
Active listening:
Restatement
Classification and summarizing
Taking feedback
Empathy
Non-verbal awareness
Use of more advanced skills to
push for Resistant information:
Confrontation and probing
Reflection
Use of silence and use of touch
Thinking loudly and acknowledge
uncertainty
Asking for more clarification
Interpretations of...
o Non-verbal communication.
o Paralanguage
o Body language
General Attitude:
Patronizing
Tenseness and nervousness
Coldness and unfriendliness
Defensiveness
Appearance of too relax or casual
Appear preoccupied
Questioning:
Direct questions,
Why question,
Suggestive question,
Yes or No questions.
Many questions at a time.
Specific Behavior:
Use of Jargon
Inability to keep quiet
Unawareness of non-verbal cues.
Interrupting the patient
Controlling & inhibition of the
patient.
Lack of purposeful direction in the
interview.
Making assumption.
Giving advice too early.
Allowing personal emotions to get
in the way.
Talking too much continuously.
Inability to take feed back.
4)
5)
6)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
75
7)
8)
The setting:
No interruption
Family support
The patient:
Right to know
Support groups
Documentation
76
77
Threatening, aggressive patient: deflect anger; ally oneself with patient and
alliance position if seated; does not hem patient in; calm voice; reflect feeling of anger.
Seductive patient: deal with issue underlying seductiveness; what does patient
really want; be aware; doctors fantasy or needs for omnipotence.
Organic brain impairment: as for (g); talk more slowly; give patient plenty of
time to respond.
Migrant: use interpreter; look at patient not at interpreter when talking; do not talk
loudly.
Elderly: if necessary ensure hearing aid or spectacles are available; talk more
slowly wait for replies; allow more time; sit face to face with patient; do not talk loudly; do
not patronize; touch can be reassuring.
Children: stay at some level as child with language and physically do not sit at a
higher level; distraction or mutual task while talking can be helpful.
Doctor as patient /the very important patient (VIP): danger of interviewer not
asking certain questions or assuming the VIP will volunteer essential information; danger
of having strong, positive or negative feelings often unconsciously towards to VIP; danger
of managing VIP differently.
Own family: conscious and unconscious biases preclude the interviewer properly
assessing family members as patients.
Reference : Ken Cox, Christine E. Ewan. The Medical Teacher. Churchill Livingstone;
London 1988.
78
6.
79
The following are examples of common simulated patients presentation in exam and the
possible approach to them in the form of checklists. However, candidate should not follow
these checklists strictly, he/she need to be flexible, and always conducts patient-centered
consultation, starting the consultation by exploration of simulated patients ideas, concerns
and expectations, he also should be sensitive to any verbal or nonverbal cues and respond
to them appropriately and immediately.
Smoking habit
Examination:
Cardiovascular system
Chest
Chest wall
Abdomen
Management:
Management of acute MI
IV access
Administration of oxygen
Cardiac monitor:
ECG
Blood studies
Transfer to hospital.
80
Associated symptoms:
o Wheezing,
o Chest pain
o Shortness of breath, or orthopnea
o Fever, night sweating, weight loss
o Heamoptysis.
Allergy history
Drug history
Smoking habit
Chest X-ray
Sputum culture
Use of medication:
Cough suppressant or expectorants, antibiotics, brochodilators or steroids.
81
82
Epiglottitis
3 7 years
Sudden onset, fulminating
Dysphagia, drooling
Fever
Respiratory stridor
Croup
Childhood
URTI problem 1-7 days
No drooling
Low grade fever or
moderate
Biphasic stredor
Hoarseness
Barking spasmodic cough
Nontoxic
Para-influenza 1
Humidification (crouptent)
IV fluid
Antibiotic contraversial
Bronchiolitis
0-2-years
May be insidious or acute
or progressive
Fever
Noisy breathing,
Expiratory wheezing,
Inspiratory crackers,
Intercontal retractions.
Cough
May be cyanosis
RSV or parainfluenza
Fluid maintenance
Bronchodilator
Oxygen
For infant: inhaled antiviral
General impression
Signs of dehydration
Examine abdomen
Stool analysis
Use of medication:
o Electrolyte replacement (rehydration solution)
o Anti-diarrhea agents?!
o Antibiotics?!
Specific therapies
Referral if indicated
83
84
Abdominal examination:
o Epigastric tenderness
o Renal tenderness
o Mass (cancer)
o Rectal examination:
o Piles or melena
Management and Education:
Microcytic hypochromic
anemia
Micricytic or normocytic
Hypochromic anemia
Macrocytic anemia
Confirmatory test
Low serum iron
Low transferin saturation
Low ferritin
Low serum iron
Normal ferritin
Normal serum iron
Haemoglobin electrophorisis
Serum B12 level
And/ or serum Folic acid
85
o
o
o
o
o
ENT problem, any dental or vision problem, e.g. acute viral infection, COPD
Drug history:
o For the headache.
o For other medical causes.
Psychosocial problems:
o New stressful events.
o Marital problems or problems at work.
Family history.
Blood pressure
Neurological examination
Management and education
Use of medication:
o Analgesics, anti-migraine or anti-depressant
o Specific medication for primary cause
o
o
o
o
o
86
Subarchinoid Hge
- Severe headache
(the worst headache
of patients life)
- Associated with
exertion & vomiting
- ECG: similar to
IHD
- CT scan then LP
presence of blood
Cluster headache
- Common in
middle age
- More in male
- Recurrent, may be
every 4 weeks
- Awaken from
sleep
- Every night
- Same time
- Lasting one
hour.
- Deep burning
sensation
- Associated with
lacrimation flushing,
nasal discharge and
conjunctivitis.
- Ptosis & popullary
constriction.
87
Previous treatments:
What sort of treatment? How long was each one used? Compliance?
Inspection of the face, shoulders, back, upper arms and chest looking for acne
Management:
Appropriate prescribing:
o Discussion of options: e.g. Topical: Retin A and/or Benzoil peroxide and/or
Systemic antibiotics e.g. minocyclin
o Explaining side effects and precautions.
Patient with such mild complain, may present with special communication problem, e.g.
requesting referral to a dermatologist or requesting special medications.
General well-being
Recurrent symptoms?
Vaginal swabs
Blood creatinine
Management and education:
Alternative diagnosis
E.g. atrophic vaginitis, urethral syndrome, vaginal discharge
Use of:
o Antibiotics
o Analgesics
o Treatment of associated cause
o Referral
o Prophylaxis
MSU 2-4 days after starting antibiotic, if positive, patient need urgent referral for
possible obstruction
All proves UTI in children under 5 should be referred for further investigations.
For more details see (Data Interpretation: Lab Tests)
88
89
Other examinations:
o E.g. rash and spleen (Infectious mononucleosis)
Investigations:
Use of:
o Analgesics: use enough dose and right frequency
o Antibiotics if bacterial infection is highly suspected
o Encourage symptomatic home remedies
Discuss patients concerns (sick leave, wary about possibility of rheumatic fever)
Usually simulated patients with minor illness appear in the exam for testing certain skills,
E.g.:
Simulated patient has a hidden agenda, E.g. marital problem or parent may be using
the child as presenting complain
90
Possible Diagnosis
o Epiglottitis
o Meningitis
o Quinsy
o Streptococcal sepsis.
o Rheumatic fever
o Palatal cellulitis
Comments
o Ashencolor, Drooling (children)
o Meningism (child. & young adult)
o Voice change, Trismus (all ages)
o Unstable vital sign (all ages)
o Murmur, Heart failure (Rare)
o Unilateral swelling, Marked tenderness.
o
o
o
o
o
91
Frequnecy of episodes
At risk factors:
o Age or Downs syndrome,
o Immunocopromised
If asymptomatic:
o Review in 4 days, in 30% of the patient the tympanic membrane will be normal
o The remaining 70% of the patient, they need to be reviewed every 3 months
o 10% persistent of the patient will continue to have persistant effusion and they will
need referral to ENT
Management of recurrent otitis media
Perform adenoidectomy !
92
Associated features:
o Reflux: cyclic, retrosternal pain, heartburn, regurgitation, water brash, weight gain
o IBS: change bowel habit, lower abdominal pain
o Dysmotility: ulcer like symptom (epigastric pain associated with meal or hunger
pain,
o Biliary colic: severe require strong analgesia
o Respiratory infection: cough
o Angina: dyspnoea, relieved by rest
o Depression: loss of interest and low mood
o Cancer: weight loss, dysphagia, vomiting
Advice in Reflux:
o Stop smoking and
o Life style modification
o Lose of weight if overweight
o Eat small frequent meals and avoid bedtime snacks
o Avoid late night eating
o Raise the head of the bed
o Avoid foods that upset you & avoid tight-fitting clothes
o Elevate head of bed may help
Advice in dysmotility:
o Small frequent meal
o Semi-liquid meals to avoid distension
o
o
o
o
o
o
o
o
o
o
93
Risk assessment:
o Pain awaken from sleep or change of pain
o Onset at elderly
o Weight loss
o Rectal bleeding
o Steatorrhea and fever
o History of steadily worsening symptoms
Reassurance:
o prevalence is 10-20% of adult population
o It is not progressive to a serious disease or develop complications
o 30% of the patient became symptomatic over time
Follow up arrangement
94
Drug Treatment
For diarrhea:
o Cholestyramin, Imodium orlomotil
For pain:
o Antispasmodic e.g. Mebeverin (Colofac)
135 mg TDS 30 min before meal.
o Pepperpment oil ( Colpermin, Mintec) .2 - 0.4 ml TDS 30 min before meal.
o Tricyclic antidepressant. Ametriptyline 25-75 mg.
For constipation:
o Osmotic laxative (Duphalac)10 mg TDS
For bloating:
o Low residue diet (low fiber)
o Peppermint oil. Cisapride 10 mg TDS.)
Risk factors :
o Familial adenomatous polyposis
o IBD > 20 Years
o Family history of colorectal cancer
95
7.
96
Iron
deficiency
Decreased
Folate deficiency
anemia
Normal or
slightly decreased
Normal or
slightly decreased
GRPD
Alpa
Hematlcrit
Decreased
Decreased
Normal or
slightly decrease
Normal or
slightly decrease
Normal or
decreased
Normal or
decreased
Decreased
Mean
corpuscular
volume
Decreased
Increased
Norma (?)
Normal
Normal or
decreased
Slightly
decreased
Mean
corpuscular
Hemoglobin
concentration
Decreased
Normal
Norma (?)
Normal
Normal or
decreased
Slightly
decreased
Transferrin
saturation
Decreases
Normal
Normal
Normal
Normal
Normal
Serum iron
Ferritin
Total iron
binding
capacity
Serum folate
Decreases
Decreases
Increased
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Decreased
Normal
Normal
Normal
Serum B12
Normal
Normal
Normal
Normal
Normal or
decreased
Normal
Sickledx
Positive
Hemoglobin
A2
Normal or
decreased
Normal
Normal
Normal
Normal
Increase
Perihpheral
smear
Microcytosis,
hypochromia
Macrocytosi,
Neutropenia,
thrombocytopenia
Normal
Normal
Microcytosi,
Neutropenia,
poikilocyosis
Microcytosi,
Neutropenia
Target cells
Decreased
Beta
Decreased
Normal
97
o
o
o
o
o
o
o
o
o
o
o
o
o
Medications
Alchol use
Nutrition
Strict vegetarianism (B12
deficiency)
Predominantly carbohydrate diet
(folate deficiency)
Advanced age
Poor dentition
Financial trouble
Neurologic symptoms
Gait disturbance
Parestjesoa
Loss of taste
Tongue paresthesia
Hepatic symptoms
Pruritus
Dark urine
Occupational
Radiation exposure
Chemical exposure
Hypothyroid symptoms
Cold intolerance
Fatigue
Change in voice
Constipation
Change in hair
Surgery
o Total or partial gastrectomy
Physical examination
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Percentage of cases *
36
21
11
7
6
5
5
12
98
o
o
o
o
o
o
Malabsorption:
Inadequate intrinsic factor
Pernicious anemia (gastric atrophy, lack of intrinsic factor secretion)
Gastrectomy
Gastric bypass surgery
Ileal disorders (sprue, regional enteritis, surgery, neoplasm)
Competition for B12 (fish tapeworm, blind loop syndrome)
o Drugs (cochicine,neomycin)
Inadequate intake:
o Strict vegetarianism
Inadequate intake:
o Alcoholism
o Advanced age
o Poverty
Decreased absorption:
o Tropical sprue
o Bacterial overgrowth
o Short-bowel syndrome
o Drugs (phenytoin, phenobarbital, oral
contraceptives)
Increased requirements:
Hemolytic anemia
Pregnancy
Exfoliative dermatitis
Infancy and growth
Loss:
o Dialysis
Chemical interference:
o Methotrexate
o
o
o
o
99
Diabetes mellitus:
o Symptoms of diabetes plus causal plasma glucose concentration >or=200mg/dl
(11.1 mmol/l)
o Casual is defined as any time of day without regard to time since last meal. The
classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight
loss
o Or
o FPG > or = 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at
least 8 h.
o Or
o 2-h PG > or = 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be
performed as described by WHO, using a glucose load containing the equivalent of
75-g anhydrous glucose dissolved in water
100
Hepatomegaly
Splenomegaly
Alkaline
Phosphatase
ALT
Bilirubin
Obstruction
__
__
3-8 times
normal
2-10 times
Normal
5-20 times
normal both
type
Viral Hepatitis
__
2-4 times
3-100
times
Infectious
Mononucleosis
__
Normal 5
times
2-20 times
Conjugated <
10 times
Hemolytic
__
__
Normal
Normal
3-5 times
Unconjugated
Alcoholic
cirrhosis
Normal 3
times
Normal 3
times
3-10 times
conjugated
Primary
biliary
cirrhosis
4-30 times
Normal 2
times
< 4 conjugated
101
Elevated
Normal
Clinical evaluation
Suggestive of
Hypatocellular disorder
(aminotransferase
Elevation dominant)
Consider:
Infection
-- (Especially viral
hepatitis)
-- Drug-induced
Hepatitis
Serological
Evaluation
Ultrasonograph
Or
Computed tomography
Depending on
clinical presentation
consider :
-- Recent sepsis or
-- systemic infection
-- Rotor syndrome
--Dubin-Johnson
syndrome
102
HBsAg
HBeAg HBsAb
HBsAb HBeAb
Interpretation
Recovery phase,
May last several years.
Usually convalescent,
May be found years after viraemia,
Favorable prognosis.
Infection years ago:
HbcAb lost or artificially immunized
and never had HbcAb.
103
5b
6a
6b
Bruecllosis Treatment
Adults:
Tetracyclin 500 mg QID for 6 wks Or Doxycylin (vibramycin) 100 mg BID for 6 wks
+
Streptomycin 1 gm IM once/day x 2 wks
Relapse:
o Children < 9 yrs Rifampicin for 6/52 + Streptomycin for 2/52
o Children > 9 yrs Tetracycline for 6/52 + Septrin for 3/52
2
6
3
4
5
104
Thyroid disorders
T3
T4
Subclinical hypothyroidism
Free T4
Index
N
TSH
TRH
test
Hypothyroid
Hyperthyroid
N,
N,
N,
N,
Eutyroid Syndrome
Secondary hypothyroidism
(Pituitary hypothalamic disease need
further investigations of hypothalamic
pituitary function
TSH secreting pituitary tumor or
Thyroid hormone resistance
105
Urine Analysis
1.
2.
UTI:
Urine:
o
o
o
o
Pyuria
Bacteruria > 105 [in symptomatic female > 102] Hematuria in 30 % of patients
Nitrate +ve in 80%
pH alkaline in Proteus and Klebsiella.
Organisms:
o
o
o
o
o
o
o C/S
o Further radiological investigations.
D Dx:
o
o
o
o
Cystitis
Prostatitis
Urethritis
Malignancy
General:
o fluid
o Hygiene advice: washing front to back
o Correct underwear (cotton)
Specific:
o C/S
o Antibiotics
o Septrin DS BID X 3 days
o Cephalexin 250 500 mg Q 60 for 3 days
o Cipro 250 500 mg BID for 3 days
o Amoxil 250 500 mg TDS for 10 14 days
3.
Oxaluria:
Causes:
1. Ileal dis. (Crohns ileal resection)
2. Hereditary (primary)
3. Food, most common: tea, nuts, chocolate, dark green vegetables
Risk: increase renal stone
4.
Glucosuria:
Causes:
DM
Low renal threshold (< 180 mg/ml)
Pregnancy
Cushings
Hyperthyroidism
Investigations:
FBS
Management:
According to the confirmed diagnosis.
1.
2.
3.
4.
5.
5.
106
Contaminated Urine:
Advice:
o Reassurance
o Proper MSU (washing first, then allowing a small amount of urine to flow, before
filling the sample tube. Avoid contact to skin)
6.
Protein-urea:
Causes:
(Normal = trace (0 30) mg/ml)
1.
2.
3.
4.
5.
6.
7.
Urine Casts:
o
o
o
o
o
o
o
o
8.
Hyaline Non-specific
Waxy advanced R.F.
RBC G.N.
Epithelial cast acute tubular injury, G.N, Nephrotic synd.
WBC Pyelonephritis, G.N, interstitial nephritis.
Granular Nephritis
Faulty (lipid) Nephritic
Mixed G.N.
Hematuria:
Def.: > 5 cells
Causes:
1.
UTI
2.
Prostatic diseases
3.
Neoplasm in urinary system
4.
Renal stone
5.
Trauma
6.
Renal disease: G.N.
7.
Drugs: Aspirin, Penicillin, and Cephalosporin.
8.
False + ve = exercise, vitamin & food
9.
False ve = vitamin C.
Investigations:
1.
2.
9.
Renal Stone:
MSU:
o Hematuria
o pH: Acidic = uric acid & cystine
o Crystals (can be normal).
Investigations:
o KUB
o U/S
Management:
o General:
- Increased fluid
- Pain killers
o Specific:
- Thiazide (in calcium oxalate stones)
- Allopurinol (in uric acid stones)
- Alkalization of the urine by NaHCo3 (uric acid & cystine)
107
10.
Sterile Pyuria:
11.
12.
pH:
o pH (5-8): Most.bacteria : Alkaline
o E.g. Klebsiella, Pseudomonas & Staph. (in UTI).
o TB: Acidic
13.
Specific Gravity:
o Normal =
1.003 1.030
o Osmolality: Normal =100 900
o Both test the ability of kidney to concentrate urine (i.e. renal function)
o Increase in = Dehydration, drugs
o Decrease in = D. insipidus, Primary polydipsia, starvation, exercise, drugs.
o
o
o
o
o
o
o
108
109
MSU in children:
o
o
o
o
o
o
Schistosomiasis:
o S. Mansoni , S. Japonicum and S. and Haematobium (Urinary tract)
Praziquantel
o
o
o
o
o
40 mg / kg / day
2 divide doses BD (4-6 hrs apart) for one day
60 mg / kg / day TD (for S. Japonicum) for one day
Giardiasis:
o Metronidazole (250 400 mg)
PO Q 8 hrs x 5/7
o
(Flagyl)
or (2 mg)
PO OD x 3/7
Note:
- Hygiene
- Treat whole family
- If R1 fails check compliance, re-infection
- If diarrhea results avoid milk (lactose intolerance for 6/52)
Trichuriasis (whipworm):
o Mebendazole 100 mg PO BID x 3/7 repeat 2 courses
o Albendazole 400 mg PO once
Strongyloides S.:
o Thiabendazole
22 mg/kg
PO BID x 2/7
o Albendazole
400 mg
PO qd x 3/7
Prednisone 20 40 mg qd x 3-5/7
Re-treatment.
Summary:
Mebendazole (Vermox) treats all parasitic infestations
Except
o Ameobiasis, Giardiasis:
Metronidazole
o Strongyloides:
Thiabendazole
o Schistosomiasis:
Praziquantel
110
8.
111
Description: Whitish layer that wipes off easily, leaving a bleeding surface.
Characteristic feature on microscopy:
o Fungal hyphae usually in the mouths of debilitated patients e.g. anaemias.
Precipitating factors:
o Diabetes mellitus
o Hypothyroidism
o Hypoparathyroidism
o Drugs e.g. contraceptive pill, antibiotic therapy, systemic steroids.
112
Pitryasis Vesicolor:
Appearance:
Refer to handout.
o With topical agents e.g. benzoic acid compound ointment BPC (Whitfielfs
ointment), selenium sulphide lotion, creams or lotions of the imidazole group. None
offers a permanent cure.
Scabies:
Description:
o Excoriations due to generalized pruritus. Pruritus starts about six weeks after the
disease is acquired.
o Burrows in finger webs.
Transmission: By close physical contact with an infested person.
Causative organism: Sarcoptes scabiei hominis, scraped out of a burrow.
Treatment:
113
Cutaneous Leishmaniasis:
Transmitted by:
The sandfly
Causative organism: The protozoan leishmania tropica
Diagnosis:
Smear demonstrates the organism with Wrights or Giemsa stain.
Pyogenic granuloma:
Kobners Phenomina:
Seen in:
Lichen planus
Proriasis
Vetiligo
Warts
Moluscum contgiosum
Acanthosis nigricans:
Associated with:
114
1) Pitting
2) Onycholysis
3) Discoloration
4) Thickening
5) Subungual Hyperkeratosis
Differential Diagnosis:
1. Trauma
2. Eczema
3. Onychomycosis
Treatment of psorisis:
Emoliants
Methotrexate, etretinate.
Associated with:
Excessive sun exposure
X-ray treatment of the area
Contact or medication with arsenic
Treatment: By curettage, cryotherapy or excision
Palmar Erythema:
Henoch-Schonlein Purpura:
Complications:
Causes:
Xanthelasmata:
Causes:
Essential familial hypercholesterolaemia
Primary biliary cirrhosis
Diabetes mellitus
Usually no underlying cause is found
Treatment: By cautery or trichloracetic acid or excision
Leprosy:
Characteristics:
Hypo-or hyper-pigmented macule
Anaesthesia, neuritis
Causative organism: Mycobacterium leprae
Diagnosis:
Skin scraping and microscopy
Biopsy
Lepromin test (Mitsuda test)
Causes:
Infections: -Herpes simplex
-Mycoplasma
-Streptococcal
-T.B.
Drugs: Barbitarates, penicillin, sulphonamides
Neoplasia: e.g. Hodgkins disease
Connective tissue diseases
115
Malignant Melanoma:
Differential Diagnosis:
Seborrheic keratosis
Compound melanocytic nevus
116
Moluscam Contagiosum:
Complications:
Secondary infection
Thrombocytopenic purpura
Encephalitis
Varicella pneumonia (usually in adults and those with an impaired immune response).
Herpes Zoster:
117
Erythema nodosum:
Causes:
2. Infections
Streptococcus
Tuberculosis
Infectious mononucleosis
Viral
Chlamydia
Leprosy
Fungal infections
Lymphogranuloma
Scratch disease
Blastomyosytis
Coccidomyositis
Yersenia
3. Drugs
Sulphonamides
Oral contraceptives
Salicylates
Bromides/iodides
Gold salts
4. Inflammatory bowel disease, Behchets disease
5. Lymphoma
Clinical features:
Erythematous, tender, nodules appear on shins and occasionall thighs and forearms.
Bed-rest
Anti-inflammatory analgesics
2)
1. Sarcoidosis
Necrobiosis Lipoidica:
Lesions are sharply marginated, yellow or brownish yellow areas of shiny atrophy
with telangiectasia.
Many but not all cases are diabetic.
Associated with diabetes mellitus.
Complication ulceration.
Differential diagnosis: Erythema nodosum; diabetic dermopathy; pretibial
myxoedema.
3)
Pretibial myxoedema:
Treatment:
118
Corticosteroids:
Angioedema
Aetiology
Clinical features
Anyone who suffers recurrent attacks of angioedema or in whom there is a family history
of angioedema should be positively screened for C1 esterase inhibitor deficiency.
Treatment
Specific drugs such as stanozolol, tranexamic acid and danazol are the only
effective prophylactic agents for hereditary angioedema.
Acute episodes:
o require injection of C1 esterase inhibitor
o infusion of fresh frozen plasma.
Angioedema associated with ordinary urticaria may be treated with antibistamines
and / or steroids.
Severe attacks should be treated as for anaphylaxis, with 0.5 ml 1/1000 adrenalin
by subcutaneous injection.
119
Oral Conditions
Lichen planus:
Mucous membrane lesions occur in 50% of cases
Differential diagnosis of lichen planus of the buccal mucosa
o Chronic irritation from gum-biting or ill-fitting bridges
o Leukoplakia
o Candidiasis
o Aphthous stomatitis
o Squamous papilloma
o Verruca vulgaris
o Secondary syphilis
Black hairy tongue:
o May follow antibiotics, cytotoxics and excessive smoking
o Elongated papillae (hair) may be yellow-brown or black
Leukoplakia:
o Small, discrete, white patches or more extensive, leathery plaques on an atrophic
erythematous base.
o Predisposed by tobacco smoking and recurrent trauma
o Risk of malignant change
1. Inflammatory:
o Infective: -Bacterial: Vincents angina, T.B, syphilis,cancrum oris
-Viral: herpes
-Fungal: candida
o Non-infective: - Traumatic: ill fitting dentures, Cheek biting, Burns
o
- Radio therapy
2. Haematological: leukaemia, agranulocytosis
3. Neoplastic: malignant ulcer
4. Auto-immune: -Aphthous (commonest)
o Others: Behccets, Reiters, Steven- Johnson syndrome
5. Skin conditions: pemphigoid, pemlphigus vulgaris, Lichen planus
o Vitamin deficiency:
o Vitamin C, Riboflavin, Nicotinic acid
120
Rinne
Tunning fork in front
of Pinna
Positive AC > BC
Normal
Conductive hearing loss
(e.g. perforation, cyromette tube)
Weber
Tunning fork (512 H2 ) on
skull in midline
No Lateralization
Negative BC > AC
Tympanosclerosis:
Appearance:
Causes:
Causes:
Treatment:
121
Ophthalmology
Diabetes Mellitus:
Although diabetes may have a number of ocular effects (e.g. cataracts, changes in
refractive status), the most important ocular complication is retinopathy.
1. Non-proliferative diabetic retinopathy (NPDR):
Treatment:
o Control of D.M. by diet, exercise and medication
o All patients with retinopathy should be referred to an ophthalmologist for
examination and follow-up.
o Patients with macular edema will require laser photocoagulation.
o For severe complications (massive vitreous hemorrhage or traction retinal
detachment), a vitrectomy may be necessary.
Hypertension Retinopathy:
Keith-Wagener-Barker Classification
Normal
Grade I
Grade II
Grade III
1/3
Present
Present
Present
Present
Slight
Right-angle
Grade IV
A/V ratio*
Fine cords
Flame hemorrhages
Present
Exudates
Present
Papilledema
Present
Copper wiring
Silver wiring
AV nipping
Same as grade
III
*A/V ratio refers to the ratio of the diameter of the arteriole to the venule.
122
Allergic Conjunctivitis
Appearance:
Upper lid: papillae, if severe [giant papillae] leads to cobble stone appearance.
Treatment:
o Sodium cromoglycate (opticrom 2% up to 4%) q 6 hrs. PRN
o If excessive tearing: short course of anti histamine, e.g.
- Livostin eye drops Bid.
- Konjuntival eye drops.
- Naphcon eye drops.
Surgery
Suture Materials
1
o
o
o
o
o
2o
o
o
o
Absorbable sutures
Organic: Catgut is the commonest example
Useful in intestinal anastomosis
closure of peritoneum
stitch7 of fat or subcutaneous tissues.
Synthetic (Dexon, Vicryl):
Synthetic absorb-ables cause less reaction and are superior.
Stronger than catgut handle and tie better than catgut, but take a longer duration
before absorption.
Non-absorbable sutures:
Organic (silk). Tie and handle easily, may precipitate infection (i.e. not preferred)
Synthetic (prolene, nylon). More difficult to handle, little tissue reaction meaning
that infection is less with it ( i.e. preferred for skin closure)
Needle types
Cutting needles used for skin or tendons.
Round-bodied needles for anastomosi of the GI tract and vascular work.
Guidelines for suture removal:
o
o
o
o
o
o
9.
ECG Interpretation
A. H. Hassan
Contents:
o
o
o
o
o
Objectives:
Is it a difficult task:
1) There are 12 leads.
2) There are 5 waves in each lead.
3) There are 3 segments or intervals.
4) In any given tracing, there are a minimum of 14 points to analyze.
Irregular rhythm:
o Number of cycles in 6 sec. x 10.
123
124
3) Rhythm
o
o
o
o
4) P-wave
Normal:
o Duration: - < 0.12 sec.
o Amplitude: - <2.5 mm.
Abnormal:
o Wide: - Left Atrial Enlargement (LAE).
o Peaked: - Right Atrial Enlargement (RAE).
5) PR- INTERVAL
Normal:
o 0.12-0.2 sec.
Abnormal:
o Prolonged: - Conduction defects.
o Shortened: - Pre-excitations e.g. Wolff Parkinson White (WPW) syndrome.
Calculation:
o 1) Midway between the axes of two extremity leads that show tall R of equal
amplitude.
o 2) Right angle (90o) to any extremity lead that shows a biphasic complex.
7) QRS Duration
o
o
o
o
o
o
o
o
o
o
o
Short:
Normal,
Obesity,
Pleural Effusion,
Extensive MI,
Emphysema
Myxedema.
Tall:
o Young adults.
o Thin chest wall.
o Ventricular Hypertrophy
9) R wave Progression
o
o
o
o
Poor Progression:
COPD.
LVH.
Anterior MI.
LBBB.
o
o
o
o
o
Prominent RV1
Infants and children.
RVH.
Posterior MI.
RBBB.
WPW.
125
11) QT interval
o
o
o
o
o
o
o
Normal duration: - 0.4 sec; (should be corrected for the heart rate).
Prolonged:
Hypocalcemia.
Hypokalemia.
Ischemia.
Hypothermia.
Subarachnoid Hemorrhage.
Procainamide.
Quinidine.
Shortened:
o Hypercalcemia.
o Digitalis effect.
12) ST segment
Elevation:
o Acute Q wave (transmural) MI.
o Prenzmetal angina (non-infarctional transmural ischemia).
o Pericarditis.
Depression:
o Acute Non- Q (sub-endocardial) MI.
o Classic angina.
13) T-wave
Normal:
o Same direction as the QRS complex.
o
o
o
o
o
Abnormal:
Ischemia.
MI.
Ventricular Strain.
Pericarditis.
BBBs.
14) U-wave
o Hypokalemia.
o Toxicity.
126
127
Transmural MI.:
Acute:
o Persistent ST elevation,
Evolving:
o Q wave.
o Deep T- wave inversion.
o
o
o
o
o
o
o
o
Site:
Ant.: - V2-4.
Ant.-septal: V1-3.
Ant.-Lateral: I, aVL, V4-6.
High Lat.: I, aVL.
Extensive Ant.: V1-5.
Inferior: II, III, aVF.
RV: - Right Chest Leads.
Posterior: Prominent RV1 (R>S), ST depression, positive TV1,2.
2) Chamber Enlargement
Right Atrial Enlargement: Peaked P (Pulmonale) > 2.5 mm, or Initial positive PV1
(>1.5mm).
Left Atrial Enlargement: Broad notched P (Mitrale) >0.12 sec. (>3 small squares),
or biphasic PV1 with terminal negative part (>0.04 sec./ >1 mm.).
RVH: RAD, r SR` V1, R V 1 > S V 1, RV5 SV5 or 6, RV1 > 10 mm, qR in V1,
SV1 < 2mm, ST-segment depression, & T-wave inversion V1-3.
LVH: SV1+ RV5 > 35 mm., R a VL > 11 mm., R I+ S III > 25 mm., Rv5 or 6
>26, or Lewis index 17 (RI-SI) + (SIII-RIII), Additional points (Left ventricular
strain pattern, Left atrial abnormalities).
128
3) Conduction Defects
o
o
o
o
o
RBBB:
Wide QRS, (if narrow incomplete BBB).
Prominent R V1.
Wide slurred R V1,2.
Wide slurred S I,aVL, and V5 or 6.
ST-segment depression, and T- wave inversion V1-3.
o
o
o
o
o
LBBB:
Wide notched QRS.
Prominent notched R I, aV L, V5,6.
Wide S V1.
ST-segment depression, and T- wave inversion I, aVL, V5-6.
No Q-wave in I and V5,6.
4) Arrhythmias
10.
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130
Chest X-Ray
Causes of a pleural effusion
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Differential Diagnosis
Miliary T.B.
Sarcoidosis
Pneumoconiosis
Haemosiderosis
Miliary carcinomatosis
131
Bronchiectasis
Bronchiectasis can be difficult to diagnose on a plain chest X-ray. If you suspect it as a
cause of increased shadowing then look for the following features:
1. Ring shadows. These look like rings and are any size up to 1 cm in diameter.
2. Tramline shadows. Look for these towards the periphery of the lung.
3. Tubular shadows. These are solid thick white shadows up to 8 mm wide.
4. Glove finger shadows. These represent a group of tubular shadows seen head on
and look like the fingers of a glove hence the name!
The presence of any of these features suggests the possibility of bronchiectasis. A
normal chest X-ray does not however exclude the diagnosis and CT scanning is the
most sensitive diagnostic test available.
o
o
o
o
Causes of bronchiectasis
Structural, e.g. Kortagener syndrome, obstruction (carcinoma, foreign body)
Infection, e.g. childhood pertussis or measles, tuberculosis, pneumonia Immune,
e.g. hypogammaglobulinaemia, allergic bronchopulmonary aspergillosis
Metabolic, e.g. cystic fibrosis
Idiopathic to stasis
Fibrosis
Fibrosis is one of the rarer causes of white lung and you need to differentiate it from
consolidation or edema, which are far more common.
Causes of fibrosis:
o Cryptogenic
o External/occupational, e.g. extrinsic allergic alveolitis, asbestosis
o Infection, e.g. tuberculosis, psittacosis, aspiration pneumonia
o Collagen vascular, e.g. rheumatoid arthritis, SLE
o Sarcoid
o Iatrogenic, e.g. amiodarone, busulphan, radiotherapy
Chickenpox Pneumonia
Chickenpox pneumonia in adulthood can cause the development of numerous calcified
nodules. To determine whether this is a likely diagnosis:
1. Look at the distribution of the nodules. In chickenpox pneumonia they tend to be
lower and midzone.
2. Look at the density of the nodules. They are calcified and so should be very white
in appearance.
3. Look at their size. They are usually less than 3 mm in diameter.
4. Look at the number. In chickenpox pneumonia you would expect to see less than
100 nodules. If there are obviously a lot more you should question this as a
diagnosis.
o
o
o
o
o
132
Pneumothorax
o
o
o
o
o
o
o
Causes of Pneumothorax
Spontaneous
Iatrogenic/trauma, e.g. pleural tap, transbronchial biopsy, central venous line
Insertion, mechanical ventilation
Obstructive lung disease, e.g. asthma, COPD
Infection, e.g. pneumonia, tuberculosis
Cystic fibrosis
Connective tissue disorders, e.g. Mar fans, Ehlers-Donlos
o
o
o
o
133
Transudate
o Congestive cardiac failure
Exudates
o Post myocardial infarction
o Infection, e.g. tuberculosis, bacterial
o Neoplastic infiltration
o Collagen vascular, e.g. rheumatoid arthritis, SLE
o Iatragenic, e.g. post cardiac surgery
o Endocrine myxoedema
Blood
o Trauma
o Neoplastic infiltration
o Aortic dissection
o Bleeding diathesis, e.g. anticoagulation, leukemiaCauses of pericardial effusions
The Widened Mediastinum
Always look carefully at the mediastinum. If you think that it is widened then relate this
finding to the clinical history. If you suspect an acute aortic aneurysm then you must
follow up your suspicions as quickly as possible with a CT, echocardiogram or MRI.
Important causes of a widened mediastinum are thyroid enlargement, enlargement of
mediastinal lymph nodes, aortic dilatation of the esophagus or thymic tumours.
Metastatic deposits
Your examination of the chest X-ray is not completed until you have looked carefully at
the ribs. They should be of a uniform density with smooth, unbroken edges. The main
abnormalities to look for are old and new fractures and metastases.
1. New fractures. Look along the edges of reach rib. A new fracture will be seen as a
break in the edge.
2. Old fractures. Again look along the edges. The callous formation that follows a
fracture will cause the rib to expand at this point.
3. Metastases. These look like dark holes in the ribs.
4. Look carefully at the other bones, which may contain similar pathology.
134
Pancoasts tumour
A number of abnormalities can be easily missed. Before dismissing an X-ray as normal:
1.
Look carefully at the apices of both lungs.
2.
Look carefully at the heart shadow
3.
Look carefully at the mediastinum.
4.
Look at the hilum.
5.
Obtain a lateral film.
6.
Read the radiologists report!
Skull X-Ray
Causes of Sull Rdiolucencies
Normal
o Squamous temporal bone
o Pacchionian granulations
o Surgery
Air
o Superficial after scalp injury
o Intracranial seen in open fractures
Outer skull table
o Rodent ulcer
Inner skull table
o Slow growing tumours
o Chronic Subdural hematoma
Diffuse lesions
o Metastases
o Multiple myeloma
o Pagets disease
o Hyperparathyroidism
Supracondylar fracture
Complications
Early:
1. Volkmans Ischemia:
(4 Ps : pain, pallor, pitting edema, pulseless)
o pain, more on extending fingers
o pallor cyanosis of hand
o edema of forearm
o low pulse.
2. Nerve injuries
3. Volkmans contracture.
Later:
1. Myositis ossfficans
2. Elbow stiffness
3. Malunion
X-Ray Findings in Osteoarthritis:
o Subchondral sclerosis
o Cyst
o Osteophytes
o Loose bodies
o interosseous distance (Joint space)
o trabecular thickness
X-Ray Findings in Rheumatoid arthritis:
o Soft tissue swelling
o Periarticular osteoporosis
o Loss of joint space
o Erosions (small bites from bone adjacent to joints)
o Bone destruction & deformity (later features)
X-Ray Findings in Osteoporosis:
(Lateral thoracic & Lumbar spine)
o Vertebral deformation
o in bone density
o Biconcavity
o Anterior wedging
o Compression
Congenital Dislocation of the Hip
Later:
o Delay in development of ossific centres of acetabulum and femoral head.
o The acetabular roof has an upward slop
o The femoral head is displaced upwards and laterally.
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136
11.
136
Question (1)
A 47-year-old male brought to the primary care center at 10 am by a friend. He has
chest pain and shortness of breath for the last 40 min. on arrival he was
semiconscious. His blood pressure was 99/55. His ECG is shown below.
A)
B)
137
Question (2)
A 34-year-old female G3P2+0 presents for routine prenatal care. The result of the
50 g one hour glucose screen was 175 mg/dl
100 g oral GTT was done and the result was
Test
Patients value
Normal value
Fasting
94 mg/dl
105 mg/dl
1 hour
180 mg/dl
190 mg/dl
2 hour
178 mg/dl
165 mg/dl
3 hour
150 mg/dl
145 mg/dl
A)
B)
138
Question (3)
A four-year-old child presents for audiogram and tempanometry testing . his results
are shown as
A)
B)
139
Question (4)
The association between hypertension and myocardial infarction is being investigated
in a study. The findings of a question send to the whole population ( 1000 ), all of
whom responded, are in the table
Whole population
History of hypertension
History of MI
present
Absent
Present
15
185
Absent
795
A)
B)
C)
Question (5)
ECG
A)
B)
C)
140
Question (6)
This is the thyroid function test of a 42 year old lady
T4 . 7 g/dl
T3 . 134 ng/dl
T3 uptake . 19 %
TSH . 22 g/dl
FIT .. 4.3
( 5 11.5 )
( 100 215 )
( 25 35 )
( 0.7 7 )
( 6 11.5 )
A)
B)
C)
Question (7)
47 year old female complaining of increased weakness and fatigue for the last two
years. She found to have a blood pressure of 155 / 97 mm Hg. Her blood chemistry
result is shown below
BUN . 60 mg/dl
Creatinine .... 4 mg/dl
Na .....146 mmol/l
K .. 5.9 mmol/l
Cl ..... 110 mmol/l
Ca 8 mg/dl
Phosphate 7.6 U/L
T. Protein . 5.6 g/dl
Albumin .. 3 g/dl
Fasting blood sugar 96 mg/dl
( 5 25 )
( 0.5 1.5 )
( 135 153 )
( 3.5 5.3 )
( 95 106 )
( 9 10.5 )
( 0 - 5.5 )
( 6.6 8.7 )
( 3.8 4.8 )
( 70 110 )
A)
B)
141
Question (8)
A 65 year old male presented to you with this urine analysis result. He has past
history of ureteric calculi. He is a known hypertensive for the last 3 years. He is
asymptomatic.
A)
B)
A)
142
Question (9)
52 year old daibetic, smoker presented with the result of his annual cholesterol
screening
T. Cholesterol . 236 mg/dl
HDL 24.6 mg/dl
TG .. 267 mg/dl
FBS 101 mg/dl
A.
A)
B.
B)
Question (10)
65 year old male presented for an evaluation after noticing that he was a little bit
yellow colored . he reported no other symptoms.
His initial laboratory results ware as follows.
AST .70 U/L
ALT 90 U/L
ALK P.tase 450 U/L
Bilirubin .. 4.5 mg/dl
A.
A)
B.
B)
143
B)
Answer (2)
A) What is your diagnosis ?
Gestational diabetes
B)
144
145
Answer (3)
B)
Impacted wax
Otitis media
Tympanic membrane perforation
Patent ventilating tube
Answer (4)
A) What is the prevalence of hypertension ?
(15 + 185 ) / 1000 = 200 : 1000 or 20 %
B) What is the prevalence of MI ?
( 15 + 5 ) / 1000 = 20 :1000 or 2 %
C) Draw 2x2 table
History of
hypertension
+ ve
- ve
Total
History of MI
+ ve
- ve
4
36
1
59
5
95
Answer (5)
A)
B)
C)
Total
40
60
100
Answer (6)
A)
B)
C)
Answer (7)
A)
Answer (8)
A)
B)
C)
Tumor
Calculus
Infection
Drugs
Systemic diseases
Essential
146
147
Answer (9)
A)
A)
B)
Drug history
Ultrasound
12.
149
Introduction:
Problem definition: this covers the candidates clinical thinking skills, his ability
to think broadly, logically and to have a high index of suspension (safe doctor)
Management (Problem solving): this covers the decision-making process. A
situation will be set or clinical problem raised and the candidate will be asked to
critically think about it and discuss his management options.
Prevention: this covers the basic knowledge of epidemiology, which is needed by
family physician.
Practice organization: this covers the candidates awareness about the system and
the regulation of health care service in his country, the obstacles and challenge
towards primary health care (PHC). It also includes practice management issues
and the PHC team
Communication: this encompasses verbal and non-verbal communication
technique, skills for effective information transfer and principles of communication
and consultation
Professional values: this covers general moral and ethical issues, patient
autonomy, medico-legal issues, flexibility and tolerance, implications of style of
practice, role of health professionals, cultural and social factors
Personal and professional growth: this focuses on the candidates personal
approach to continuing professional development, self-appraisal and evaluation,
stress awareness and burnout management
150
o
o
o
o
o
o
o
o
Listen to every single word in the question, and think broadly for possible issues
the examiners try to raise with you.
Analyze of the problem and remember the family medicine dimensions (physical,
social, psychological, ethical problems, or management problemetc) and
describe to the examiners your analysis of the problem.
This step is very important for the following reasons:
It helps you to give comprehensive answer
It demonstrates to the examiner your holistic approach in thinking
Organize your answer according to the different dimensions of the problems e.g.
You can say for the physical part of the problem I need to do ..etc.
For the ethical part of the problem I need to do . etc.
See next table (Systematic Thinking)
The examiner may give you a challenging question:
Remember the examiner is not looking for a definite answer (yes or no). He/she
will be looking at your abilities to make decisions
Be flexible and discuss options, advantages and disadvantages and avoid strong
statements.
When a preferred course of action is chosen, justify it in a rational and coherent
manner.
Systematic Thinking
The examiner may present to you a short case scenario, and ask you an open-ended
question, e.g. how would you proceed?
Suggested Systematic Thinking:
o Remember the consultation models
o You may need to ask for more history
o History, include patients ideas, concerns and expectations regarding his illness,
important past history and risk factors.
o Be specific and ask for relevant information only
o Think loudly
o Think broadly
o Common things first
o Have high index of suspicioun for serious possibilities
o If you are asked about physical examination, the examiner generally wants to know
your objectives from conducting a physical examination, he will not be interested
to examine your skills in conducting physical examination
The examiner may present to you a short case scenario, and ask you about
differential diagnosis
Suggested Systematic Thinking:
o Infection,
o Auto-immune
o Endocrine
o Psychological
o Malignancy
o Miscellaneous
o When you discuss your differential hypotheses, be ready to demonstrate to the
examiner how the differential hypotheses were proven or refuted
o Avoid giving number of problems or causes you are sure you will fill this number,
e.g. dont say this is caused by three cause, rather say: it can be caused by.. and ..
151
The examiner may present to you a short case scenario, and ask you about the
etiological factors of this situation
The examiner may present to you a short case scenario, and ask you about your
management of this situation
Suggested Systematic Thinking
o In your management plan, consider the patients physical, psychological and social
factors contributing to his illness.
Remember CRAPRIOP:
o C = Clarification
o R = Reassurance
o A = Advice & counseling
o P = Prescribing: If you mention a drug, be willing to specify dose, side effects,
precautions and contraindications
o R = Referral: Dont forget to make use of primary health care team e.g., social
workers. If you decide to refer the patient, be able to discuss
advantages and disadvantages and outcome expected
o I = Investigation: When you think a problem needs investigation, dont forget to
take into account the financial cost, effect on patient and benefit
expected
o O = Observation: Continuity of care is one of your important role as a family
physician.
o P = Prevention of complications
The examiner may present to you a short case scenario, and ask you what is the
effect of the problem
Suggested Systematic Thinking
o The effect on the patient,
o The effect on the family,
o The effect on PHC team,
o The effect on the community
The examiner may present to you a short case scenario, and ask you what is your
role in managing a health problem?
Suggested Systematic Thinking
o Patient management,
o Disease management,
o Practice management
The examiner may present to you a short case scenario, and ask you How do you
explain this behavior?
Suggested Systematic Thinking
o Patient factors,
o Doctor factors or PHC team,
o Disease factors,
o Others.
152
Thought Block:
o Think of alternative solution
E.g. I cant remember the dose of the drug, but I can look for it in BNF
Or I may use the practice protocol or the emergency room protocol.
o Think broadly & answer broadly.
You do not need to be very specific e.g. guidelines in management instead of
drug treatment.
o Review the list of problem definition: Some time specific questions need specific
answers. Be ready for it.
o
o
o
o
Rigid Answers:
o Instead of saying I should do it is preferable to say I may do so
o Instead of saying I always do it is preferable to say I prefer to do so
o Instead of saying I never do it is preferable to say I do not prefer to do so.
No Clear Answer:
o Go around the question
E.g. Q1.
What is your policy?
Q2.
What are you going to do now?
Q3.
What are you going to tell the patient?
Answer: Honestly I have no definite answer, However;
My Objectives are so and so, I may do so, I prefer to do so.
No Answer at all:
o CME might be an acceptable solution
o Referral might be the perfect answer, e.g.:
Q1. What is a cellular DPT vaccine?
Q2. You suspect pheochromocytoma. What are you going to do?
Disorganized Answer:
o Think before you talk
o Have enough training and develop your own system of thinking
153
2.
3. Tell me a bout your research (The research question, the objectives, your
methodology, your final recommendations and how can your result help in improving
health care?)
4. What might you do if you are assigned as a general directorate of PHC in the
Kingdom?
5.
6. Tell me about an important article you have read during the last year & how it
affected your practice?
7. (Audit) what is it? What are the advantages & disadvantages of Audit? How you do
it?
8. (Practice Formulary) What do you understand by this term? How do you make your
own formulary? What are the advantages & disadvantages of the formulary?
9.
10. A drug Rep. offers you an invitation to conference in Italy, how do you respond?
11. How would you deal with a patient requesting a sick note although you feel he is
healthy?
12. A 28 year old woman presents with a vaginal discharge which was proven to be
chlamydia infection. She asks if she caught it from her husband. What is your
reply?
13. A businessman returns from a trip abroad and present with a penile discharge.
He refuses referral to STD clinic and demand that you do not tell his wife. What are
the implications?
14. A 2-year-old child is a frequent attender to your PHC center with his mother
complaining of minor symptoms, what is your approach to frequent attenders?
154
15. You suspect sexual abuse in a 7-year-old girl. What is your management plan?
16. (We should treat all menopausal pt. with HRT). Discuss.
17. A 70-year-old woman has noticed some vaginal spotting. Examination reveals an
atrophic epithelium. How do you treat her?
18. 35-year-old healthy lady presents to you saying: (Can I have some Betnovate
ointment for that rash on my face? How do you respond?
19. Can dietary restriction be helpful in the management of skin disease?
20. There is debate as to whether good control reduces the long-term complications
of DM. What is your opinion?
21. What problems might face a new diabetic? Consider the case of a15 year old and
70 year old.
22. Despite advances in treatment of asthma, the mortality rate from asthma has not
dramatically fallen. What reasons may account for these facts?
23. What are the likely explanations of a sudden dramatic increase in consultation
rate in your practice? How would you determine the cause?
24. How may bad records result in bad medical care?
25. Discuss the advantages & disadvantages of the practice owning its own ECG
machine?
26. How could you modify your medical records to improve preventive care?
27. What do you know about the current public health problem in KSA or/and current
public health problem in the world?
(E.g. Rift Valley Fever / Mad Cow Disease..)
155
List the possible serious complications and/or the possible serious differential
diagnoses for the following problems.
Q2
List the most specific symptoms or signs that would make you suspect these serious
diagnoses or complications
1. A 45-year-old patient with dyspepsia
2. A 50-year-old patient with severe headache
3. A 48-year-old patient with symptoms suggestive of irritable bowel syndrome
for 2 months duration
4. A 25-year-old patient complaining of weight loss
5. A 65-year-old patient with chronic cough
6. A 6-year-old boy with fever for three weeks
7. A 45-year-old illiterate male from badia (rural area) presented with fever for
one month.
8. A 5-day-old infant with jaundice
9. A 9-year-old boy complaining of short stature
10. A 10-month old baby unable to sit independently
11. A 3-year-old child with gastro enteritis
12. A 35-year-old lady with a breast mass
13. A 44-year-old lady with thyroid enlargement
14. A 58-year-old lady with vaginal bleeding
15. A 60-year-old gentle man with prostatic hypertrophy
16. You discover a systolic murmur in a healthy pregnant lady
17. You discover a systolic murmur in a child
18. A 60-year-old lady severely depressed
19. A 25-year old male with first degree hypertension
o
o
o
156
13.
Important topics
Primary health care.
Management.
o management cycle.
o audit cycle.
o planning health care activities.
o planning health education program.
Epidemiology.
Others:
o Screening.
o Periodic health assessment.
o Evidence based medicine.
o Immunization (vaccinology).
o Polio. Eradication.
o Tetanus neonatorum elimination.
o New epidemics.
o You the family doctor.
o Up-date.
157
158
Management Cycle
Planning
Define objectives
(General & specific)
Prioritization of Objectives
Organization
Who to do what
Resuorce needed:
Personnel
Equipments
Time
Budget
Monitoring
(Audit):
Structure
Process
Outcome
Implementation
Effective Communications
Effective delegation
Teamwork
Epidemiology
159
Epidemiology
Control of Communicable Disease
1) Identification of cases.
2) Causative Agent.
3) Occurrence.
4) Reservoir.
5) Mode of transmission.
6) Incubation period.
7) Period of Communicability.
8) Susceptibility and resistance.
9) Control:
Preventive measures:
o Health education
o Prophylaxis.
Control of patient, contact, and environment.
o Notification, isolation, disinfection, quarantine, investigations, treatment.
Epidemic measures.
Disaster implications.
International measures
160
161
Investigation of an epidemic
1) verify the diagnosis.
2) establish the existence of an epidemic.
3) characterize the distribution of cases.
4) develop the hypothesis.
5) test the hypothesis.
6) formulate a conclusion.
7) institute control measures.
Disaster management
Preparation of relief plan:
1) rescue of victims.
2) provision of emergency medical care.
3) elimination of physical dangers.
4) evacuation of population.
5) provision of preventive and routine medical care.
6) provision of water, food, clothing, and shelter.
7) disposal of human and solid wastes, and human bodies.
8) control of vector-borne diseases.
Field survey
Definition:
Detailed field study in a period of time to determine magnitude and
epidemiological factors
To help in planning and evaluation of preventive and control program
A) preparation: personnel, finance, equipment, forms,etc.
B) steps:
1) define area and population.
2) examination and/or investigation.
3) existing program.
4) analysis of data.
5) report and recommendations.
162
163
Surveillance
Definition:
Regular collection and summarization and analysis of data on newly diagnosed
cases of any infectious disease for the purpose of identifying high risk groups in
the population, understanding the mode(s) of transmission, and reducing or
eliminating its transmission.
Types:
Active: collection of data (usually on a specific disease) for a limited period of
time by regular outsearch on the part of health department personnel.
Passive (reporting): data generated without solicitation, intervention, or contact by
the health agency carrying out the surveillance.
Screening
Definition:
The presumptive identification of unrecognized disease or defect or individuals at high
risk by the application of tests (question, physical examination, investigation, or other
procedures), which can be applied rapidly to sort out apparently well people who
probably have a disease from those who probably do not.
Prerequisites:
Problem:
o Important.
o Treatable.
o Available treatment.
o Understandable natural history.
o Asymptomatic stage.
Test:
o Suitable.
o Acceptable.
o Reasonable cost.
o Reliable.
o Valid.
164
165
166
Missed opportunity
A child in need of immunization seeks health care but receives either no immunizations
or does not receive all the needed immunizations.
o Child seeks immunization but; not offered the needed vaccines.
o Child seeks other health care services but; not his immunization status not
assessed.
o Child is enrolled in assistance program for vaccination but; missed.
The most important, immediately implemented actions for reducing missed
opportunities for vaccination are:
o Assess vaccination status of all < 5 at all visits.
o Elimination of invalid contraindications to vaccination.
o The use of simultaneous administration role whenever needed.
Invalid contraindications to vaccination:
1) minor illness:
Low-grade fever, upper respiratory tract infection, common cold, otitis media and
mild diarrhea.
2) antibiotic therapy
3) disease exposure or convalescence:o If the child is not severely ill
o It will not affect the response
o It will not increase the likelihood of an adverse event.
4) pregnancy in household:o The risk is similar to non-pregnant household
o Measles & mumps produce a non-communicable infection.
5) breast feeding
6) prematurity
7) Allergies:o Nonspecific allergies
o Non-severe egg allergies
o Allergies to antibiotics not in vaccine
o Allergies to duck antigens
o Family history of allergy
8) family history of adverse events to a vaccine.
9) tuberculin testing:
o All vaccines can be given with PPD or any time after testing and .except
MMR wait for 4-6 weeks after MMR before PPD testing.
167
New epidemics
RTA, CVD, HIV, Substance abuse
14.
Important Definitions
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Sensitivity.
Specificity.
A positive predictive value.
A negative predictive value.
Likelihood ratio of a positive test.
Type 1 error.
Type 2 error.
P value.
Incidence.
Prevalence. (Point prevalence and Period prevalence)
Odds ratio.
Relative risk.
Absolute risk.
Attributable risk.
Sensitivity
o Proportion of diseased persons with positive test result.
o Measures the true positive.
o Positivity in disease.
o Ability to include person with a disease.
168
Specivity
o Proportion of healthy persons with negative test result.
o Measures the true negative.
o Negativity in health.
o Ability to exclude person without a disease
Highly Sensitive
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Highly Specific
169
170
Definitions
Positive predictive value: probability of a disease in a person with a positive test.
Negative predictive value: probability of absence of disease in a person with a
negative test.
Likelihood ratio: the ability of a test to discriminate between diseased and nondiseased persons.
i.e. Probability of a positive result in a diseased person / Probability of a positive
result in a healthy person.
Type 1 error: true null hypothesis rejected.
Type 2 error: false null hypothesis accepted.
P value: the probability of the result of the study occurring by chance, if the null
hypothesis were true.
Incidence: the number of new cases of a disease in a population over a period of
time.
Prevalence: the proportion of individuals in a population who have the disease at a
given time.
o Point prevalence: prevalence at one point of time.
o Period prevalence: prevalence at a point time, plus new cases in a time period.
Odds ratio: the odds that a disease will occur among exposed compared to
occurrence among nonexposed. (the probability of contracting a disease divided by
the probability of not contracting the disease).
Relative risk: the ratio of the incidence among exposed to the incidence among
nonexposed.
Absolute risk: the probability of occurrence due to exposure.
Attributable risk: the excess risk of a disease that can be ascribed to the exposure to
a risk factor.
Population attributable risk: the excess risk of a disease in a population that can be
solely attributed to the exposure to the risk factor.
171
172
Vital Rates
Definition:
The expression of the probability of occurrence of a particular event in a defined
population during a specified period of time. Mathematically, a rate is expressed as
X
/Y X K.
Where
X= the number of events or Cases,
Y= the total population at risk, and
K is a round number, or base, chosen to express the rate as a number greater
than one.
Natality Rates
Crude Birth Rate:
number of live births reported during a given time interval
---------------------------------------------------------- x 1000
Estimated midinterval population
The crude birth rate is expressed per 1000 population. (Note that the total population
is used in the denominator even though many individuals are not at risk of becoming
pregnant).
Fertility Rate:
Number of live births reported during a given time interval
--------------------------------------------------- x 1000
Estimated number of women age 15-44 years at midinterval
Fertility rate is expressed per 1000 population.
Morbidity Rates
Incidence Rate:
Number of new cases of a specific disease during a given time interval
--------------------------------------------------------------- x 100
Estimated midinterval population at risk
A high incidence rate means a high occurrence of disease; a low incidence rate
means a low occurrence of disease.
1) Because incidence rate is a measure of the rate at which healthy people develop
disease during a specific time period, it is a statement of probability.
2) Since incidence rates are affected by any factor that affects the development of a
disease, they can be used to detect etiologic factors.
173
Morbidity Rates
Prevalence Rate:
Number of current cases [old (i.e. people who contracted disease before time period
began and who still have the disease) and new] of a specified disease during a
specified time period
----------------------------------------------------- x 100
Estimated midinterval population at risk
1) Point prevalence refers to a specific point in time
2) Period prevalence refers to a given time interval
Morbidity Rates
Prevalence:
o Since prevalence rate contains all known cases in the numerator, it is used primarily
to measure the amount of illness in a community and, thus, can be used to determine
the health care needs of that community.
o Prevalence rates are influenced by both the incidence of disease and by the duration
of illness.
Morbidity Rates
Attack rate:
Number of new cases of a specific disease during a specific time interval
---------------------------------------------------------------------------- x 100
Total population at risk during the same time interval
Attack rate normally is expressed as a percentage. It is an incidence rate that is
calculated in an epidemic situation using a particular population observed for a
limited period of time.
174
Morbidity Rates
Secondary Attack Rate:
(number of new cases in a group) (index case or cases during a specified time period)
---------------------------------------------------------------------------- x 100
(number of susceptible individuals in the group) (index case or cases)
Note that the index case or cases that introduced the disease into the group are
removed from both the numerator and denominator. The secondary attack rate
measures spread within an epidemiologic unit. Coindex cases are two or more cases
that, based on the incubation period of the disease, were infected by someone
outside the group.
Crude Death Rate:
Total number of deaths reported during a given interval
------------------------------------------------ x 1000
Estimated midinterval population
Crude death rate is expressed per 1000 population. (Note that the total population is
used even though the risk of death is different for different age-groups.)
Cause-Specific Death Rate:
number of deaths assigned to a specified cause during a given time interval
---------------------------------------------------- x 100,000
Estimated midinterval population
Cause-specific death rate is expressed per 100,000 population.
Maternal Mortality Rate:
Number of deaths related to pregnancy during a given interval
--------------------------------------------------------------------- x 1000
Number of live births reported during the same time interval
Although the true population at risk should be the number of pregnant women, this is
an impossible figure to determine. The number of live births is chosen because it
reflects the number of pregnant women; thus, this is a pseudorate, or index.
Case-Fatality Rate:
Number of deaths assigned to a specific disease
------------------------------------------- x 100
Number of cases of the disease
Case-fatality rate is frequently expressed as a percentage. It predicts the risk of dying
if the disease is contracted. Tetanus has a case-fatality rate of 30-90%, depending on
the age of the host, the length of the incubation period, and the type and length of
therapy.
175
Mortality Rate
Proportionate Mortality Ratio (PMR):
Number of deaths from a given cause in a specified time period
--------------------------------------- x 100
Total deaths in the same time period
PMR usually is expressed as a percentage.
o The PMR is not a rate and does not measure the probability of dying from a particular
cause.
o The PMR is primarily used to determine the relative importance of a specific cause of
death in relation to all causes of death within a population.
Exercise:
In a small town the estimated population on 6/98 was 500,000 persons ; of them
300,000 were Nationals. At the same time, it was estimated that the total live birth for
Nationals is 9000 & for Non-Nationals 6000. Number of deaths for all ages from all
causes was 2700 for Nationals & 2400 for Non-Nationals. The infant death numbers
were 180 & 360 for Nationals & Non-Nationals; while deaths due to IHD were 1200
& 600 respectively.
Define Infant mortality rate (IMR).
Calculate IMR for Nationals.
Define Crude Death Rate (CDR).
Calculate CDR for Nationals.
Define Cause Specific Proportional Mortality Rate (CSPMR) for Nationals & NonNationals due to IHD.
o
o
Objectives (Aim).
Design.
Sampling:
Technique
size.
Conclusion.
Recommendations.
Types Of Studies
o
o
Observational
Descriptive
Analytic
Experimental
Observational Studies
Descriptive studies:
o Ecological (correlational).
o Cross sectional (prevalence).
o Longitudinal.
o Case seires or report.
Descriptive study
o
o
o
o
Descriptive study
Descriptive study can be:
Qualitative research concerned with opinions, perceptions and attitudes towards a
topic, for example family panning.
Quantitative research aiming at quantifying the distribution of certain variables
among the study population e.g. prevalence of certain disease.
Observational Studies
Aanalytic studies:
o Case control (case reference).
o Cohort (interventional):
- Prospective.
- Retrospective.
Case-control studies
o Begin after individuals developed or failed to develop the disease.
o Incidence cases should be selected.
o Useful in early stages of development of knowledge about a particular disease.
176
Selection of controls
o
o
o
o
177
178
Cohort study
Individuals are selected on the basis of the presence or the absence of exposure to
suspected risk factors
Definition of cohort
Cohort: is a group of persons who share a common experience within a defined time
period. A birth cohort and survivors of myocardial infarction in one particular year are
examples of cohort
179
Experimental Studies
1) Randomized control trial (clinical trial)
2) Field trial
3) Community trial
Experimental study
Experimental study is the strongest possible type of study to prove causation.
The unique feature of experimental study is the method for assigning individuals to
study and control groups.
Experimental study
Used to evaluate: o Prophylactic agent, such as vaccine.
o Public health procedure, such as screening test.
15.
Definition of PHC
o It is the first level of contact of individuals with the health system.
o It is the provision of essential health care based on practical,
scientifically sound, and socially accepted methods and technology
made universally accessible to individuals, families, and community;
through their full participation and within a reasonable cost.
Elements of PHC
1. Health education.
2. Proper nutrition.
3. Maternal and child health.
4. Immunization.
5. Safe water supply.
6. Control of endemic diseases, and environmental health.
7. Referral.
8. Treatment of common health problems.
9. Treatment of acute respiratory tract infections.
10. Provision of essential drugs.
11. Mental health.
12. Dental health.
13. Geriatric care.
Principles of PHC
o
o
o
o
Equity of distribution.
Appropriate technology.
Multisectorial approach.
Community participation.
180
Instruments of PHC
o
o
o
o
o
181
182
183
Cholesterol Screening
F. Rayes
Cholesterol level mmol / L Action
Follow-up
None
Re-check in 3 years
5.2 - 6.5
Dietary advice
Re-check in 1 year
Above 6.5
Dietary advice
Drug history ?!
TFTs, LFTs
Or referral if
Creatinine is high or FBS
is high
Re-check in 3 ms
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
184
Poliomyelitis
F. Rayes
Poliomyelitis
Epidemiology of poliomyelitis
o Infectious agent:
- Polio virus I, II & III.
o Occurrence: World - wide.
o Reservoir: Man
o Mode of Transmission: Food, water and droplet
o Incubation Period:
- 7 - 14 days commonly
- 3 - 35 days range
o Period of Communicability:3 - 6 weeks.
- Case are most infectious during the first few days before and
after onset of symptom.
o Susceptibility & Resistance :
- Susceptibility is common but paralysis is rare.
o Factors increase risk of paralysis:
- IM injection
- Surgery
- Muscular exhaustion
- Pregnancy
185
Global Eradication :
WHO called for Global Eradication of poliomyelitis by year 2000.
Achievement and maintenance of high immunization level.
Vaccine quality control and availability.
Training and supervision of in-country personnel.
Acute Flacid Paralysis ( AFP ) surveillence.
National Immunization Days ( NID ).
Research and development to increase the effect of vaccine.
No more than 14 cases / year, average 8 cases/ year since 1980.
One case / 2.6 million doses of OPV, the relative frequency of paralysis
- with first dose
( 1/520,000 doses)
- with subsequent doses
( 1 / 12.3 million dose ).
Note: Preparations are now available in USA which incorporate killed poliomyelitis
with DPT.
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
186
Tuberculosis
F. Rayes & N Dashash
Developed
2-3%
Developing
60 - 80 %
KSA
7%
12 - 20
1-2
0.1 %
250-500
60 - 100
3 - 10 %
30 - 40
-----
TB / Approach to Prevention
o Countries of high prevalence: Vaccination at birth (60-80% efficacy).
o Country of low prevalence: Case finding and INH prophylaxis (80% efficacy).
o
o
o
o
o
o
o
o
o
o
o
o
TB / Facts
BCG efficacy 60-80%.
BCG cause +ve skin test for 6-7 years after immunization.
False -ve PPD in 20% of active TB.
False -ve PPD in 50% of HIV.
Chest x-ray is normal in 50% of extrapulmonary TB.
TB / Diagnosis
Clinically:
High index of suspicion
Screening Tests
PPD skin test: if positive test = infection has occurred.
X-ray chest: it is less sensitive than skin test.
Confirmatory test
Sputum
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
187
188
Appendix
Studying advice
Nisreen Jastaniah
Preparing your self for the exam:
For the written part:
You need to do more reading hours with good use of time.
Try to cover as much as you can of the MCQ books; you are advised to read with
their explanations. While studying keep some notes of things that you think were
difficult for you,
MCQs always need revision in order to remember them later. (Use your long-term
memory).
For MEQs do more practice, try to write at least one MEQ / day 3-4 weeks before
the exam. (Consider the time, review the answer & you may need to re-write them
later if you could not gather most points)
For CRQ you must have good basic knowledge by now. Tray to answer a paper
/week at least 5 papers. (Consider the time).
For the oral:
Your performance most of the time will depend on your knowledge & you real
practice (peer help can be useful).
Try to be exposed to more cases.
Practice consultation skills.
Prepare you self for the data.
Try to do more oral exams before the real one.
Remember always follow a written plan & modify it according to your need.
Best wishes
189
Studying advice
Manal Khursheed
In the beginning, I thank God and then the Family & Community medicine program
in Jeddah for my graduation in family medicine specialty.
My advice to our colleges for succeeding their exam:
Dont leave any day without reading any thing related to our requirement
Be updated ,always search for new knowledge in journals, internet ,courses & so
on
MCQs, need a lot of concentration and repetition, read them in quiet place, at least
three months before your final exam, it is better to read them alone not with
company, & if you have a mistake put a sign beside it and review it again before
you finish that MCQ book.
SIMULATED CLINIC, needs practice & practice, don't escape from your clinic.
At least six months before exam, you need to be trained on them, not alone but as
a group (at least two per group) & use an alarm clock to be on time.
MEQ, needs training by writing & also try to use an alarm clock to be on time.
SLIDES, need practice and practice, read from atlases and related books that are
available in the program library
DATA INTERPRETATIONS, need practice in the clinic and also read the books
of data available in the program library.
Listen to the advises of your trainer staff & dont ignore them.
Finally I ask God to help you to succeed your exams.
190
Internet Resources
H. Hajjar
Site name
Address
http://www.uwo.ca/fammed/clfm/sites.html
http://www.wonca.org/resources/journals/wonca_journals.htm
Journals
American Family
Physician
Family practice
management
Royal Collage of General
Practitioners
British Journal of General
Practice
Electronic BMJ
Jama
Royal Australian Collage
of General Practice
The Collage of Family
Physicians of Canada
http://www.aafp.org/afp/index.html
http://www.aafp.org/fpm/index.html
http://www.rcgp.org.uk/
http://www.rcgp.org.uk/rcgp/webmaster/bjgp_sub.asp
http://www.bmj.com/
http://jama.ama-assn.org/
http://www.racgp.org.au/publications/
http://www.cfpc.ca/index.htm
MEDLINE
Pub med
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?SUBMIT=y
Infotrieve
http://www3.infotrieve.com/medline/infotrieve/
American Academy of
Family Physician
American Medical
Association
American Diabetes
Association
British Hypertension
Society
British Thoracic Society
Center of Disease Control
and Prevention
Canadian Medical
Association
National , Heart, Lung and
Blood Institute
WHO
http://www.aafp.org/
http://www.ama-assn.org/
http://www.diabetes.org/
http://www.hyp.ac.uk/bhs/
http://www.brit-thoracic.org.uk/
http://www.cdc.gov/
http://www.cma.ca/eng-index.htm
http://www.nhlbi.nih.gov/index.htm
http://www.who.int/home-page/
http://www.wonca.org/
Site name
191
Address
Evidence Based Medicine
National Guideline
Clearinghouse
Primary Care Clinical
Practice Guidelines
http://www.guideline.gov/body_home_nf.asp?view=home
Evidence-Based Medicine
(Journal)
http://hiru.mcmaster.ca/ebmj/default.htm
http://hiru.mcmaster.ca/cochrane/cochrane/cdsr.htm
http://medicine.ucsf.edu/resources/guidelines/
http://www.mayohealth.org/home
Medscape
The Emergency
Medicine and Primary
Auscultation Assistant
http://www.medscape.com/
http://www.embbs.com/
http://www.wilkes.med.ucla.edu/intro.html
http://www.arabcom.net/chp/scfhs/
194
Index
87
84
84, 96
97
47
32
30
19
19
20
21
135
8
9
9
10
10
11
183
23
23
25
59
55
42
81
80
127
184
157
81
82
66
67
160
161
96
111
123
129
136
195
F
G
J
K
M
12
13
99
111
31
83
162
34
34
92
93
120
51
160
164
53
162
57
49
190, 192
99
85
86
86
62
100
61
15
15
16
18
36
37
109
64
196
162
94
100
42
46
97
158
61
48
54
196
N
O
R
S
U
V
W
X
41
58
59
121
50
148
91
27
159
164
29
49
21
1
184
95
99
44
188
70
168
122
163
60
89
194,195
40
187
197
182
103
28
104
68
193
88
105
166
166
165
38
39
34
56
42
129
197