NAC OSCE

Medicine (SEP 2018)

 Internal Medicine Cases
1. Chest pain (ACUTE: couple hours - couple days)

Pre-door prep: Chest pain cases present either as an acute or chronic chest pain. Beside the timing,
it is very important to note the age of the patient and the setting.
Introduction: Good morning/afternoon Mr/Mrs. ...

Analysis of OsCfD: When / setting: what were you doing? Has the pain been there? How?
CC PQRST:
— Position: where did it start? Can you point with one finger on it?
— Quality: how does this pain feel like? Sharp, tightness
— Radiation: does it travel anywhere? Your jaw, your shoulders, your back?
What ↑ or ↓:
— Breathing / position / meals / exercise / stress
— How did you come to the clinic today? Ambulance ?Did they give you
any medication (Aspirin/ nitrates) ? Did that help?
Same System Nausea / vomiting
Sweating / feeling tired
SOB! if yes, analyze (OsCfD)
Do you feel your heart racing?
Did you feel dizzy / light headedness / LOC? Are you tired?
Did you notice swelling in your ankles? Legs? Calf muscles?

CHF:
— SOB? How many pillows do you use? Do you wake up gasping for air?
— Any swelling in your LL? How high does it go? Is it related to position?
— Eye puffiness? Pain on the liver?
Near by CHEST:
systems — Any cough or phlegm? Chest tightness? Wheezes?
— Recent fever / flu like symptoms? Muscles/ joint ache?
GIT:
— Difficulty swallowing (esophageal spasm)
— Heart burn / acidic taste in your mouth?
— Any hx of PUD? Reflux? GERD?
Chest wall: any trauma, any blisters / skin rash on your skin
DVT: any pain / swelling / redness in your legs / calves? Any
recent long travel?
Constitutional Fever / night sweats / chills
symptoms How about your appetite? Any weight changes?
Any lumps or bumps in your body?
Risk factors CAD
(see next page) Pericarditis
PE
PMH
FH
SH

Page 2 of 34
 Internal Medicine Cases

Risk Factors:
— CAD (Coronary Artery Disease):
MAJOR:
o High blood pressure
o High blood sugar
o High cholesterol: have you got your cholesterol measured before?
o Family hx of heart attack at male < 55 yrs ; Female < 65 yrs
o SAD: Smoking / Cocaine
MINOR:
o Look for obesity
o Do you exercise
o How about your diet, do you eat a lot of fast food?
o Are you under stress?
— Pericarditis:
o Recent flu like symptoms
o Medications (Isoniazide / Rifampicin)
o Hx of surgery
o Hx of heart attack
o Hx of kidney disease / puffy face / frothy urine
o Hx of TB
o Hx of autoimmune disease
— Pulmonary Embolism:
o Recent long flight
o History of malignancy
o Family history of blood clots
o Female: pregnancy / OCPs / HRT
Chest Pain
Acute Chronic
Minutes – hours Hours – days Intermittent Continuous
Cardiac: Cardiac: Cardiac:
- ACS - Pericarditis - Stable Angina
- Aortic dissection - Unstable Angina
Non-cardiac: Non-cardiac - Cancer
- Tension - Pneumonia - Herpes zoster
pneumothorax - Pleurisy - Trauma
Panic attack Pulmonary embolism Panic attack
GIT: GIT: Mediastinal
- GERD - GERD - Lymphoma
- PUD - PUD - Thymoma
- Esophageal spasm - Esophageal spasm

Ischemic Heart Disease

 2. Chest pain – CHRONIC : Chest pain for couple weeks

Pre-door Prep Name, age, gender duration, possible DD

Intro
Analysis of OsCfD: Onset / setting: what were you doing?
CC PQRST:
— Position: where did it start? Can you point with one finger on it?
— Quality: how does it feel like? Squeezing, tightness
— Radiation: does it shoot anywhere? Your jaw, your shoulders, your back?
What ↑ or ↓:
— Breathing / position
— Is it related to activity? How many blocks were you able to walk? And
now?
— How about rest? And during night?
— When was the last attack
Triggers Angina GERD
Exertion Golf (leaning forward)
Stress (emotional) Coffee / dairy products
Cold air Smoking / Alcohol
Heavy meals Heavy / late meals
Sexual activity Pregnancy (progestin)
Differential Same system Nausea / vomiting
diagnosis Sweating / feeling tired
SOB: if yes, analyze (OsCfD)
Do you feel your heart racing?
Did you feel dizzy / light headedness / LOC? Are you tired?
Did you notice swelling in your ankles? Legs? Calf muscles?
Near by CHEST:
systems — Any cough or phlegm?
— Chest tightness? Wheezes?
— Recent fever / flu like symptoms? Muscles/ joint ache?
GIT:
— Difficulty swallowing (esophageal spasm)
— Heart burn / acidic taste in your mouth?
— Any hx of PUD? Reflux? GERD?
Chest wall: any trauma, any blisters / skin rash on your skin
DVT: any pain / swelling / redness in your legs / calves? Any
recent long travel?

Impact Effect Atherosclerosis Chronic cough
CHF Change in the voice
Red flags Constitutional Fever / night sweats / chills
symptoms How about your appetite? Any weight changes?
Any lumps or bumps in your body?
Risk factors CAD

PMH DO NOT FROGET TO ASK ABOUT MEDS & ALLERGIES

FH
SH
Post Encounter Probes :
Investigations: ECG / Cardiac enzymes etc.
Be prepared to analyze common ECG's such as ( STEMI's, Non-STEMI's, Arrhythmias, Heart Blocks
and diffuse ST segment elevation)

Page 4 of 34
 Difficulty swallowing : Dysphagia

How to approach Dysphagia?

It is very important to ask the patient about what do they mean by "Difficulty Swallowing"

• Is it dysphagia localized to the neck? Difficulty initiating swallowing?

• Is it dysphagia localized to the chest? Do you feel the food gets stuck?
• Is there pain when you swallow?

Cases:

• 64 years old female presenting with difficulty swallowing for the past 6 month à Esophageal Cancer

• 40 years old male presents with chest pain for the past 6 weeks àGERD
 Case of mechanical Dysphagia:

Pre door prep

Intro
Analysis OsCfD: gradual, ↑ progressively, to solids then fluids / PQRST / What ↑ / ↓
of CC Associated symptoms:
— The same system:
o Nausea / vomiting / undigested food
o Change in bowel movements
o Change in the size of the abdomen / abd pain / blood in stools
o Liver: yellowish discoloration / itching / dark urine/ pale stools
— Near-by systems:
o Any chest pain / tightness
o Any cough / change in your voice / neck swelling (thyroid lump)
Impact Weight loss
Red flags Constitutional symptoms: fever/ night sweats/ chills / change in appetite / loss of
weight / lumps & bumps
Risk factors:
— GERD / PUD:
o Hx of heart burn
o Were you ever diagnosed with a condition called GERD / PUD
o Have you ever checked with a camera or a light (endoscope)
inserted into your stomach
— Smoking / Alcohol
— Family history: esophageal cancer
— Radiation to chest
— Have you ever swallowed any chemical?
PMH DO NOT FROGET TO ASK ABOUT MEDS & ALLERGIES
FH
SH

Page 6 of 34
 GERD: Post encounter probes

Investigations
- Usually, a clinical diagnosis is sufficient based on symptom history and relief following a
trial of pharmacotherapy (PPI: symptom relief 80% sensitive for reflux)

Gastroscopy indications

Absolute indications:
- heartburn accompanied by red-flags (bleeding, weight loss, etc.)
- persistent reflux symptoms or prior severe erosive esophagitis after therapeutic trial
of 4-8 wk of PPI 2x daily
- history suggests esophageal stricture especially dysphagia
- high risk for Barrett’s (male, age >50, obese, white, tobacco use, long history of symptoms)

Treatment
- PPIs are the most effective therapy and usually need to be continued as maintenance therapy
- On-demand: antacids (Mg(OH)2, Al(OH)3, alginate), H2-blockers, or PPIs can be used for
NERD
- Diet helps symptoms, not the disease; avoid alcohol, coffee, spices, tomatoes, and citrus juices
- Only beneficial lifestyle changes are weight loss (if obese) and elevating the head of bed (if
nocturnal symptoms)
- Symptoms may recur if therapy is discontinued

Complications
- Esophageal stricture disease – scarring can lead to dysphagia (solids)
- Esophagitis
- Ulcer
- Bleeding
- Barrett’s esophagus and esophageal adenocarcinoma
PUD:

Risk Facors for NSAID-induced Peptic Ulcer

- Previous peptic ulcers
- Age (≥65 yr)
- High dose of NSAID/multiple NSAIDs being taken
- Concomitant corticosteroid use
- Concomitant cardiovascular disease/other significant diseases
Treatment
- Prophylactic cytoprotective therapy with a PPI is recommended
- Lower NSAID dose or stop all together and replace with acetaminophen

Treatment: H. pylori Eradication

Bismuth quadruple therapy recommended for 10-14 d: PPI + bismuth + metronidazole + tetracycline

Alternatively, concomitant nonbismuth quadruple therapy for 10-14 d: PPI + amoxicillin + metronidazole +
clarithromycin
 Congestive heart failure – CHF

74 years old man comes to ER with 4 weeks of SOB

Pre door prep
Introduction
Analysis of Clarification 1- When do you say SOB; what do you mean? Cardiac or chest?
CC — Is it difficult to breathe in and out? ! cardiac / anemia
— Is it difficult to breathe out? ! COPD / asthma
2- Do you have any hx of asthma? Lung disease?
— Any wheezes? Chest tightness? Cough?
3- Do you have any hx of heart disease?
— No ànewly dx
— Yes ? à acute on top of CHF
— Any racing heart? Dizziness? LOC? Any hx of HTN?
O S C fD Is it first time? Or you had it before? When and how were you
PQRST diagnosed? How about treatment?
↑↓ Is it related to activity? How many blocks were you able to walk?
And now?
How about at rest? And at night?
Impact Left ventricle:
— SOB? How many pillows do you use?
— Do you wake up at night gasping for air?
— Cough / crackles?
Right ventricle:
— Any swelling in your LL? How high does it go? Related to position / standing?
Weight gain?
— Eye puffiness? Swollen face? Pain on the liver?
Other cardiac symptoms:
— Chest pain? Nausea/vomiting? Sweating?
— Heart racing / dizziness / LOC? Do you feel tired?
Red flags Constitutional symptoms – for infection / cancer
Risk factors for ischemic heart diseases – IHD
DD Causes (that precipitated acute on top of CHF):
Compliance
Diet
Medical
PMH DM / Kidney / Liver diseases
FH HTN / heart attacks
SH SAD

DD (Causes that precipitated acute on top of CHF):

Compliance:
— Are you receiving treatment? Which medications do you take? How much? For how long? Any
change in medications? Change in dose?
— Do you take it on regular basis? Any chance that you may skip one or more doses?
— Do you take it by yourself or do you need help?
— Did you get your Digoxin level measured before / recently?
— Did you start new medication? Rx or (OTC) over the counter? e.g. indomethacin
— How about water pills?
— Are you under regular F/U? How often? When was the last time? Were you symptoms free at that
time?
Diet:
— Do you have special diet? Salt-free diet? Do you monitor that?
— Any new changes in diet?
— Any chance of salty food, e.g. olives, canned food, dried meet and fish

Page 8 of 34
 Medical:
— Do you take medications on regular basis? Any new medication? Advil?
— Any hx of thyroid dx, any sweating / diarrhea?
— Any hx of heart disease / HTN (à A Fib) / heart attack / CAD (ischemia) / did you feel your
heart bouncing (arrhythmias)? Any congenital or valvular disease / Chest pain / tightness /
dizziness / light-headedness / LOC?
— Any chest / lung disease (wheezes, cough, chest tightness)
— Any kidney disease? Renal failure?
— Any bleeding? Anemia?

New York Heart Association functional Classification of heart failure:

Class I: ordinary physical activity does not cause symptoms of HF
Class II: comfortable at rest, ordinary physical activity results in symptoms
Class III: marked limitation of ordinary activity; less than ordinary physical activity ! symptoms
Class IV: inability to carry out any physical activity without discomfort; symptoms may be present at rest

Investigations:
Labs: CBC / lytes / ABG (arterial blood gases) / glucose / INR / PTT / serial cardiac enzymes (q8h x 3)
/ ECG / fluid balance
Chest x-ray findings of CHF: (1) Enlarged heart, (2) Upper lobe vascular redistribution, (3) Kerley B
lines (thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the
lungs), (4) Bilateral interstitial infiltrates, (5) Bilateral small effusions

Treatment:
— Acute heart failure (short term management):
o Treat acute precipitating factors (e.g. ischemia. arrhythmias)
o L Lasix (diuretics) à ↓ pre-load (furosemide: 40-500 mg IV)
o M Morphine; 2-4 mg IV – decreases anxiety and preload (venodilation)
o N Nitrates (venous and arterial dilator à↑ kidney perfusion)
o O Oxygen
o P Positive airway pressure (CPAP/BiPAP) – decreases preload and need for
ventilation / Position (sit patient up with legs hanging down unless hypotensive)
o In ICU or failure of LMNOP: sympathomimetics (dopamine or dobutamine)
— Chronic heart failure (long term management):
o ACEI (slow progression and improve survival) or ARBs (if ACEI not tolerated)
o Beta blockers: slow progression and improve survival
Should be used cautiously, titrate slowly because may initially worsen CHF
Side effects: fatigue / bradycardia
If pt on β-blockers àexacerbation àstop the β-blockers for 2 days
o Diuretics: symptom control, management of fluid overload; furosemide 80 mg OD
(furosemide opposes the hyperkalemia induced by beta-blockers, ACEIs)

• Spironolactone for class Ill-b and IV CHF already on ACEI and loop diuretic
• If still uncompensated: Implantable Cardioverter Defibrillator (ICD)
o Anti-arrhythmic drugs: for use in CHF with arrhythmia can use amiodarone, beta-
blocker, or digoxin
o Anticoagulants: warfarin for prevention of thromboembolic events
 Ankle swelling – Bilateral

Pre door prep

Introduction
CC uni- vs. bi- lateral
Analysis of O s C fD What ↑? Walking / standing what ↓ Raising legs?
CC ↑↓ How high does it go?
AS Local symptoms:
— Pain / fullness / heaviness / tightness
— Skin changes (redness / swelling / do you feel your feet warm?)
— Nail changes
Other swellings in your body:
— How about swelling in your face? Eye puffiness? Do you find it
difficult to open your eyes in the morning?
— How about your belly? Did you need to ↑ the size of your belt?
— Hands, did you feel it is tight to wear your ring?
Impact How does this affect your life?
Red flags Constitutional symptoms – for infection / cancer
Differential Differential diagnosis of BILATERAL ankle swelling:
diagnosis Failure Heart
Failure Liver
Failure Kidney: history of kidney disease (changes in urine / bruising /
frequency / burning / frothy urine / clear or no)
Hypoalbuminemia
Thyroid diseases
Specific cause within this system (e.g. kidney)
Hx or Dx of DM
Any medications (penicellamine, gold, NSAIDs, …)
Recent sore throat
Any skin infection / rash
Hx of autoimmune disease
How about diet? Is it balanced? Any diarrhea?
PMH
FH
SH

Case: patient with face swelling, BP 150/90, protein in urine, ketones, no blood, no glucose, no WBCs
Diagnosis: nephritic syndrome (minimal changes)
Investigations:
— Kidney function tests / urinalysis / 24 hrs protein in urine / renal biopsy
— Lipid profile / blood glucose studies
— Hepatitis B serology / ANA / C3 and C4
Management:
— Salt restriction / avoid fats
— Diuretics / monitor fluids in and out
— Anti-HTN: ACE inhibitors
— Prednisolone

Page 10 of 34
Classifications of Headaches
 Headache
Pre door prep
Intro
HPI
— OsCfD: gradual onset / all the time / increasing / for few days
— PQRST: temporal area / vague deep pain / severe
o If sever show mpathy: this must be difficult, were you able to sleep
o Triggers:
What brings your headache?
Is it related to: stress / lack of sleep / flashing lights / smells / diet?
If female: is it related to your periods? Are you taking any OCPs?
— What ↑ or ↓? Lying down / coughing / resting in quiet room / …

Associated symptoms / differential diagnosis:

1- Infection:
— Fever / night sweats / chills / constitutional symptoms
— Neck pain / stiffness
— Recent flu like symptoms / skin rash
— Bothered by light
— Nausea / vomiting

2- Subdural hematoma:
— Trauma / fall
— SAD (Smoking, Alcohol, Drugs)

3- Subarachnoid hemorrhage:
— Very acute /+/ Very severe headache / the worst headache
— History of aneurysm or polycystic kidney disease
— Visual changes (pupil changes)
— Your heart is beating slow

4- Neurological screening:
If while you are doing the neurological screening, you suspect particular cause, e.g.
temporal arteritis ! go to TA block then return to complete the neurological screening.
— Cranial nerves:
o Any change in smelling perception?
o Any difficulty in vision / vision loss?
o Any difficulty in hearing / buzzing sounds?
o Difficulty finding words? Aphasia?
o Difficulty swallowing?
— Brain:
o Any dizziness / light headedness / LOC?
o Any tremors / jerky movements / hx of seizures?
— Personality and cognition:
o Any memory / mood / concentration problems?
o Did anybody tell you that you there is a change in your personality recently?
— UL/LL:
o Any weakness / numbness / tingling in your arms / legs
o Any difficulty in your balance / any falls?
— Spine:
o Any difficulty with urination / need to strain to pass urine?
o Any change in bowel movements?

Page 12 of 34
5- Temporal arteritis:
— Age > 55 years
— When you touch this part of your head, is it painful? Can you comb your hair?
— Do you feel cord-like structure?
— Do you have any visual disturbances / impairment?
— When you are chewing, is it painful, cramps in your jaws?
— Any weakness / numbness in your shoulders / hips?
— Is there any cough? Mild fever?
6- HTN:
— Were you diagnosed before with high blood pressure?
— Do you know your blood pressure? Have you had it checked before?
— Salty food? Family history of HTN / heart disease?
— Any history of repeated headaches?
7- Extra-cranial causes of headache:
— Eyes: any hx of glaucoma, red eye, pain in your eyes? Do you usually wear eyeglasses?
Do you see well? Any vision problems? When was last time you saw your optometrist?
— E – do you have any pain / discharge in your ears?
— N – nasal discharge / sinusitis / hx of facial pain?
— T – any teeth pain / difficulty swallowing?
8- Medications:
— Do you take any nitrates?
— Do use too much of advil (or other NSAIDs)? For how long?
— Were you used to take large amounts of coffee and then you stopped abruptly?
— OCPs?

Temporal Arteritis:
Investigations: Treatment: If suspect GCA (Giant Call Arteritis),
— TA biopsy immediately start high dose prednisone (to
— ESR prevent blindness) then maintain dose daily, then
— CT head?? taper prednisone dose after symptoms resolve.

Polymyalgia Rheumatica:
— Constitutional symptoms + Fatigue Treatment: Corticosteroids; 15 mg/day (for long
— Age > 50 yrs periods of time). Taper after ESR decreases < 50
— ESR > 50 mm/hr mm/hr and stop if ESR normalizes (< 20 mm/hr)
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Page 14 of 34
Abdominal Pain ( Acute Abdomen)

45 Male presenting with abdominal pain for the past 24 hour

Pre-door Prep Name, age, gender duration , possible DD

Intro
Analysis of OsCfD: When / setting: what were you doing? Gradual, colicky,
CC continuous, dull?? How?
─ PQRST: Position: where did it start? Can you point with one finger on it?
— Quality: how does this pain feel like? Sharp, tightness
— Radiation: does it travel anywhere? Umbilicus?
What ↑ or ↓: Eating/Antacids/Defecation/Meds....?

AS Nausea / vomiting
Which started first pain or N/V? Does it relief the pain?
For vomiting! if yes, analyze COCCA +/- B
Screen for Dehydration (Dizziness , Lightheadedness ...)

Bowl Movement

Any blood? Still passing gas?

Did you notice swelling in your ankles? Legs? Calf muscles?
Risk Factors for Intestinal Obstructions
— Previous surgery? Type? When?
— Hx of any gall stones?
— Hx of IBD (Croh's , UC) Family Hx? Hx of Hernia?
Constit Fever / night sweats / chills
symptoms How about your appetite? Any weight changes?
Any lumps or bumps in your body?

DDx Gastroenteritis:
— What did you eat yesterday? Any new place? Diarrhea? Blood in the Stool?
— Anyone else who ate with you suffered the same sysmptoms?

— Renal: flank pain? Burning sensation? Going more frequently to the washroom?
— Liver: Yellowish discoloration? Itching? dark urine? Pale stool?

ROS
PMH
FH
SH
 Diarrhea – ACUTE

Analysis of O s C fD How many times?

CC COCA What bout during night?
± B/Mucous — Yes à organic
↑↓ — No à irritable bowel syndrome (IBS) – day only
— How does if affect your sleep?
Consistency: watery / loose / formed / bulky. Any floating fat
droplets / difficult to flush / undigested food
Did you notice blood? When did it start?
— Before you have your bowel move?
— Mixed (higher source of bleeding)?
— On the surface?
AS Pain ! OCD / PQRST
— If pain improves after bowel movement: IBS
Vomiting
Alteration with constipation
Impact Acute! dehydration: thirsty / dizziness / light headedness / LOC / weak
Red flags Constitutional symptoms – for infection / cancer
Flu like symptoms
Any body around you have the same diarrhea?
Differential Other causes:
diagnosis — Hyperthyroidisms: heat intolerance
— Stress? What do you do for life? Any stress? Does the diarrhea ↑ with
stress? How about your mood?
— Infectious: travel / camping / with whom do you live? Any other person
at home with diarrhea?
— HIV – if risk factors
— Diet: Celiac disease / a lot of dairy products / lactose intolerance / lots of
juice / sugars
— Medications: antibiotics / stool softeners
Rheumatic diseases: red eyes / mouth ulcers / skin changes/ rash / nail
changes / hx of psoriasis / joint pain / swelling / back pain / stiffness
(especially in morning) / discharge / renal stones
PMH
FH
SH

Bloody diarrhea DD:

— GE (gastroenteritis)
— IBD (inflammatory bowel disease)
— Bleeding peptic ulcer
Investigations for clostridium difficile Treatment for clostridium difficile
CBC / differential / lytes and chemistry Stop the antibiotic
Stool culture for parasites Metronidazole (500 mg tid x 7 days)
Stool assay for clostridium toxin If metronidazole is not effective or severe
Endoscopy case à vancomycin (125 mg qid x 14 d)
Blood grouping and cross matching

Page 16 of 34
 Internal Medicine Cases

Diarrhea – CHRONIC

The same as acute diarrhea, except the impact and red flags

Pre door prep

Introduction
CC
Analysis of O s C fD How many times?
CC COCA What bout during night?
± B/Mucous — Yesà organic
↑↓ — No à irritable bowel syndrome (IBS) – day only
— How does if affect your sleep?
Consistency: watery / loose / formed / bulky. Any floating fat
droplets / difficult to flush / undigested food
Did you notice blood? When did it start?
— Before you have your bowel move?
— Mixed (higher source of bleeding)?
— On the surface?
AS Painà OCD / PQRST
— If pain improves after bowel movement: IBS
Vomiting
Alteration with constipation
Impact Acute! dehydration: thirsty / dizziness / light headedness / LOC / weak
Chronic ! weight loss
Red flags Constitutional symptoms – for infection / cancer
For cancer: Age / family hx of Ca colon / change in the calibre of stools /
what kind of diet
Differential Rheumatic diseases: red eyes / mouth ulcers / skin changes/ rash / nail
diagnosis changes / hx of psoriasis / joint pain / swelling / back pain / stiffness
(especially in morning) / discharge / renal stones
Other causes:
— Hyperthyroidisms: heat intolerance
— Stress? What do you do for life? Any stress? Does the diarrhea ↑ with
stress? How about your mood?
— Infectious: travel / camping / with whom do you live? Any other person
at home with diarrhea?
— HIV – if risk factors
— Diet: Celiac disease / a lot of dairy products / lactose intolerance / lots of
juice / sugars
— Medications: antibiotics / stool softeners
PMH
FH
SH
 Abdominal Cases

48 Male with abdominal pain x 24 hrs

74 Male with abdominal pain after meals x 4 weeks (ischemic)

Increased Liver Enzymes:

• 33 male presenting with ALT>>AST
• 58 male presenting with AST > ALT
•
Diarrhea:
• Chronic Diarrhea x 6 weeks
• Chronic Diarrhea x 6 weeks
• Acute Diarrhea x 3 days

Page 18 of 34
 Internal Medicine Cases

Fever

Pre door prep

Intro
CC • Tell me more about it?

Analysis O s C fD
• Did you measure it? How often? How? What is highest?
• And medications? Did it help?
• Any flu / illness / sickness
• Any diurnal variation? Any special pattern? Is it more every 3rd or 4th day?
(malaria)
Impact Are you able to function?
Red flags Constitutional symptoms
Differential CNS: headache / neck pain / stiffness / nausea / vomiting / vision changes /
diagnosis bothered by light / weakness / numbness
ENT:
Extensive — Ears: pain / discharge
review of — Nose: runny nose / sinusitis (facial pain)
systems — Throat: sore throat / teeth pain / difficulty swallowing
Cardiac: chest pain / heart racing (pericarditis)
Lung (pneumonia, PE (DVT), TB, cancer): cough / blood / phlegm / wheezes /
chest tightness / contact with TB pt
3
GIT (except the liver ): abd pain / distension / change in bowel movements /
blood in stools
Urinary: burning / frequency / flank pain / blood in urine
Do you have any discharge? Ulcers? Blisters? Warts?
MSK: joint pain / swelling / ulcers in your body / mouth / skin rash / red eye
Autoimmune: fm hx / dx before with autoimmune dis
The LIVER:
— Local: yellow / itching / dark urine / pale stools
— Dx before with liver dis? Screened? Vaccinated?
— Transition to risky behaviour
PMH Cancer / Autoimmune disease
FH Cancer / Autoimmune disease
SH Does your partner have any fever? Discharge? Skin rash?

What investigations do you want to order ?

Labs: CBC/D, Electrolytes, Ca2+, Mg2+, BUN, CR

TSH, T4, B12, Iron Studies (Fe, TIBC, Ferritin, Transferin)
ALT, AST, ALP, Bilirubin, Total Protein, Albumin
CXR, Sleep Study, EKG,
Mammogram and Colonoscopy if needed
 Fatigue (tired)

DDX
1. Psych: Depression, Stress, Anxiety
2. Infection: Hepatitis, Mono
3. Endocrinology: Diabetes, Hypothyroidism
4. Sleep: OSA
5. Anemia: ask about period, diet, drinking, meds
6. Malignancy

Page 20 of 34
 Internal Medicine Cases

Ankle swelling – Unilateral

Pre door prep

Introduction
CC uni- vs. bi- lateral
Analysis of O s C fD What ↑ / ↓?
CC ↑↓ How high does it go?
If pain ! PQRST
AS Local symptoms:
— Pain / fullness / heaviness / tightness
— Skin changes (redness / swelling / do you feel your feet warm?)
— Nail changes
Other joints? Toes? Other ankle?
Impact How does this affect your life?
Red flags Constitutional symptoms – for infection / cancer
Differential Differential diagnosis of UNILATERAL ankle swelling:
diagnosis Any trauma, any twist in your ankle?
Gout; previous attacks, screen kidney ! for kidney stones
Infection, sepsis, cellulitis; fever, pus, discharge, tenderness
Gonorrhea septic arthritis; Sexual history, penile discharge? Unprotected sex
recently?
DVT
Specific cause within this system (e.g. gout)
Tell me more about your diet? Too much protein?
How about alcohol?
Medications? Pain meds (aspirin) / diuretics (furosemide, thiazides)?
Hx of cancer / chemotherapy (cytotoxic drugs) / radiation?
Family hx of gout / kidney stones?
PMH
FH
SH
 Peripheral vascular disease:

58 year old make presents to the ER with Calf pain / swelling

Introduction
Analysis of O s C fD
CC PQRST
— P: unilateral or bilateral
— R: what about other joints, knees? Thighs? Feet?
What ↑ or ↓: did you notice that your pain ↑ while walking up or down hill?
— ↑ while walking uphill: peripheral arterial disease
— ↑ while walking downhill: spinal stenosis
Is it first time? Or you had it before? When and how were you diagnosed?
How about treatment?
Is it related to activity? How many blocks were you able to walk? And
now?
How about at rest? And at night?
When was the last attack? And what is the duration of the longest attack?
Impact History of strokes / TIAs / neurological symptoms
Chest pain / SOB / heart racing
Pain after eating (intestinal ischemia)
Effect of pain on daily activities / work?
Leriche syndrome (aorto-iliac occlusive disease): numbness in buttocks &
thighs / absent or decreased femoral pulses / impotence
Red flags Constitutional symptoms – for infection / cancer
Risk factors for ischemic heart diseases – IHD
— Smoking? How much and for how long?
— High blood pressure? For how long? Controlled or not?
— Diabetes mellitus
— Cholesterol measured? When? What was it?
DD Peripheral Arterial Disease versus Spinal Canal Stenosis
Vascular symptoms Neuro symptoms
Cold feet / ulcers Weakness / numbness / tingling
Swelling / redness Back trauma / back pain
Delayed wound healing Sexual dysfunction / difficulty with
Nail changes / hair loss erection
PMH Past history of heart disease / stroke / symptoms of stroke / DM / Kidney / Liver
diseases
FH Family history of heart disease / HTN / heart attacks
SH SAD

What are the the 6 Ps of ischemia:

Pallor / Pain / Parathesia / Paralysis / Pulseless / Polar (cold)

Page 22 of 34
Investigations:
CBC/D, Lytes, fasting lipid, glucose, Bun, Cr, (very important because of the contrast) ABI

(if ABI <0.9) then it is abnormal

CTA or MRA is good for large vessels (aortic, iliac, femoral, popliteal) Arteriography
Duplex US

Management:
1. Risk factor modification ( smoking cessation, tx of HTN, Dyslipidemia, DM)
2. Exercise program: Improves collateral circulation & oxygen extraction at the muscle
3. Foot care especially in DM
4. Pharmacotherapy: antiplatelet agents (Aspirin or clopidogrel)
5. Surgical options: Stenting, angioplasty, endoarterectomy, bypasss grafts
6. Refer to neurovascular surgeon
 ASTHMA
24 female, acute asthma was seen in the ER 3 days ago, she was treated and discharged with
advice to see his family physician.
Introduction How do you feel now?
EVENT OS Cf D
Which medication was used? How many times did you need to puff?
Symptoms: SOB / Tightness / Wheezes / Sweating / heart racing /
LOC / did you turn blue? Were you able to talk?
Did you call 911 or someone called for you? Did they give you meds?
What were these meds?
Were you admitted to hospital? ER? Did they need to put a tube?
What were the discharge meds?
Asthma history When were you diagnosed? How? Type of buffers?
Were you controlled? How many times do you puff (excluding
exercise)? Are you using spacer?
Recently, did you notice a need to ↑ the doses?
Any attacks during the night?
Do you use peak flow meter?
Did you have PFTs (pulmonary function tests) done?
How many times did you have to go to ER?
Triggers Infection Recent chest infection? Flu-like symptoms? Fever / chills?
Medications How do you use puffers? Stored properly? Not expired?
Did you start new medication? β-blockers? Aspirin? Any recent ↑ in
dose of these medications?
Outdoor Exercise
Cold air
Pollens (is it seasonal?)
Dust: construction / smug (smoke/ fog/ exhaust)
Indoor Do you smoke? Anybody around you?
Do you have pets? People around you?
Fabrics related: carpets floor? Any change in linen? Pillows?
Blankets? Mattress? Curtains?
Relation to any type of food?
Perfumes
Do you live in a house (basement ! mold)?
Any construction renovation? Exposure to chemicals?
Stress Any new stressful situations?
PMH, FH, SH

Asthma Management
1- Confirm diagnosis:
— Symptoms:
o Cough (dry / more at night / more with exercise / induced by allergens)
o Wheezes (noisy breathing)
o Chest tightness
— Examination: wheezes
— Diagnosis:
o Chest x-ray: R/O pneumonia / infection / cancer
o Pulmonary Function Tests (PFTs):
FEV1/FVC < 80% of expected !obstructive lung disease
Give bronchodilators, repeat PFTs after 20 min, if ↑ > 12% à Asthma
Page 24 of 34
2- Management:
— Environment control: avoidance of irritant and allergic triggers (e.g. avoid smoking /
change β-blocker for treatment of HTN)
— Patient education: the allergic nature of the disease and triggering factors
— Written action plan: see the diagram below (next page)

Short-acting Inhaled Beta2-agonists (SABAs):

Albuterol, Salbutamol and terbutaline are selective beta2-agonists that are agents of first
choice for treatment of acute exacerbations and for prevention of exercise-induced asthma.
They are best used as required rather than on a fixed schedule.

Long-acting Inhaled Beta2-agonists (LABAs) :

Salmeterol and formoterol are long-acting beta2-agonists for regular twice daily
treatment of asthma. Salmeterol has a slow onset of action and should not be used for
immediate relief of bronchospasm.
 Palpitations
38 year old female comes to see a doctor because she feels her heart is racing for the past 3 weeks.

Pre door prep

Inro
CC
Analysis of Clarification When do you say your heart is racing; what do you mean?
CC — Do you feel your heart is going fast
— Or is skipping beats
— Can you tap it for me please? …
— It sounds irregular for me!
O S C fD Is it first time? Or you had it before? When and how were you
PQRST diagnosed? How about treatment?
↑↓ Is it related to activity? How many blocks were you able to
walk? And now?
How about at rest? And at night?
When was the last attack? And what is the duration of the
longest attack?
Is it related to caffeine, chocolate, coke, any other type of
food?
SAD (Cocaine, Heroin, Marijuana or any other stimulant)
Impact CVA (any weakness / numbness / difficulty finding words / visual problems)
Heart failure (SOB / limitation of activity / swelling in your legs / how many
pillows do you use??
Other cardiac symptoms:
— Chest pain? Nausea/vomiting? Sweating?
— Heart racing / dizziness / LOC? Do you feel tired?
Red flags Constitutional symptoms – for infection / cancer
Risk factors for ischemic heart diseases – IHD
DD Do you take medications on regular basis? Any new medication?
Any hx of thyroid dx, any sweating / diarrhea?
" Any hx of heart disease / HTN (! A Fib) / heart attack / CAD (ischemia) /
did you feel your heart bouncing (arrhythmias)? Any congenital or valvular
disease / Chest pain / tightness / dizziness / light headedness / LOC?
" Any chest / lung disease (wheezes, cough, chest tightness)
" Any kidney disease? Renal failure?
Any bleeding? Anemia?
PMH DM / Kidney / Liver diseases
FH Family history of sudden death at a young age? (cardiomyopathy)
HTN / heart attacks
SH SAD
Physical Vitals
examination Cardiac exam (looking for mid-diastolic, mitral stenosis, rumbling character)
Thyroid exam
Neurological exam: brief / gross motor and reflexes

Page 26 of 34
 Internal Medicine Cases

Causes for AF: Causes for TACHYCARDIA

• Hypertension / CHF • Exercise

• Hyper-thyroidism • Pregnancy
• Medications (e.g. digoxin, some anti- • Caffeine/ stimulants/ Anemia
arrhythmic meds – class I) • Hypovolemia
• Electrolytes imbalance • Fever
• Too much alcohol (holiday heart) • Stress
• Cardiomyopathy • Smoking
• Valvular heart diseases • Hyper-thyroidism
• Congenital heart diseases
• Loan AF • Pheochromocytoma
• Myocarditis
• COPD / pneumonia
• Cardiac surgery
• Cocaine
• Any condition that lead to
tachycardia in a susceptible person
 Atrial fibrillation

Cardiac risk factors: Diabetes, Smoking , HTN, Dyslipidemia, FHx, Hx of A-fib, WPW,
arrhythmia, CAD, CHF, stroke, TIA, Syncope.
Psych Hx: Anxiety, Panic Disorders,
Depression Endocrine: Thyroid,
Diabetes/Hypoglycemia

Episodic pallor, episodic tremor, episodic headache, diaphoresisà Pheochromocytoma

Labs: CBC/D, troponin, glucose, lytes, TSH, Bun, Cr,

Ca, Mg, For patients with suspicious cardiac disease,
get EKG and echo
Holter monitor for patients with paroxysmal palpitations, syncope/pre-syncope, suspected
mild ischemia Urine metanephrines if you are suspecting pheochromocytoma.
Electro-physiological studies are done if EKG or Holter monitor reveals serious arrhythmias

Treatment:
SVT: carotid sinus massage, Valsalva maneuver, Adenosine IV push, BB if recurrent
VT: Amiodrone, Lidocaine or Procinamide
A-fib: a. <48 hours : do cardioversion, BB, or non DHPCCB if recurrent
b. > 48 hours anticoagulation for 3 weeks and then attempt cardioversion

Page 28 of 34
Fall

Orthostatic hypotension
76 years old male patient came to clinic because he fell few days ago. He was getting out of bed,
when he fell to the ground

Pre door prep

Intro
HPI: analysis of CC Was this the first time, or did it happen before?
Was it related to Emotions? Coughing? Urination?
Associated During Did you lose conscious? Did you hit your head?
Symptoms Were you alone or with someone? Did your wife describe it to you?
Is she with you? If it is ok with you, after we finish, I would like
to speak with her to get some info.
Were you shaking? Certain part of your body or whole?
For any Were you breathing? Did you turn blue?
Fall, Did you bite your tongue? Roll your eyes? Wet yourself?
LOC Before Were you able to take few steps or did you fall immediately
or seizure (orthostatic hypotension)?
Before you lose consciousness, did you feel:
— Dizzy, lightheaded, nausea, vomiting, any chest pain, heart
racing (cardiac)
— Things are spinning around you (vertigo)
— Weakness, numbness, vision changes (stroke)
— Any flashing light, strange smells (epilepsy)
— Sweaty, shaky, hungry (hypoglycemia)
After How long did it last?
How did you regain consciousness? By yourself or did you need
intervention?
After you regain consciousness; were you able to recognize the
surroundings? Able to talk? Able to move?
Did you feel any weakness, numbness?
Impact Did you hurt yourself? How do you feel now?
Red flags Constitutional symptoms
Risk factor for IHD
Any geriatric Balance
patient; ASK about: Vision
Hearing
Urination
DD Diseases: arrhythmia / CAD, CVA, seizure, hypoglycemia
(already analyzed – before the event)
Environment: is your room well lit? Any chance you tripped?
Do you take any medications? Do you have a list?
— Go through it one by one
— Which one was added / changed recently?
— Each medication: ask about the disease, when started?
— Any OTC? Aspirin? Who prescribed it to you?
Are you getting enough fluids
 Meds: Any medication for the heart, anti-epileptic, nitrates, supplements, herbals?
PMH: Any Hx of heart disease, HTN, valvular disease, arrhythmias?
FH: Any history of heart disease, Neurologic: Strokes, seizures?
SH: OCCUPATION (School bus drivers, pilot, etc....)

Physical Exam:
1. VS, O2 saturation, BP sitting and lying down to check for orthostatic hypotension, radial pulse
2. Glucometer reading
3. Inspection (look for pallor, cyanosis, edema)
4. JVP
5. Heart Exam (complete + Carotid)
6. Brief Neurologic Exam ( CN, DTR, Sensory; Motor)

Labs:
CBC-D, Lytes including Mg2+, Ca2+, Bun, Cr
EKG/Echo, continuous EKG / Outpatient Holter monitor
EEG
Exercise stress test (R/O exercise induced arrhythmia's)

Radiology:
CT if focal neurological deficits

Dizzy:

ask what do you mean by dizzy?

A. Light headed: Syncope (Vaso-vagal, orthostatic hypotension, arrhythmias, etc )

B. Things spinning: Vertigo à Is it associated with moving the head?

Ø Yes (Benign paroxysmal positional vertigo (BPPV)

Ø No à then ask about hearing loss? a. Yes: 1. Acoustic Neuroma or 2. Mennier's disease
b. No : Vestibular Neuronitis

Seizures:
Bite tongue, post-ictal confusion, loss of urine control

Page 30 of 34
Anuria

Pre door prep

Introduction
Analysis of CC O s C fD
PQRST
What ↑ or ↓
Is it first time? Or did it happen before? When and how were you diagnosed? How
about treatment?
Associated
symptoms: Obstructive symptoms
Irritative symptoms
Urine analysis (changes): COCA ± Blood
Local symptoms:
Any problems with passing stools? What? When?
Any masses in the groin / pelvic mass / pain?
Abdominal pain? Distension?
Metastasis Back: pain / weakness / numbness
Liver: yellow / itchy / urine / stools
Lungs: cough / phlegm / hemoptysis
Brain: headache / nausea / vomiting
Renal failure Generalized swelling / face puffiness / itching
Sexual Sexual dysfunction
Red flags Constitutional symptoms – for infection / cancer
Risk factors for cancer prostate / bladder
— Were you ever diagnosed with prostate disease? Screened for prostate
diseases? (DRE or PSA)
— Family history of prostate disease / cancer?
— Ca bladder (radiation / exposed to chemicals / aniline dye)
— Smoking? Alcohol?
DD 1. Renal stones: Have you ever had a renal stone? Any history of colicky pain in
flanks? Have you ever passed a small crystals or stone during voiding? Hx or
repeated UTIs? 2. Medications: glaucoma / anti-psychotic meds / anti-
cholinergic drugs; like those used for incontinence; e.g. Ditropan (Oxybutynin),
Detrol (Tolterodine)
3. Neuro:
— Back problem: trauma – metastasis – cauda equine (spoiled himself with stools
/ buttocks numbness)
— Stroke (diagnosed / weakness / numbness / difficulty)
4 Cancer:
— prostate
— bladder (hematuria)
PMH
FH Diabetes, Cancer etc
SH SAD
 When analyzing the urinary symptoms, check if:

A. Obstructive:
Difficulty to initiate urine? Do you need to strain?
Any changes in the stream?
Any dripping?
After you pass urine, do you feel that you emptied your bladder completely or do you need to go again?

B. Irritative :
How many times do you go to the washroom?
How about before? Any change?
How about during night time? How does this affect your sleep? How about your
concentration and mood?
Do you need to rush to washroom? Are you able to make it all the time?Have
you ever lost control or wet yourself?
Any burning sensation? Any flank pain?
Fever / night sweats / other constitutional symptoms

Labs:
U/A with C&S, Voiding diary, post-void residual test, voiding cystouretrogram,
Ultracystoscopy, US ...

CBC/D, lytes, fasting blood glucose, HBA1c, PSA if needed

DDx:
1. BPH
2. Prostate Cancer
3. Bladder Cancer
4. UTI
5. Renal Failure

Page 32 of 34
 Internal Medicine Cases

Incontinence
64 years old female presents with history of urinary incontinence for the year and a half

Pre door prep

Introduction Empathy – how do you feel right now?
Analysis of O s C fD
CC What ↑ or ↓: lifting objects / coughing / straining
Is it first time? Or did it happen before? When and how were you
diagnosed? How about treatment?
Associated symptoms:
Obstructive symptoms
Irritative symptoms
Urine analysis (changes): COCA ±
Blood
Local symptoms:
Any problems with passing stools? What? When?
Any masses in the groin / pelvic mass / pain?
Any perineal skin lesions?
Impact How does it affect your life? Daily activities?
Red flags Constitutional symptoms – for infection / cancer
Risk factors (MGOS):
M Menopausal symptoms, and HRT
LMP
G Gynaecological history
Previous abdominal or pelvic surgeries
O Obstetric: How many pregnancies? Route of delivery?
S Sexual: Repeated infections / dryness / dyspareunia
DD
1. Urge Incontinence
2. Stress Incontinence
3. Overflow Incontinence
4. UTI
5. Others: Deliruim/ Dementia, Infections, stroke

Labs:
U/A with C&S, Voiding diary, post-void residual test (PVR), voiding cystouretrogram,
Ultracystoscopy, US ...
CBC/D, lytes, fasting blood glucose, HBA1c ,

Imaging: Urethrocystoscopy 2. Voiding Cystourethrogram

 Sensory Irritative:

• In the history you will find urgency, frequency, dysuria or asymptomatic

• Dx is made by urinalysis (WBC, Bacteria, RBC); urine culture
• Treatment: Antibiotics; Cystoscopy (hematuria) is there a stone?

Genuine Stress (most common):

• Never occurs at night

• Loss of support of the proximal urethral bladder / neck
• Dx is made by +ve Q-tip test, normal cystometry
• Treatment: Kegels, estrogen or Surgical: urethropexy

Urge , Hypertonic

• Involuntary bladder contraction, neurologic condition, aging

• Dx is made by abnormal cystometry & normal pelvic exam
• Treatment: Anticholinergics, NSAIDs, Timed voiding

Hypotonic, Neurogenic, Overflow

• neurologic condition or medication side effect

• abnormal cystometry and abnormal neuro exam
• Treatment: Cholinergics, alpha adrenergics blockers, intermittent catheter

Fistula

• Continuous leakage, history of pelvic surgery, radiation, pelvic trauma

• Diagnosis is made by Intravenous pylogram (IVP), cystometry is normal
• Treatment: Surgical repair

Page 34 of 34