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 How will mx at ED
- Fluid resus
- Establish IV access and give crystalloid fluid
- Blood à cross matched and transfused if
indicated
- Catherized and record fluid balance chart
- Send blood sample to FBC, U&E, LFT, clotting
factor
- Monitor vitals and urine output
11301ns
Hx - PPI is started for early tx à omeprazole 40 mg
- Onset, constant/intermittent, mm man unmeren
IV and stop aspirin/clopidogrel/ibuprofen.
precipitate, progression, prev ep, Tranexamic acid is given
frequency, pain
- Travel, n/v, ca symptoms, anemic
- Endoscopic therapy is required for peptic
sx a ulcers with spurting or oozing active bleeding
-
-
PMH , DH à NSAIDs
FH, alcohol, tobacco, diet
la
(1a or 1b) or visible vessels (2a) as
- Ulcers with adherent clots (2b) should have
the clot removed where possible and
Diagnostic study
- CBC, coag, H.pylori testing endoscopic therapy applied if active bleeding
- Esophagogastroduodenoscopy or visible vessels are identified
(OGDS) - Do not use adrenaline alone for endoscopic
mx of non-variceal bleeding
- Clips are particularly useful for raised vessels
in an accessible non fibrotic ulcers

Discharged plan : Patient with bleeding PUD should be

discharged with oral PPI . those with gastric ulcers
should be re-endoscope in 6 weeks to assess healing
and rule out ca.

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 Hepatoportoenterostomy à jejunum anastomose to bile
ductules (bile duct and GB removed)
(Before Kasai Operation) you can see that the bile ducts
longer
plan la sidas
than are missing, because of this bile cannot flow causing
cirrhosis of the liver. (After Kasai Operation) the small
expmm
intestine has been hooked up to the liver so that the bile
can flow. à if not succesful, liver transplant.

Albumin transfusion à increased oncotic pressure

prevention of recurrent ascites. Guidelines recommend
albumin replacement after large volume paracenteses if
>4-5 L are removed, 6-8 g/L of albumin should be given.

BCAA à branched chained amino acid à high protein

such as milk, soy, beef, chicken, egg
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 The oculomotor, trochlear and abducens nerves are purely motor, and are
all tested together. The oculomotor nerve also has a parasympathetic
component involved in pupil constriction and lens accommodation.
Accommodation was tested previously with the optic nerve.

con Begin with quick inspection for ptosis and strabismus (divergence or
size convergence of the eyes) and once again ask the patient if they are in any
pain. Next ask the patient to focus on a white pin whilst keeping their chin
Oculomotor nerve palsy still and to report any diplopia (double vision) or pain. Move the pin in an
Supplies motor innervation to the levator H pattern and focus on the eye movements. Finally, test for nystagmus
palpebrae superioris (elevates the eyelid), (indicative of vestibular disease [VIII]) by moving the pin slowly laterally
the inferior oblique, the superior, inferior, and then rapidly in the opposite direction.

L
and medial rectus muscles.
Its parasympathetic component is to the
sphincter pupillae and ciliary muscle. As a Testing the extrinsic ocular muscles
result, an oculomotor nerve palsy will result The following movements are used to test each of the extrinsic ocular
in: muscles:
- Ptosis, due to weakness of the
levator palpebrae superioris. Abduction: Tests the function of the lateral rectus [VI].
- Eye in the "down and out" Elevation whilst abducted: Tests the function of the superior rectus [III].
position, due to weakness of Depression whilst abducted: Tests the function of the inferior rectus [III].
Adduction: Tests the function of the medial rectus [III].

in
ocular muscles supplied by [III].
- Mydriasis (pupillary dilation), due Elevation whilst adducted: Tests the function of the inferior oblique [III].
to weakness of the sphincter Depression whilst adducted: Tests the function of the superior oblique
[IV].
manana pupillae.
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Trochlear nerve palsy
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Supplies the superior oblique muscle.
- will result in vertical diplopia, as
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Supplies the lateral rectus muscle.
fan - result in a convergent squint, as
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(QUESTION 1)
4 years old child, presented with 2 days of shortness of breath. (PAEDS) a. Take history
1) What caused acute exacerbation
a) Duration of sx, recurrent, number of episode
b) SOB - occurring with exercise, laughing or playing
c) Nocturnal cough- Cough in the absence of respiratory infections, usually with
laughing, crying or exposure to tobacco smoke.
d) Wheeze -Recurrent wheezing during sleep or with triggers such as activity,
laughing, crying or exposure to tobacco smoke or air pollution
e) Reduced activity- not running, playing, or laughing at the same intensity as
other children.
f) Ask about sx respiratory infection
g) Exacerbating, relieving fx

2) What is the control

a) Identify secondary cause
i) Ask about other triggering factor (exposed)
(1) Cold weather → inhaling cold air
(2) Allergies → food, medication
(3) Exercise
(4) Pollen , pets, mold
(5) Smokes
(6) Stress
b) PMH + Birth Hx (Prev hosp admission → require nebulisation)
i) Underlying atopy → eczema and allergic rhinitis
c) DH + immunization +allergic +First degree FH atopy
d) SH + diet + developmental
3) Examiners will ask you a few questions.
a) Dx and justify: patient has exercise induced symptoms for
1months, nocturnal symptoms for 3 months, 1 history of nebulizer,
reversible symptoms
i) Acute exacerbation of severe persistent Bronchial
asthma (new case)
b) How to determine severity in AEBA : Speaking
words/sentences, Spo2, Pulsus paradoxus (exaggerated
drop in systolic BP during inspiration), Silent chest
c) Outline your long term management.
i) Start with at least step 4 management. SABA,
medium conc. Of ICS with LABA
ii) Pt education : avoid triggers, asthma action plan,
compliance, technique to use MDI plus spacer with
mask, monitor for atopy, follow up (1 months).
iii) Step-up; assess patient after 1 month of initiation
of treatment and if control is not adequate,
consider step-up after looking into factors as
above.
iv) Step down next TCA 3 months
d) Give a name of drug for leukotriene receptors antagonist
i) Montelukast - 4mg granules/ 10 mg/tablet ON
ii) Zafirlukast
2) Around 24++ female with vaginal discharge, diagnosed with trichomonas. (frothy grey,
metronidazole) (PRESCRIPTION AND PATIENT SAFETY)
a) Take PMH and relevant medication hx
i) Med hx
(1) Allergy
(2) Current meds (C/I to metronidazole)→ Disulfiram (causes
psychosis), Warfarin (potentiate), Lithium (retain it→ renal
damage), Anticonvulsant, Traditional medication, OCP
ii) PMH
(1) seizure/epilepsy
(2) hepatic/renal ds
iii) Gynae hx
(1) LMP
(2) Possibility of pregnancy (unprotected intercourse)
iv) SH → alcohol intake
v) Sexual hx, patient safety, regarding other STIs
b) Prescribe the patient with one medication, write down on the prescription slip,
explain to the patient regarding the medication
i) Prescription slip :PT name complete, IC, RN, age (reconfirm patient
detail when writing), dx, name, sign, designation
(1) Metronidazole

ii) Abx need complete the whole course

iii) Side effect → peripheral and optic
neuropathy, tinnitus, sharp unpleasant
metallic taste, nystagmus, abd pain,
diarrhea, nausea, dry mouth,
hypersensitivity
iv) What food and drink to avoid (ALCOHOL-
3 days after completed treatment)
v) Examiner will ask a few question
(1) What organism is metronidazole
for : anaerobic
(2) How metronidazole act on
anaerobic organism (MOA)
(3) Why choose this and not others
abx
(4) Why need to avoid alcohol,
MOA, effect
(5) Advice on STD, pregnancy
(a) Any partners within 4 weeks prior of ssx onset should
be treated → incubation period → 5-28 days
(b) Abstinence until tx completed or use barrier
(c) Advice to screened to other STI
3) T2DM blurring vision 3 months (INT MED)
a) Focused medical history of visual problems
i) Details of blurring of vision - uni or bilateral , Onset (apparently patient
says its 3 years), Gradual worsening, Impairment of color vision
Change spectacles, Far or close range, Difficult to move around
(aggravating/relieving factor)
ii) Hx of diabetes, Duration of DM and tx, Peripheral neuropathy,
Compliance to tx, Symptoms of hypoglycaemia
iii) Screening for DM retinopathy, abnormal fundus photograph
iv) Other relevant PMH (HTN) , FH, Occupational hx
v) Impact on ADL if chronic
vi) * NCDs just go thru 3C (control, compliance, complication, comeback,
counseling)
b) Relevant eye examination
i) Switch on light on snellen chart, use the mirror, remember to use the
pinhole as well (look around the room on anything that can be used,
cause some of them in my stream missed the pinhole stuff)
ii) Proceed with Fundoscopy & Interpretation (remember to dim the room
light, dilated the pupil with mydriatic drops,all those….)
iii) Fundoscopy: mentioned what you are looking for: red reflex (got
mannequin, if cant see just tell them cant see, they
got printed pic de)
iv) Interpretation: non proliferative diabetic retinopathy
4) XX, came for left mastectomy with axillary clearance (ANAES)
a) Pre op assessment
i) History → preoperative diagnosis → R breast cancer
ii) Confirmed operation and side → Radical modified mastectomy
b) Take a details bronchial asthma history (assess risk of bronchoconstriction) and assess her
asthma severity
i) Duration
ii) Systematic review → infection, chest pain, sob, chronic cough, orthopnea/OSA, bowel
or urine changes, any dentures used or loose teeth
iii) If women → menstrual hx, last LMP, pregnancy
iv) Other comorbids → hypertension, dyslipidemia, cardiac ds, DM
v) Hx of epilepsy/seizure
vi) Past surgical hx → what type of anaesthesia and any complication
vii) Past hx of hosp → intubation, nebulisation
viii) Reaffirming hx of allergy
ix) FH → anaes complication/ICU
x) Drug hx → medication, compliance, OTC, herbal and supplement, allergies to drugs
and food (soybean and egg allergy)
xi) SH → smoke and alcohol
xii) ICE
c) Tell her that her investigations are normal
d) Explain & take the consent for anaesthesia, explain the risk of anaesthesia -
i) Take informed consent: talk about good things first only the things that can go wrong,
patient will be totally unaware of what is going on, pain free, under GA she will be able
to ambulate faster as compared to regional
ii) Precautions for asthma: prevent attack (risk of attack perioperative), post op nausea
and vomiting (opioids), sore throat, allergic response to drugs that are use
(1) Start on oral corticosteroid (hydrocortisone) 3-5 days prior to surgery (pt on
long term high ICS/ received OCS >2 weeks during the prev 6 months)
iii) Alleviate her anxiety by explaining the operation to her and the measures taken to
prevent asthma attack, consider anxiolytic → Oral midazolam (don’t need IV)
iv) NBM last solid 6 hours before surgery,last breast milk 4 hours, last clear fluid 2 hour
v) Bring along her inhaler
vi) Don't need aspiration prophylaxis (cos patient not at risk for aspiration) (preventing
aspiration → omeprazole + sodium citrate + metoclopramide)
vii) Scheduled early in OT list to prevent prolonged preop fasting
e) Outline pre med plan
i) 1 puff salbutamol just prior to operation
(1) If controlled asthma → may only need a SABA just prior to surgery
(2) If moderate controlled asthma → should add inhaled corticosteroids to their
SABA 1 week prior to surgery
(3) If poorly controlled asthma → may need to add oral corticosteroid to their
regimes
ii) Cont other med as usual
iii) Bring along her inhaler
iv) Oral midazolam (don’t need IV), don't need aspiration prophylaxis (cos patient not at
risk for aspiration)
v) Pain management:
(1) Given that this patient has no contraindication to analgesic, i would start with
PCA IV Morphine, then slowly taper down (don’t give thoracic epidural, too
dangerous)
(a) But in case of asthma → morphine is not preferred → use fentanyl
(2) if no PCA, according to analgesic step ladder, give multimodal analgesics
(a) After op → assess pain score and follow the WHO step ladder
5. 20 years old patient, comes with episodic vertigo, TRIAD
tinnitus, hearing loss (left）(FAM MED)

❖ Perform relevant examination

➢ Full hearing examination: whisper test, Rinne and Weber test, otoscopy
➢ Dx : meniere’s disease

b. Explain the diagnosis and treatment plan to patient

● Ménière's disease is a condition of the inner ear that causes sudden attacks of: feeling
like the room is spinning around you (vertigo) a ringing noise inside the ear (tinnitus)
pressure felt deep inside the ear.

72ep720min

● Need to Refer for audiogram → sensorineural hearing loss

Vertigo management is usually comprised of symptomatic and non-pharmacological therapy
● Acute and severe episodes of vertigo, regardless of the underlying cause, will usually
settle 24-48 hours due to the effect of brainstem compensation
● Symptoms relieve :
○ Antiemetic medications (eg Metoclopramide, Promethazine,
Prochlorperazine) for nausea and vomiting control
○ Diuretics (combination of Hydrochlorothiazide and Acetazolamide) helps
lower endolymphatic pressure I endolymph
○ Betahistine and labyrinth ablation therapies with intratympanic Gentamicin
vestibular also aids in lowering endolymphatic pressure
suppressant○ Intratympanic glucocorticoids showed some benefit in patients with

I
intractable unilateral Meniere’s disease

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 ○ Vestibular blocking/suppressant agents (eg Meclizine, Betahistine,
Dimenhydrinate, Diazepam, Glycopyrrolate, Lorazepam) to reduce the
spinning sensation
○ Antihistamines with calcium channel blocking activity, eg Cinnarizine, may
be effective in patients with “vestibular Meniere’s” due to the high
prevalence of migraine in these patients
● Surgical Intervention
○ Surgery is recommended if conservative and medical treatments have failed
and the disease is severe
○ Endolymphatic duct/sac procedures and sacculotomy
■ The procedure exposes the endolymphatic sac and duct with the aim
of improving endolymph drainage
■ Commonly done in Meniere’s disease patients with intact hearing
■ Control of vertigo has been reported in 75-80% in an uncontrolled
case series
■ Low risk of sensorineural hearing loss
○ Vestibular nerve section or Vestibular neurectomy
■ Vestibular nerve bundle is surgically lysed as it enters the internal
auditory canal
■ Relieves vertigo in 90-95% of patients
■ Low risk of sensorineural hearing loss
○ Labyrinthectomy
■ Neuroepithelium of the bony and membranous labyrinth is surgically
removed, thus eliminating both balance and hearing function from
the affected ear
■ Due to the irreversible hearing loss, this procedure is reserved for
patients with intractable symptoms despite pharmacotherapy, and
with poor hearing or complete hearing loss on the affected side
 Questions Answers
Why diagnosis is incomplete miscarriage
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conception remain in the womb, causing heavy bleeding
pan and severe cramping.
- Based on the imaging, there is retained product of
conception

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 Emptybladder
- A digital rectal exam, or DRE, is a
medical test that checks for
Pre :
-
y
You don’t have to do anything to prepare for a digital
abnormalities in your rectum and anus rectal exam. If you have any tears in your anal tissue
(bowel opening) (anal fissures) or swollen veins in your anus or rectum
- I will put on gloves and apply lubricant (haemorrhoids), be sure to alert your healthcare
before gently sliding their index finger provider. A DRE can make these conditions worse.
into your rectum. No preparation is During :

d
sumn
required. The procedure is typically fast
(short procedure) and painless.
- A digital rectal exam is a diagnostic tool
- Your healthcare provider will perform the digital rectal
exam in a private exam room at their office. You will
need to undress from the waist down, and you’ll be
for many different medical issues. DREs given a gown or cloth to cover yourself. The procedure
can help with the early diagnosis of only takes a few minutes. It’s typically painless, but you
colon cancer, other types of cancer and may be slightly uncomfortable. Some people may feel a
other conditions involving your pelvic need to pee (urinate).
region. - There will be chaperone provided (female) or you can
Symptoms that could indicate a health bring family member
concern include: Post :
- Bleeding from your rectum. - After a digital rectal exam, you may return to normal
- Blood in your poop (stool). activities immediately. Light bleeding from your rectum
- If you discover blood in your poop, in is rare but may occur. If you have anal fissures or
the toilet or on toilet paper after you haemorrhoids, bleeding is more likely. Let your
wipe, a DRE can be an important tool. healthcare provider know if you have a lot of rectal
Blood within your stool may be a sign of bleeding after the DRE.
disease in your upper or lower intestinal - Your healthcare provider should be able to tell you the
tract. It will prompt further studies (such results of the digital rectal exam immediately.
as a colonoscopy) to look for cancer, - Normal results of a digital rectal exam mean your
internal hemorrhoids or inflammation of healthcare provider didn’t find anything abnormal
your bowel wall. during the exam. However, they may recommend
- If you have abnormal changes in your additional tests to confirm the results.
bowel habits (such as poop that’s pencil- - An abnormal digital rectal exam may mean many
thin, flat or difficult to pass), a provider different things. There may be blood present, palpable
can perform a DRE to check for a nodules, tears in your rectum, haemorrhoids or
physical obstruction like a tumor. significant pain with the exam. Your provider will
discuss this more with you during your visit as well as
any next steps.
Questions Answers
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