family medicine osce

The Joint Program of Family and Community Medicine in Jeddah

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The Final Examination of the

Saudi Board for Family Medicine

A. Assaggaf

The final examination of the Saudi Board for Family Medicine consists of two parts:

I. The Written examination

II. The Clinical and Oral Examination

I. The Written examination, consists of the following three components:

1. Multiple Choice Questions.

2. Modified Essay Questions.

3. Critical Reading Questions.

II. The Clinical and Oral Examination, which also consist of three components:

1. Simulated Clinics.

2. Data and slides Interpretation.

3. Oral Examination.

I. The Written Examination

1. Multiple Choice Questions Paper

Time allowed is three hours

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.

The distribution of the question will be as the following:

Areas Number of Question

Pediatrics

Therapeutics

Psychiatry

Internal Medicine

Obstetrics/Gynecology

Surgery/Orthopedic

Dermatology

Accident and Emergency

Community Medicine

ENT

Ophthalmology

19

8

12

13

11

9

7

8

5

4

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2. Modified Essay Questions (MEQ)

Usually three MEQs will appear in the exam

Time allowed: 11/2 hours


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3. Critical Reading Questions (CRQ)

Time allowed: 2 hours

The guidelines for appraisal of scientific papers recommended by the Evidence-

Based Medicine working group published in JAMA are adopted

Time allowed: 11/2 hours

Marking of the written part.

1. MCQ…………..40 marks

2. MEQ………… 35 marks

3. CRQ…………...25 marks

II. Clinical And Oral Examination

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. Data and Slides Interpretation

Format of date interpretation exam:

A group of candidates may sit in a hall or a big room and would be given a booklet

containing the data and shown slides using slide projector and are supposed to write their

answers in the booklets provided to them.

A) The data may include some or all of the following investigations:

EBC

Biochemistry

Serology


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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. The Oral Examination:

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.

Marking of the Clinical and Oral Examinations:

The marking of the clinical and oral examinations is distributed as the following:

The mark distributed as follows:

1. Simulated clinic 40%

2. Data and slide interpretation 30%

3. 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. Clear pass

2. Pass

3. Borderline Pass

4. 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)


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Arab Board Final Examination

A. Assaggaf

Arab Board Final Written Examination

The final written examination consist of a total 210 MCQs

Divided to two parts:

Part I:

Content: 150 Traditional MCQ (Factual Knowledge questions)

Time Allowed: 3 hours.

Part II:

Content: 60 Question in the form of patient management Question (P.M.Q)

Time allowed: 2 hours.

Passing Score & marks distribution:

Each one of the 210 multiple choice questions (Part I + Part II) is given an equal score &

the exam mark will be out of 210 which then will be transferred into percentage (%).

To pass the written examination, it is essential to score 60% as a minimum.

Only those who pass the written examination will be allowed to set for the Clinical

examination.

Arab Board Final Clinical Examination (OSCE)

The final clinical examination consist of two parts:

I. Objective Structured Clinical Examination (OSCE)

II. Oral Exam

I. Objective Structured Clinical Examination (OSCE)

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.


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One circuit of 20 stations will allow 20 students to be examined simultaneously. If the

number of students is greater than 20, this can be accommodated by running parallel

circuits of stations or by repeating the single circuit with another group of students.

Although the concept of an examination with stations round which students rotate

represents an important aspect of the OSCE, the examination is more than just a ‘multi-station’ examination.

OSCE

O “Objective” Subjective bias is removed as possible

S “Structured” The content of the examination are planned carefully in

advance

C “Clinical” It is a performance assessment, It is concerned with what

candidate can do rather with what they know

E “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.

Candidates see a number of examiners in the course of the examination, usually

eight or more.

What is to be assessed at each station is agreed in advance and a marking schedule

is produced which lists what is expected of the candidate at each station.

Examiners use a checklist, which reflects what is to be tasted at the station. The

examiners agree this in advance.

The aim in the examination is to produce a profile for each candidate rather than a

single composite mark. A candidate, for example, may be competent in physical

examination techniques, but have an unsatisfactory attitude and may be taking in

interpersonal skills.

The standard on criteria for pass, distinction (if appropriate), fail, and dangerous

fail can be agreed.

Examiners can be trained for the task expected of them and their performance can

be assessed in advance on practice videotapes.

The examination tests a wide range of skills thus greatly reducing the sampling

error. This very significantly improves the reliability of the examination.

Students all face the same tasks.

Simulated patients help to ensure that all students are presented with a similar

challenge.

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


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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, problem-

solving, 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

patient’s 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 candidate’s 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.


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What About Arab Board OSCE Exam:

You will rotate round 17 stations (Number 1-17) spending 7 minutes at

Each station. A bell will ring at the beginning of the examination and at the end of each 7-

minute period.

1) At each station you will be asked to perform certain tasks e.g.

a) Take history

b) Examine a patient

c) Interpret x-rays or other clinical materials

d) 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 The Oral Examination:

a) Two panels will examine each candidate, spending around 25-30 minutes at

each one.

b) Each panel consists of two examiners.

Marking of the Clinical Examination:

The marks of clinical examination are distributed as the following:

1) OSCE 60%

2) Oral Exam. 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).

The Joint Program of Family and Community Medicine - Jeddah

8

1.

Approach to Common Chronic Problems in PHC

Approach to Patient With Asthma

F. Rayes, M. Alatta & A. Al Harthy

The following items may need to be considered in each follow up visit:

Doctor-patient relationship

Encouragement of patient contribution

Patient’s 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

Current peak flow (PF):

The percentage of best and predicted PF

Before and after bronchodilators

Consider spirometry

Inhaler technique

Review of home recordings of PF

Management:

Discuss any concerns

Provide printed information if required

Consider others tests, e.g. allergy

Agree management program:

Self-management protocol

Action in emergency

Arrange for follow-up

The frequency of follow-up depends on the severity of the asthma, medication use,

number of exacerbations, etc. Well-stabilized patients with asthma probably do not

need review more than yearly.

Common problems in follow up of asthmatic patients:

o Denial and refusing to accept the diagnosis

o Asthmatic child of a smoking parent

o False believes about asthma medication (it is dangerous or it is addictive)

o Wrong technique in using PFM or inhalers


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Asthma General Advice:

Establish rapport Encourage patient’s 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 patient’s 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

Inhalation Technique Instructions:

If the patient is using dilator or anti-inflammatory

Explain why it is used and what is there effect

Explain about machine and its parts

o Remove cap (hold in correct position not upside down) and shake.

o Breath out gently through your mouth.

o Put the mouthpiece into your mouth (or 4 cm) always and in front of your mouth.

o Start to breathe in slowly, then in the middle of the breath press the canister down

go on breathing (head up right and back) and keep pressing.

o When you can not breath in any more take the inhaler out and hold breath 5-1 0

seconds.

o In case of more than one puff repeat steps 4-8 after one min.

o Wipe mouthpiece of inhaler and cover it.

o Check the expiratory date of the medicine

Wash it twice a week.

Demonstrate to patient

Let him do it and observe him, in order to correct him.

Tell him about spacer and its benefits.

If patient using 2 types. Use dilator first.

If using steroids wash mouth after.

Take feedback and encourage patient to ask questions



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How to Use the Peak Flow Meter?

As a doctor you should have your peak flow meter at your clinic to measure your patient

peak flow rate.

The educated patient should have at home to check his own peak flow rate specially if sign

is worsening to start the action plan (see later).

This is a checklist of proper use of peak flow meter:

o Explain the machine and why to use it?

o Put mark to zero

o Stand up

o Finger away of horizontal not too tight

o Breath in as much as you can

o Lip sealing tongue should not be inside

o Breath out as hard and as fast as you can

o Write down the level (aside) put marker back to zero

o Repeat three times and record the maximum on chart

o Demonstrate (change mouth pieces)

o Let him do it and observe to correct

o Monitor bid daily, it is not a flat line

o Any drop below the zone step up medications

PEFR & Severity of Acute Attack:

80-100% of the patient best = Mild attack

50-80% of the patient best = Moderate attack

≤ 50% of the patient best = Sever attack

< 33% of the patient best = Life threatening attack

Patient Education:

What is asthma?

Asthma is a chronic breathing problem, it’s 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.

What is an asthma attack?

Asthma frequently present in attacks which mean the person can have no symptoms, then

when he is exposed to a precipitating factor. The attack start (and this cause many doctors

miss the diagnosis if they see the patient in between attacks).

What is the precipitating factors of asthma attack?

The precipitating factor can be: cold air, dust, smoking, exercise, perfumes,

emotional stress and others.

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


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Avoidance of Irritant & Allergens:

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.

House dust mite: Which is increase in humid areas. These measure lower it

amount:

o Washing all the bedding sheets, blankets and covers in hot water.

o Vacuum the carpet regularly while the patient not in the room (if you

can takeout the carpeting out).

o Avoid having animals in the house (cats or birds).

o Frequent cleaning and apply insecticide when asthmatic not present.

o If the patient has occupational exposure to allergies should be referred

to specialist.

Action Plan: (as mentioned in the National Protocol)

The action plan can be symptom based and/or peak flow based to suit the person’s understanding of his/her problem. All people with asthma need to:

o Be able to recognize deterioration

o Know what action to take

o Have their action plan reviewed and, if necessary, modified

o Following an acute attack

o All people with asthma should know how to obtain prompt medical assistance:

o Provide patients and families with a written ACTION PLAN –CARD

The Traffic Light Zone System:

The following zone system that puts the control asthma into one of 3 different zones each

with specific instructions. Traffic light colors indicating the various zones have been

chosen since most patients are familiar with them.

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.


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Approach to Patient With Diabetes Mallets M. Alatta & F. Rayes

The following items may need to be considered in each visit:



Patient’s cues

Well-being and psychosocial component of patient problem

Physical complaints

Dietary problems

Medication problems

Examination & investigation:

Fasting, blood glucose

Urinary protein and glucose

Body mass index

Blood pressure

Visual acuity

Management & education:

Discussion of immediate concerns

Discussion of current management

Follow-up arrangement made

The following items may need to be considered in annual visit:

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

Common problems in follow up of diabetic patients:

o Uncontrolled or poor control of DM

o Misunderstanding of diabetic diet

o False believes about hypoglycemic medication (it is dangerous or it is addective)

o Refusing to accept insulin injection


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Counseling Newly Diagnosed Diabetic Patient:



Patient’s cues

Exploration of patient ideas, worries and concerns

(What do you know about diabetes?)

Explanation about diabetes:

It is a common, chronic illness, characterized by primary hyperglycemia.

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 patient’s 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.

Blood Glucose Level: o Home blood glucose measurement technique if the patient has glucometer

o It is the best way of monitoring

o Show the patient how to use this monitoring device.

Urine Glucose Level: o Explain to patient how to use the dipstick.

o It is less effective way of monitoring.

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.

Low Blood Sugar: o Your medication may cause sometimes your blood sugar to drop too low.

o When this happen you may feel the following:

o Headache, weakness, sweating, feeling of anxiety...


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What to do if you develop symptoms of hypoglycemia: o Quickly eat or drink something sweet.

o (Sugar in water, Orange juice, honey)

o Call your doctor right away.

Medic alert card:

You can buy it from drug stores. Wear it all time.

Care of your feet:

o It is very important for you to always keep your feet dry and clean.

o Wear socks and good shoes.

o Health educator will give you a pamphlet about foot care.

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.

Give patient printed educational material (Leaflets or booklets).

Arrange appointment with dietitian within two weeks.

Follow up in 4-8 weeks You can ask the patient to come with care taker e.g. his wife, his mother.

Take continues feedback and answer any questions.

Discuss complications and how to prevent them.


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Approach to Patient With Hypertension H. Al Hajjar & F. Rayes

The following items may need to be considered in history taking in the first visit:



Patient’s 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:

o Hairsutism

o Easy bruising

o Palpitation, sweating

o Muscle cramps

o Leg claudication

Symptoms suggestive end organ damage:

o Chest pain

o Breathlessness

o Orthopnia

o claudication

o Transient visual loss

Past medical history :

o Renal disease

o Obstetric history (pre eclampsia)

Cardiovascular risk factors:

o Smoking

o Obesity

o Hyperlipidemia

o Diabetes mellitus

Family history (Assessment of degree of risk) :

o Hypertension

o Ischemic heart disease

o Stroke

o Hyperlipidemia

o Premature cardiovascular death

o Renal disease as autosomal dominant polycystic kidney

Drug history :

o For hypertension : efficacy and side effects

o Other drugs : OCP, Steroids, Thyroid hormone, NSAID

o Over the counter medications

o Alternative medicine products

o Substance abuse

Social history :

o Smoking and alcohol

o Diet : salt, fat, weight gain

o Caffeine

o Leisure activity & exercise

o Work environment and stresses

o Family and home situation

o Education level


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The following items may need to be considered in examination of patient with

hypertension the first visit:

Blood pressure measurement:

o Tow or more

o Sitting or supine (after 2 min) plus

o Standing (after 2 min)

o Both arms (take the higher reading)

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 )

Guidelines for blood pressure measurements

o Patient relaxed in a quiet room

o Use od accurate cuff dimensions o Ensure forearm is supported and at heart level o Inflate cuff to 30 mmHg above pulse occlusion o Observe at ‘eye level’ with mercury column o Deflate cuff at 2mmHg per second o Record systolic blood pressure when sounds disappear (phase 5) o Measure blood pressure to nearest 2mmHg. o Measure at least twice at each consultation o At first visit measure sitting and standing blood pressure.


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White Coat Hypertension :

o Incidence is 10-20% of hypertensive patients.

o Diagnosis by home monitoring or ambulatory monitoring.

o No drug treatment unless there is end organ damage.

o Follow-up annually using home or ambulatory monitoring

When do you suspect secondary hypertension?

o Renal cause: if the patient has end organ damage.

o Onset of hypertension at very young or elderly (> 55 y).

o Aldosteronism: if blood k+ < 3.5 mEq /L.

o Pheochromocytoma:in labile hypertension with severe headache.

o Coarctation: if the patient is young with systolic hypertension.

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

Weight and body mass index

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.

Importance of non pharmacological treatment

However medications is also sometime needed

Relative safety of anti-hypertension medications

The effect of medications to decrease morbidity & mortality

Need for good compliance with medication & advice

Need for follow-up

Management:

Shared understanding of problems

Appropriate prescribing

Advise about possible side effects

Follow-up arrangement

Stressing on non-pharmacological treatment

Discussion management or change management

Follow-up arrangements made


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Poor Compliance

Poor compliance is a common problem inpatient with a symptomatic chronic disease, e.g.

patient may not respond to doctor’s advices and he may not take his medication.

The following approach may need to be considered in dealing with poor compliant

patient:

Establishing and maintain effective doctor-patient relationship:

o Great the patient, empathetic approach,

o Respond to verbal & non verbal cues

o Use open ended questions

o Respect patient autonomy

o Encourage patient’s contribution o Active listening

Exploration of patient’s health beliefs: o What the patient knows about hypertension?

o What the patient knows about medications?

o What dose he beliefs about himself?

o What does he expect from the doctor?

Explore the social & psychological context of the problem: e.g.

possible life stresses

Assessment of degree of risk (if it is not clearly documented in the patient’s file) and use the information to improve patient’s compliance

o Family history of BP., IHD.CVA.

o Complication of BP / DM.

o Or other significant systemic disease

Education and reassurance:

o Shared understanding of problems

o Discuss possible complications of hypertension.

o Stress the importance of non pharmacological treatment

o However medications is also sometime needed

o Relative safety of anti-hypertension medications

o Insurance of accessibility

o The effect of medications to decrease morbidity &mortality

o Emphasize the need for good compliance with medication & advice

o Emphasize the need for follow-up

o


19

Approach to Patient With Arthritis F. Rayes

The following items may need to be considered in history taking in the first visit:



Patient’s 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 Reiter’s syndrome

o Ocular symptom: Reiter’s syndrome

o Oral symptom: SLE, Reiter’s

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


20

The following items may need to be considered in examination of patient with joint

pain in the first visit:

Inspection:

Attitude: Relax, normal, restricted movement abnormal posture

Skin Changes:

o Scars of skin disease

o Erythema: periarticular inflammation

o Red joint or bursa: sepsis or crystals

Swelling: fluid, soft tissue or bone

Deformity:

o Correctable: soft tissue abnormalities

o Non-correctable: capsular restriction or joint damage

o Muscle wasting

Inspection during active movement

Palpation:

Warmth, swelling and tenderness

Palpation during movement:

o Passive movement: crepitus

o Active movement: muscle power, instability, swelling

General examination:

Nodules: back of the hands, elbow, posterior heel, sacrum

Palmer erythema: RA

Nail changes:

o Clubbing (arthritis with COAD)

o Pitting (psoriasis, Reiter’s syndrome) o Splinter: Vasculitis

Mucous membrane lesion: Reiter syndrome / Lupus

Vasculitis

Eye changes:

o Episcleritis (RA)

o Iritis: Ankylosing spondylitis chronic Reiter’s disease

o Iridocyclitis: juvenile chronic arthritis

o Conjunctivitis: Acute Reiter’s disease

Assimilation of findings:

Number of joints involved

Distribution

Degree of inflammatory component

Extra-articular features


21

Differential Diagnosis of Joint Pain

Ostioartheitis Arthritis Reuhmatoide Arthritis Fibromyalgia

Common in elderly patients

More in female

- Duration months to

several years

Clinical features:

- Hand stiffness

bilaterally, lasting for

less than 30 minutes

- Morning worse

- Bony swelling, DIP

joints (Heberden

shoder)

- Bony swelling, DIP

joints (Bouchord’s nodes)

Common in middle age

More in female

- Duration months to

several years

Clinical features:

- Morning stiffness both

hands, lasting for more

then 30 min

- pain both wrists.

- Fatigues, malais, wt loss

parasthesias & vague

pain both wrists.

- Swelling, redness &

tenderness PIP &

metacarpo-phalangeal

joints

- Nondules over elbow

extenso

- Swelling in the

metacarpophalangeal

joints.

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

Differential Diagnosis of Joint Pain (Continue)

Gout Gonococcal Septic

Arthritis

Nongonococcal Septic

Arthritis

- More in males

- Monoarticular, first

metatarsophalagel 90%

- Very painful.

- Signs of intense

inflammation.

- Definitive diagnosis :

urate crystals in

synovial fluid.

Management:

- Colchicine dramatic

improvement NSAID

(indomethacin).

- Female 2/3 of patient.

- One or two joints, wrist,

finger, knee & ankles.

- Migratory arthritis

- Synovitis

- Conococcemia : fever,

polyarthralgias & skin

eruption prior to arthitis

compare to other septic

arthritis.

Management:

- Hospitalization

Ceftriaxime 1 g IV

TDS.

- Both genders

- Swelling, pain, warmth

With severe constitutional

symptoms

- Monoarticular synovitis

particularly knee rarely

small joints.

- 75% gram positive

stapheloccocal aureas.

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

Laboratory Findings in rheumatoid arthritis:

o High ESR

o Normocytic normochomic anemia

o Rheumatoid Factor in 80% of the patient is positive

o Antinuclear antibody in 20-60% of the patient is positive

o Anti DNA is usually negative

Facts about Rheumatoid Factor (RA factor):

o It does not confirm the diagnosis of RA

o It can be of prognostic significance, as patient with high titers tend to have

severe progressive RA.

o All patient with extra-articular manifestation of RA have positive Rh factor.

Other Conditions with Positive RA factor:

o 5% of healthy persons

o 10-20% individual over 65 years old

o SLE

o Sjogren’s syndrome

o Chronic liver disease

o Sarcoidosis

o Interstitial pulmonary fibrosis

o Hepatitis B

o TB

o Leprosy

o Sub-acute bacterial endocarditis

o Syphilis

o Malaria

o Visceral leishmania

o Bilharziasis


23

Approach to Patient With Backache F. Rayes & H. Al Hajjar

The following items may need to be considered in history taking from patient with

backache



Patient’s 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”

Aggravating activities & alleviating factors

“Morning stiffness relieved by activity suggests ankylosing spondylitis or other

inflammatory conditions. Worsening by standing or walking spinal sclerosis and relief

by bending Check for depression and somatization”.

Work situation and situation at home

Consequences in term of daily functioning

Past history of pain

The following items may need to be considered in examination of patient with

backache

Patient Standing:

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:

Inspection: scoliosis, muscle wasting.

Movement:

o Rotation

o Extend knees role out disc prolapse.

o Knee reflex.


24

Patient Supine:

Examine free side first.

Movement:

o Straight leg raising test (S L R) Active, passive & crossed SLR

o Bragard test.

o Lasegue test.

o 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

Differential Etiological Factors in Backache:

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


25

Counseling Patient with chronic backache:

Explore patient’s Ideas about backache, concerns & expectations. Educate patient about backache.

o Multiple etiology &- mechanics.

o Nature.

o Prognosis.

o Why acute pain became chronic? (Social, psychological, stress)

What to do in acute attack?

(Bed rest, heat / cold, posture, analgesia)

Disc herniation may need up to 3 weeks bed rest

However there is little evidence to support prolonged bed rest (EBM)

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

Other treatment modalities:

o Massage

o Traction

o Manipulation: osteopathy

o Chiropractic

o Acupuncture

Leaflets, booklets

Follow up


26

Preliminary Investigations:

Erythrocyte Sedimentation Rate (ESR)

X-ray of lumbar spine and pelvis

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

Indications For X-ray:

Suspect malignancy (over 50 years, persistent bone pain)

Compression fracture (prolonged use of corticosteroids severe trauma, focal

tenderness)

Ankylosing spondylitis (young male, limited spinal motion, sacroiliac pain)

Chronic osteomyelitis (low grade fever, ESR)

Major trauma

Major neurological deficit

Indications For Referral:

Rapidly progressive neurologic deficits

Symptoms suggestive of cunda equina syndrome or cord compression

Suspicion of osteomyelitis or epidural abscess

Persistent pain after 4-6 weeks of conservative management

For reassurance if patient insist


27

2.

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)

(1) History Taking from Patient Complaining of Palpitation

A. Al Harthy

The following items may need to be considered: Introduce yourself and establish doctor-patient relationship

Encourage patient contribution

Respond to patient’s cues

Clarification of the symptom (what the patient means by palpitation).

Exploration of the details of the main complaint:

Onset, course, frequency, duration, rate, rhythm, pattern (how it end abrupt or

gradual), precipitating factors and relieving factors.

Associated symptoms: e.g. chest pain, shortness of breath, fainting, sweating,

tremor, feeling of tension (fear), any symptoms of thyrotoxcosis.

Presence of mood changes, concentration or memory problems any phobias (e.g.

social phobia).

Past history of cardiac disease.

Drug history or stimulant use: e.g. tea, coffee (it’s amount). Social history & any history of stressful life events.

Exploration of patient s ideas, concerns and expectations and the effect of the

problem in patient’s life. Family history of.

Exploration of any continuous problems or at risk factors: DM, hypertension,

asthma or smoking (the amount of smoking).

A good history is often diagnostic, particularly with respect to precipitating factors.

Differential Hypotheses

o Anxiety

o Cardiac causes: e.g. sinus ventricular tachycardia, ventricular ectopics, atrial

fibrillation or flatter or sinus tachycardia

o Drug induced arrhythmias

o Thyrotoxicosis or anemia

Management:

o In case of infrequent palpitation or missed beats with no associated symptoms:

reassurance and advice patient to avoid the precipitating factors

o In case of frequent palpitation associated with chest pain or breathlessness:

- Urea and electrolyte

- TFTs and treat if abnormal

- ECG: if normal refer for 24 hours ECG


28

(2) History Taking from Patient Complaining of Tremor N. Dashash

The following items may need to be considered:

Introduce yourself and establish doctor-patient relationship



Exploration of patient Ideas, Concerns, Expectations and feeling.

Problem identification:

o What is meant by tremor?

o Is it visible or only a sensation of tremor?

o Duration of the problem?

o Onset gradual or sudden?

o Part of the body involved? (Head, voice, trunk...

o Type of movement and its spread.

o Is it a resting tremor or a movement tremor?

o Aggravating and relieving factors.

Other associated symptoms of:

o Cerebellar disease

o Hyperthyroidism

o Anxiety

o Parkinson’s

The effect of the problem on the patient's life (e.g. work, marital life).

History of drugs: e.g.

o Lithium

o Tricyclic antidepressants.

History of alcohol drinking and smoking

Past medical history:

o Brain disorder or head trauma

o Multiple sclerosis

o Other diseases, e.g. DM or hypertension.

Family History of similar problems.

Differential Hypotheses:

o Alcohol

o Medications

o Cerebellar disease

o Hyperthyroidism

o Anxiety

o Parkinson’s


29

(3) History Taking from Patient Complaining of Pruritis N. Dashash & F. Rayes





Identification of the problem:

o What is meant by pruritis?

o Which part of the body is involved?

o Onset, duration, clinical course.

o Precipitating factors.

o Severity of pruritis (interfering with sleep and daily activity)

o Any associated skin rash or any skin changes (describe it).

Associated symptoms of:

o Hyperthyroidism.

o Renal failure

o Drug reaction,

o Iron deficiency anemia

o Malignancy

o Liver failure

o Pregnancy.

Sensitivity to food, soap, perfumes...

Any thing new in the patient's life.

Past medical history

Drug history: opiates, amphetamine, quanidine, aspirin, and vitamin B.

Occupational history.

Family history of similar problem.

Psychological stress.

Exploration of patient ideas, concerns, expectations and feeling.

Exploration of the effect of the problem on the patient's life (work, marital life.

Systemic Causes of Pruritus

Cholestasis: o Primarily biliary cirrhosis,

pregnancy o Extrahepatic obstruction, drugs e.g.

Contraception Endocrine:

o Thyrotoxiosis, myxoedema o Hyperparathyroidism, DM

Haematological / myeloproliferative: o Iron deficiency, polycythemia o Hodgkin’s disease, multiple

myeloma Chronic Renal Failure Malignency

o Miscellaneous e.g. gout,

psychological, old age.

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

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

(4) History Taking from patient Complaining of Anxiety N. Dashash

The majority of patients may present with somatic complaint, e.g. palpitation or dyspnoea

or chest tightness. Candidate needs to suspect the diagnosis from the patient’s verbal and nonverbal cues, e.g. excessive hand movement…





Identify the problem:

o Duration of symptoms, onset: sudden or gradual

o Course: continuous or episodic (to rule out panic attacks and phobia)

o Change in severity

o Precipitating factors e.g. problem at work or home, death of relative

Exploration of patient ideas, concerns, expectations and feelings

Effect of the problem in patient life (physical, social and psychological)

Etiology: It is necessarily to exclude the following diseases:

o CVS diseases: ask about palpitation, chest pain, paroxysmal nocturnal dyspnea,

relation of symptoms to exercise and irregular beats.

o Depression: ask about loss of interest, low mood, change in wt ... etc.

o Hyperthyroid: ask about heat intolerance, excessive sweating...etc.

Symptoms of anxiety disorder (diagnostic criteria):

o Psychological: excessive worrying, nervous mood, apprehension, irritability,

disturbed sleep, and difficulty in concentration. Psychotic features (e.g.

hallucinations).

o Neurological: dizziness, headache, twitching, paraesthesia, blurring of vision

o CVS: palpitation, chest discomfort, flushing

o Respiratory: hyperventilation, difficult breathing, and chest tightness.

o GIT: dry mouth, nausea, difficult swallowing, choking, frequent loose motions,

abdominal discomfort, wt. Loss, and nausea/vomiting

o Urinary: frequency and/or urgency.

o Menstrual disturbances and reduce libido.

o Others: muscle aches and tension, tiredness

Drugs History: e.g. Alcohol, drugs, benzodiazepene withdrawal, caffeine (amount)

and smoking history.

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

(5) History Taking from Patient Complaining of Depression A. Assaggaf

The majority of the depressed patients may present to their family doctor complaining of

fatigue or somatic symptoms. Candidate needs to suspect the diagnosis from the patient

verbal and nonverbal cues, e.g. lack of eye contact, self-neglect, or multiple somatic

complains does not fit to any diagnosis…





Clarification of the symptom

History of the problem:

o Duration

o Mood

o Loss of interest in his usual activities

o Activity level:

Decrease, retarded, slow, loss of energy or increase, restless or agitated.

o Diurnal variation

o Sleep disturbance: (increase or decrease)

o Change in appetite and weight

o Loss of libido

o Decrease ability to concentrate

o Guilt feelings

o Suicidal thoughts and/or attempts

Patient's ideas, concerns, expectations and effects of the problem

Etiology of the problem

Psychosocial history:

o Home environment,

o Emotional problems

o Financial problems

o Loss of job or loss of relative.

Drug History

o Substance abuse

o Antihypertensives or steroids.

Presence of somatic complaint e.g. headache, back pain, shortness of breath, ---etc.

General medical illness

Past history of similar condition (or other psychiatric illnesses)

Family history of similar condition (or other psychiatric illnesses)


32

Prescribing of Antidepressants Fayza Rayes

Associated problems Suggested

Treatment Comments

Depression

1) SSRIs

2)Tricyclic antidepressants

Consider the cost

Depression with

Psychosocial stress

1) SSRIs

2)Tricyclic antidepressants

Social support

Psychotherapy

Depression with

Anxiety symptoms

1) Imipramine (Tofranil)

2) SSRIs (Prozac)

3) (Tofranil) + Alprazolam

Benzodiazepin (Xanax)

(75-150 mg)

(20-60 mg)

(250-500 microgram) TDS for 6Ws

then tapered slowly over 4 Ws

Depression with

insomnia

Amitryptylin (Tryptezol)

Dothiapin (Prothadin)

Maprotiline (Ludiomil)

Trazodone(Trazolan)

(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

Depression with DM SSRIs No Wt. gain

Depression with CHF

or IHD

SSRIs Less cardiotoxic

Depression with

Arrhythmia

SSRIs

Trazodon (Trazolan)

Less cardiotoxic

(see insomnia)

Depression with

Hypertension

SSRIs

Trazodon (Trazolan)

(see insomnia)

Depression with

Hypotension

Nortriptylin (Nortrilen)

SSRIs

(10-150mg in devided dose)

no hypotension, no sedation,

less anticholinigic, safe in elderly Depression with

Urologic disease

Trazodon (Trazolan)

SSRIs

(see insomnia)

Depression with

Parkinson 's Disease


Trazodon (Trazolan)

(see Hypotension)

(see insomnia)

Depression with Stroke

SSRIs


(see Hypotension)

Depression with

Migraine headache


Imipramin (Tofranil)


(see Insomnia)

(25-300 mg in devided dose) not

sedative constipation, nausea,

headache, sexual disfunction

(see Hypotension)

Depression with

Chronic urticarea ,

allergic disease


Imipramine (Tofranil)


(see Insomnia)

(see Migraine)

(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 Significant Side effect Indication

Amitriptylin

(Tryptyzol)

25-300 mg

in devided dose

Histaminic blockade / Sedative

Anticholinergic effect

Alpha 2 adrenoreceptor

blokade Hypotension/sexual

dysfunction

Depression with insomnia

Migraine

Not for hypotensive patient

Imepramine

(Tofranil) 25-300 mg

in devided dose

Seratonin uptake blokcade /

Constipation, dizziness

Not sedative

Depression

GAD

Panic attacks

Clomipramine

(Anafranil)

10-250 mg

Seratonin uptake blokcade /

Constipation, dizziness

Not sedative

OCD (Drug of first choice)

Phopias

Panic attacks (Drug of first

choice)

Nortriptylin

(Nortrialen)

10-200 mg / day

No hypotension, no sedation

Less Anticholinergic effect

Elderly

Maprotiline

(Loduomil)

25- 150 mg

Not in epelipsy or risk of

convulsion


Trazodone

(Trazodam)

150- 400 mg / day

Minimum effects

Hypotenssion

Priapism (1/6000 cases)


Strong sedatve / Insomnia (half

tablet for 3 days)

Sertralin

(Zoloft)or (Lustral)

25-100 mg

Seratonin uptake blokcade :

GIT / anxiety / tremor /

insomnia / palpitation

/drowsiness / agitation /

hypomania / hypotenssion /

convulsion / movement

disorders & dyskinezia /

neuroleptic malignant

syndrome / violent behavior /

hematological complications

Cautions: cardiac diseases

Mania / epelipsy / concurrent

ECT / hepatic or renal

impairement / pregnansy /

breast feeding / interactions

Depression 50-200 mg

Maintenance 50 mg

Fluoxetine

(Prozac)

10- 80 mg / day

Depression 20 mg

Bulimia 60 mg

OCD 20- 60 mg

GAD & Panic attacks

Citalopram

(Cipram)

20-60mg

Depression 20-60 mg

Panic disorder 10mg increase

evrey week by 10mg / mux 60

mg

Fluvoxamine

(Faverin)

100-300 mg

in devided doses

Depression 100-300 mg

OCD (the drug of first choice)

Insomnia

Parooxetine

(Seroxat)

20-60 mg

Depression 20mg increse by 10

mg every week / mux 50 mg

OCD / start by 10 mg / mux 60

mg

Effect after 2 weeks and diagnosis of medication failure after 2 months


34

(6) History Taking from Patient Complaining of Dizziness/ Vertigo H. Al Hajjar & M. Alatta




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 Standing

o Auricle manipulation,

o Fatigue

o Valsalva maneuver

o Viral infection

o Hyperventilation

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

Differential Diagnosis of Vertigo:

Benign paroxysmal vertigo

o Sudden vertigo positional changes (e.g. head turning)

o Recurrent lasting minutes to hours.

o Released if pt is motionless.

o Associated Nystagmus

o Adult uncommon in children.


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

Vestibular Neuritis or Labyrithitis.

o Sudden onset after U.R.T.I lasting days to weeks

o Nausea & vomiting

o Tinnitus hearing loss

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

Vertebro Basillar insufficient.

o Acute onset. Onset in elderly

o Recurrent

o Brainstem Symptoms. No Nausea OR vomiting

o Nystagmus.

Multiple Sclerosis

o Sudden or transient, persistent as or Recurrent

o Lasting day’s 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 Antidepressent

o Diuretics & antihypertensive

o Hydrocarbons exposure

o Organic -Carbon Monoxide.

Exposure


36

(7) History Taking from Male Complaining of Impotence

H. Al Hajjar

The majority of impotent patients do not complain directly from impotence. Candidate

needs to suspect the hidden agenda from the patient’s verbal and nonverbal cues, e.g. patient may ask for vitamins or any other tonics, or he may complain of backache or

psychological symptoms…





Details of the complain: onset & course of the impotence

Degree of dysfunction: chronic, occasional or situational.

Early morning and nocturnal erection.

Is there other wife? Is the problem the same with her?


o Is the marriage stable & Happy?

o Does the wife contribute to the problem?

o History of: pelvic trauma, pelvic surgery, and spinal cord surgery.

o History of: diabetes, renal failure, hepatic cirrhosis,

o Medications: Diuretics, antihypertensives, H2 blockers

Antidepressant or alcohol.

o Any new stressful event


o Loss of libido, Gynecomastia.

o Presence of visual or neurological symptoms.

o Psychosocial history: depressive symptoms

Exploration of patient's ideas, concerns & expectations.

Effect on patient life & relation to wife and family.

Previous treatment modalities


37

(8) History Taking from Female Complaining of Infertility

A. Assaggaf





Detail of the complain:

o Nature of the problem. Is it infertility?

o Duration

o Type of infertility: primary or secondary?

Patient’s ideas, concerns, expectations & Effect of the problem. Etiology

Menstrual History

o Age of the patient

o Age at menarche

o Duration of periods

o Menstrual irregularities

o History of amenorrhea

Obstetric History:

o Previous pregnancies

o Abortion

o Ectopic pregnancy

o Complicated deliveries.

Gynecological History

o History of PID

o Fibroids

Marked weight loss

Excess exercise

Symptoms of general diseases e.g. DM., hypothyroidism or hyperprolactinemia.

Marital relationship

o Duration of marriage

o Sexual activity: (technique and frequency).

Information about the husband:

o Age, occupation (exposure to toxin or radiation)

o History of previous marriage, children & age of youngest child.

o Past medical history

o History of mumps, undescended tests, varicocele.

Family History of infertility, DM or chromosomal abnormalities.


38

(9) History Taking from Patient Complaining of

Vaginal Discharge

A. Assaggaf, M. Alatta & F. Rayes






o What does the patient mean by vaginal discharge

o Onset

o Duration of symptoms

Description of the discharge in relation to:

o Amount,

o Color & appearance

o Odor

o Consistency

o Any associated blood with the discharge.


o Dysurea

o Pruritus

o Pelvic pain

o Dyspareunia

o Fever or skin rash.

Menstrual history and LMP.

Relation to menstrual cycle

Relation to intercourse

Symptoms in the partner

Previous history of discharge

Possible etiological factors: e.g.

o DM

o Concurrent use of medications (steroids or antibiotics),

o Use of tampons, pessaries & antiseptics,

o Possible exposure to STD

o Use of contraception (Pills, IUD).

Exploration of patient’s ideas, concerns and expectations. Exploration of patient’s fear or anxieties related to the discharge. Exploration of the effect of the problem in patient’s life

(Physical, social and psychological)

Differential diagnoses for causes of vaginal discharge

Symptom Alternative Diagnosis o Dysuria Urinary tract infection o Altered bleeding patternd Side-effect of hormonal method of

contraception- combined and progesterone-only contraceptive pills, injectable contraception (Depo-Provera), implants n) or intrauterine system (Mirena) o Abdominal pain Irritable bowel syndrome, constipation, endometriosis


39

Differential diagnoses for causes of vaginal discharge (continue)

Candida:

o Most common

o Itchy, white, thick, lumpy discharge

Bacterial vaginitis:

o Copious greyish & fishy smelling, burning or itching

Trichomonas vaginalis:

o Offensive, greenish yellow, thin, bubbly discharge, with pruritis valvae.

Chlamydia:

o 8% of VD in UK, and only 0.5% of VD in KSA

Gonorrhoea:

o Very uncommon cause purulent vaginal discharge.

Microbiological investigations for vaginal discharge.

Investigations Infection

o High vaginal swab Candidiasis, bacterial vaginosis,

Trichomonas vaginalis

o Cervical swab Gonorrhea

o Endocervical swab (culture, direct Chlamydia trachomatis

fluorescent antibody or enzyme

Immunoassay)

Investigations for no infective causes of vaginal discharge

Investigation Cause

o Urinalysis/blood glucose Diabetes

o Midstream urine Urine infection

o Serum follicle-stimulating Oestrogen deficiency

Hormone and oestradiol -perimenoausal -Inadequate hormone replacement

Treatment

Treatment of vaginal discharge:

Condition Drug Treatment

Bacterial vaginosis

Trichomoniasis

Candidiasis

Metronidazole (Flagyl) 400 mg BD X 5 ds

Or Nimorazole (Naxogin 500) 2 g single dose.

Metronidazole 400 mg BD X 5 days or 2 g single dose.

Clotrimazole (Canesten) single 500 mg pessary

Or Nystatin 2 pessaries at night/ 2 weeks.


40

(10) History Taking from Patient Suspecting to have

Sexually Transmitted Disease (STD) A. Al Harthy

Candidate may suspect STD from the patient main complaint, e.g. urethral discharge or

ulcer in genital area. Other helpful cues should also be considered, e.g. travel history,

young age, and single…


Introduce yourself

Establish good rapport

o Be communicative

o Non-judgmental,

o Confidentiality is essential,



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).

Presence of itching, dysuria, frequency,

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).

Presence of symptoms in husband or wife,

Previous similar attack,

Past history of STD,

Drug abuse or use of alcohol,

Any contraception: e.g. barrier contraception.

Any drug use or self-treatment.

Exploration of patient s ideas, concerns and expectations and the effect of the

problem in patient’s life. If the patient is female: ask about her gynecological history:

o LMP

o Dysparunia: superficial or deep

o Dysuria: external or internal


41

(11) History Taking from Patient with Epistaxsis M. Alatta





o How severe is it?

o When did it begin?

o How is the patient responding?

o Is the patient alone?

Nasal Characteristics:

o Is there respiratory difficulty?

o Can the patient breath through the mouth without difficulty?

History of possible etiological factors:

o Any trauma

o Any foreign body

o Any drugs taken

o Any underling medical condition

Instructions For Nose Bleed

o Sit up.

o Pinch soft parts of nose to gather between thumb and index finger.

o Breath through mouth.

o Hold pinched nose for 10 minutes without letting go.

o Fill a plastic bag with crushed ice, wrap bag in a towel, and apply to upper nose.

o Remain sitting in a quiet environment for 30 minutes.

o Avoid blowing or picking nose (this will remove blood clot, and bleeding will

reoccur.

o Avoid straining or lifting this may increase pressure and bleeding will reoccur).

o Hot, cold, or windy weather may cause drying and crusting of the nasal / mucus

membranes. Heaters and air conditioners add additional drying to the environment.

To prevent nose bleeds:

o Use a vaporizer or humidifier, especially at night.

o Lubricate the anterior nasal opening with a small amount of Vaseline.

o Avoid picking or intense blowing of the nose.

o If bleeding reoccurs, nasal / packing or cautery may be necessary.

o For frequent nose bleeds, call for an appointment with a health care provider to

evaluate the cause.


42

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

Remember proper exposure of the patient

Always expose and examine both sides for comparison

Ask patient permission

Tell the patient what you are doing

Gentle approach

Be systematic

Thanks the patient at the end

Wrest & Hand Examination H. Al Hajjar & M. Alatta

Inspect: dorsum, palmer & sides:

o Deformity: Radial or ulnar deviation, RA. (Swan neck,

Boutonniere & Z deformities)

o Nerve injury deformities (drop wrist, claw hand)

o Wasting: thenar, hypothenar & interossious.

o Skin: swelling, scars, color

Palpate:

o Skin for temperature.

o Wrist joint

o Snuffbox

o Over nerves: median & ulnar.

o Over sheet of abductor pollices longus & extensor

o Pollices brevis (dorso lateral aspect of radius)

Move:

o Dorsiflexion.

o Palmerflexion.

o Radial deviation.

o Ulnar deviation.

o Finger adduction.

o Finger abduction.

o Opposition.

Special tests:

o Power and sensation:

Carpal tunnel syndrome:

o Thenar eminence for wasting.

o Tinel's test: taping over the median nerve at the carpal tunnel

o Causes pain or numbness in median nerve distribution.


43

o Phalen test: flexing the wrist 90º 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.

Ulnar nerve syndrome:

o Forman's sign: paralysis of adductor pollices.

o Claw hand

o Sensory loss: anterior & posterior aspect of little and lateral half of ring finger.

Management of Carpal tunnel syndrome

None-surgical in non-complicated, short duration less> 1 year;

o Wrist support

o Palmer wrist splint at night

o Advice about work related hazard

o NSAI drug

o Pyridoxine

o Local steroid injection

Surgical

Simple decompression


44

o

(1) Shoulder Examination H. Al Hajjar

Ask patient to Stand and expose:

o Both shoulders

o Neck

o Upper chest

Look always for patient face (pain)

Tell the examiner what you are doing

Inspection:

In Good light, compare both sides, front, side, back, above &

Axilla, Skin for Scars, redness, bruising or swelling

Front:

o Soft tissue. Contour of shoulder muscle wasting

o Bones & joints:

Prominent sternoclavicular joint

Clavicle deformity

Prominent acromioclavicular joint

Side:

o Glenohumeral joint

Behind:

o Scapula shape & position

o Neck webbing

Above: o SupraclavicIlar fossa, shoulder,

o Clavicle swelling, deformity, asymmetry

Palpation:

o Skin for hotness

o Bony points:

Anterior & lateral sides of Glenohumeral joint

Upper humeral shaft (from axilla)

Acromioclavicular joint lipping & Crepitation

Clavicle

Greater tuberosity

o Soft tissue.

Deltoid bursa

Biceps tendon

Supraspinatus tendon

Movements: active, passive if restricted

o Abduction & adduction (observe painful arc)

o Flexion

o Extension

o Apply's scratch test:

Internal rotation

External rotation

o Push against wall (winging of scapula)

Power: resisted movements

o Long head of biceps speed test

o Supraspinatous resisted can emptying position

o Infraspinatous resisted external rotation

o Subscapularis resisted internal rotation


45

Special tests:

o Cross over test (acromioclavicular joint)

o Anterior drawing test / apprehension test (dislocation)

o Posterior drawer test (dislocation)

o Clunk test (labral tear)

o Impingement test

Examine the neck.

Aply's scratch test:

o Ask patient to put hands behind neck, elbows backward

(Tests: external rotation & Abduction)

o Ask patient to put hands behind back reaching up as he can

(Tests. Internal rotation & adduction)

Cross over test. Reach across chest to other shoulder

Tests: acromioclavicular joint

Anterior drawer test:

o Patient supine at bed edge

o Steady scapula with your left thumb on coracoid’s fingers behind draw anteriorly the head of humerus by your right hand

o Observe for click, movement or apprehension

Apprehension test:

Patient sitting, doctor behind patient stabilize scapula

Abduct shoulder 90 º, elbow flexed 90 º, externally rotate

Apprehension Not pain positive test

Posterior drawer test: o Patient supine shoulder flexed 20º abducted 90º

o Place thumb just lateral to coracoid

o Rotate shoulder internally & flex 90º

o Observe movement by your thumb

Clunk test:

o Elbow flexed, shoulder abducted

o Rotate while applying axial pressure

Speed test: o Force downward patient's supinated arm with elbow flexed 90 º, shoulder

o adducted, observe biceps swelling.

Impingement test:

o Patient standing, doctor from behind

o Ask patient to flex shoulder forward

o Apply pressure downward over shoulder

o Look for pain


46

(2) Knee Examination H. Al Hajjar

Expose both knees and start by normal knee.

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

Palpate:

o Temperature: all sides & compare.

o Tenderness: slight flexion.

o Attachment of collateral ligaments.

o Joint line: menisci.

o Tibial tubercle.

o Anterior surface of patella.

o Synovial membrane thickening.

o Effusion:

- Patellar tap.

- Fluid displacement test (most reliable)

- Fluctuation test.

Move: flexion & extension

o Active

o Passive.

o Against resistance

Special tests:

o Varus & vulgus stress instability (for collateral ligaments)

o Anterior & posterior drawer tests for cruciate ligaments.

o McMurray manuver for menisci.

o Friction test. (For patello-femoral joint.)

o Apprehension test. ( For patello-femoral joint.)

Patient Prone: popletial fossa

o Look: mass, deformity, scar and skin color.

o Palpate. Mass, pulsation, tenderness and temperature.

Examine hip & ankle joints quickly (movements)


47

(3) Ankle Examination H. Al Hajjar

Inspection:

o Gate

o Deformity

o Skin

o Swelling

o Compare with other foot

o From behind

Palpation: o Site of pain

o Tenderness at ligaments sites, anterior capsule, lateral malleolus and base of 5th

metatarsal

o Skin temperature

Movements: o Active planter and dorsiflexion

o Passive planter and dorsiflexion and inversion and eversion

o Compare both sides

Special movements: o Anterior drawer test

o Talar tilt test (inversion stress test)

o Comparing two sides

Quick knee examination Arrangement

Important ligaments around ankle joint: o Anterior talofibular

o Posterior talofibular

o Calcaneofibular

Most common injuries;

o Strain: does not involve joint instability or ligament tear o Sprain: stress applied to ankle in an unstable position causing ligaments to

overstretch

Degrees of ankle sprain: o First degree: stretching of ligamentous fibers

o Second degree: tear of some fibers

o Third degree: complete ligamentous separation

Inversion injury is most common injury


48

(4) Mental Status Examination

A. Al Harthy

Mental state appearance and behavior:

o Appearance: dress, posture, facial expression, eye contact

o Example: poor eye contact, masked face or crying in depressed patient

Speech and preoccupations:

o Rate of speech:

Example: pressured as in mania

Retarded as in depression

o Tone:

o Example: monotonus tone in depressed patient

(Normal tone in variable)

o Form: Thought block as in schizophrenia

o Content: depressive ideas in depression

hypochondrial ideas as in hypochondriasis, which is a preoccupation with

a fear of having a serious disease.

Abnormal beliefs:

o Delusions: Which is a false belief

Example: persecutory, grandiose, thought broadcasting in schizophrenia

Mood:

Example: anxious in anxiety

Depressed in depression

Phobias and Obsessions:

o Phobic anxiety symptoms and it’s effect o Example: avoidance behavior as in social phobia

o Obsess ional ideas or compulsion

These symptoms you need to ask specifically about it ‘patient many times don’t volunteer it’

Abnormal experiences

Depersonalization

Hallucinations: which is a false perception arising without external stimulus

Example: auditory hallucination in schizophrenia

Cognition:

o Orientation: to time and place

o Attention and concentration:

o Example: asking patient to mention days of the week in the opposite order.

o Memory: short term

Long term

Example: patient with Alzheimer dementia can’t remember what they cat for lunch. But can remember some events happened 20 years

back.

Insight and Judgment:

Insight: is weather the patient is aware of his illness or not.

Intelligence: more special test is done for that by more specialized personnel.


49

(5) Painful Red Eye examination A. H. Hassan & A. Al Harthy

Swelling /secretion / redness scars / pallor

Palpation for tenderness and tension.

Size and reaction to light of the pupils.

Visual acuity:

Far vision

o Cover the other eye

o Use the chart and record the finding

Near vision

o Field confrontation method.

o Color vision: using lshibara plates.

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


50

Chronic Open-Angle Glaucoma

Symptoms: can be asymptmatic,

o Restriction of visual fields.

o Gradual loss of peripheral vision, (tunnel vision)

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.

(6) Optic Nerve Examination A. H. Hassan

Visual Acuity:

o Far vision:

Chart + 6 m., cover the other eye.

o Near vision

Field:

o Confrontation method.

o One meter apart, cover one eye, Eye fixed, bring the object into the field.

Color Vision

o lshibara plates.

Funduscopy:

o Dilatation, Check the machine, darken the room, and fix a target.

o Right hand for right eye, from the tight side.

o Red reflexes

o Optic disc.


51

4.

Counseling and Advice H. Al Hajjar, A. Al Harthy, M Alatta & N. Dashash

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 patient’s agenda) may perform badly in counseling stations.

(1) Epilepsy Counseling H. Al Hajjar

Topics:

1. Ask about age, work, and marital status.

2. What do you know about epilepsy?

3. Explain what is epilepsy.

4. Prognosis

5. What to do during an attack?

6. Status epileptics

7. Medications

8. Avoid precipitating Factors

9. When to call your doctor.

10. Home environment

11. Work

12. School teachers &. Social contacts

13. Learning abilities & IQ. Epilepsy is not a mental disease

14. Activities & sport

15. Driving

16. Bracelet / necklace / card

17. Inheritance & genetics

18. Marriage

19. Follow up

20. Help groups / associations / foundations.

21. Leaflets & booklets

What to do during an attack?

Grand mal. Don't restrain convulsion movements

Don't place any thing in mouth

Don't cover with blankets. Don't move to other place.

Position on side during clinic phase, wipe away froth

From mouth to help airway. Take, away items that could cause injury.

Allow patient to rest post seizure.

Myoclonal: Remove objects which may cause injury

Absence: Don't try to alert patient (useless)


52

Home environment:

Don't be in potentially dangerous state alone (kitchen, fire, bath drain, door locking).

Activities & sport

o Freely encouraged: Football, basketball cricket despite poor control

o No boxing

o Supervised: horse riding, cycling on busy roads, solo fishing or canoeing, climbing

o Swimming: is permissible if supervised on a one-to- one basis (inadvisable in

school groups)

Bracelet / necklace / card:

With details of medication & fits, GP & hospital phone number.

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

Avoid precipitating Factors:

Sleep deprivation, extreme hunger & fatigue, constipation, flicker (view screen from at

least 2 m in an illuminated room, if nearer cover one eye with palm of hand, Polaroid

sunglasses at seaside).

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.

Marriage inheritance & genetics:

You can live normal live and get married,

Inheritance to offspring: There is family history in 15 - 40 % of cases

?? Autosomal dominance mood of inheritance

When to call your doctor:

o If seizure change in number.

o Any time you change your medications or take another medications.

Pregnancy:

o Risk of fetal abnormalities with medications

o Uncontrolled seizures affect the fetus. Balance risk / benefits.


53

(2) Counseling parents of a child with febrile convulsion A. Al Harthy


Explore mother’s ideas regarding breast feeding, concerns & expectations

Explain nature of the problem

Reassure about the benign nature.

When the child has fever do; reduce fever by: bath, tape sponges, paracetamole,

and light clothes.

If the child having convulsion:

o Protect your child air way.

o If you child has any thing in the mouth clear it with a finger to prevent choking

o Place the child on the side or abdomen (face down) to help drain secretions.

o During seizure, don’t try to restrain your child or stop seizure movements.

o Don’t try to force anything into your child mouth. o In the way to the doctor keep fever down, Dress child lightly, continue sponging.

o If your physician decides seizures can be treated at home follow instructions

o Keep diazepam 5 mg for rectal use at home.

Prophylactic anticonvulsants can prevent convulsion from occurrence but it has

Side effects, pediatrician will decide when to use.

Fever is common after DPT vaccine, so start paracetamol in the physician’s office

and continue it for at least24h.

Avoid covering your child with more than one blanket, it increase temperature 1-2

extra degree.

At the end ask the parents if they have any questions or clarifications

Thank the parents


54

(3) Post-Myocardial Infarction Counseling M. Alatta

Discuss with the patient the following issues:

The nature of coronary artery disease

Common post-infarction symptoms:

o Niggling left-side chest pain

o Ectopic beat

o Light headedness

o Fatigue

Risk Factors: weight, avoid stress, and stop smoking.

Exercise: Why it’s important to him?

o What are the kinds suitable for him? E.g. walking, jogging.

o Start slowly & gradually 3 times / week 10-30 minutes,

o Warm up before exercising.

Diet:

o Why it is important?

o Types of diet and how to prepare?

Drugs:

o Importance of compliance

o E.g.: Aspirin, ACE and B-Blockers

Sex:

o 4 weeks after,

o Position?

Driving:

o 4 weeks after MI

o Short distances avoiding heavy traffic

Job counseling:

o How strenuous is her/ his work?

o Return to work should be post pond until after an exercise test

o Patient can go back to work 4 - 12 weeks.

o Or return after 4-6 weeks depending on patient’s recovery and demand of his job

Other issues:

o Air traveling after 4-6 weeks, and preferably after review by the doctor

o Relaxation therapy and stress management

o Any other questions he 1 she would like to ask.

Annual Review:

o Evaluate patient’s life style and coronary risk

o Simple assessment for anxiety and depression

o Review of drug treatment

o Assess patient’s ability to continue with normal activity and work

o 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


55

(4) Advice Mother About Breast Feeding A. Al Harthy


Explore mother’s ideas regarding breast feeding, concerns & expectations

Educate mother about importance of breast feeding

o Establish a psychological bonding between baby and mother

o Less cost

o Easier (no need to prepare)

o Increase immunity of the baby

o Decrease the chance of developing allergic diseases and bronchial

asthma

Current situation:

o Attempt of breast-feeding?

o Difficulties?

o Duration?

Social condition

o Facilities at work

Contraception

Technique of breast feeding

o Inform her that breast feeding should be initiated as soon after

delivery as possible

o The mother should sit comfortably with support for her back

(pillows can help), be in a private comfortable place if possible

o Make sure that the mother knows these technique:

- The baby should have a large part of the areola in his mouth

- During first 2 weeks, feed on demand

- Nurse baby 10 minutes on first breast and as long as he want on the

second breast

- Alternate which breast you start with each time

- Feeding less at night is OK; but no more than 5 hours should pass

between feeding

- Don’t offer the baby any bottles during first 6 weeks

- Milk supply improve by adequate sleep, fluids, relaxed environment,

reduced stress

How the mother know if the baby is getting enough breast milk:

The baby is getting enough milk if

o The baby has a 6-8 wet diapers /day

o The baby is back up to birth weight by two weeks of age

o You can hear the baby swallowing while breast feeding

o The milk leaks from one breast when you are feeding the baby on

the other

o Baby has 3-4 bowel movements per day

Important points about breast feeding

Counseling a mother about breast-feeding should start early enough, during

prenatal care or even earlier.

The first 4 weeks after delivery is the most important time to establish breast-

feeding.

By the start the baby is 3 month old, he need extra feeding and you need to start

introduce him to cereals (see weaning), but still you can continue breast feeding up


56

to age 1-2 years.

For working mothers:

o Still you have enough and excellent time to feed your baby during

your maternity leave, even if you plan to stop after, but the best is to

continue

o By using break hours to feed the baby or

o By pump breast and keep milk in a refrigerator

Counseling the mother about contraception and if she choose the pills, she can use

either progesterone only pill or even combined pills provided she is well motivated

to breast feed.

(5) Advice Mother About Weaning A. Al Harthy


Ask about history of current feeding,

Explore mother ideas regarding weaning: her concerns and expectations

Explain the continuous increase in dietary requirement by increase of age,

Explain how to introduce weaning food,

Begin with small amount, one kind of food at a time,

Weaning should be gradual,

Use a spoon and do not give solids in feeding bottle,

Give food before breast feed - gradually food replace feeding,

Problems during weaning,

Explain advantage of early start of cup feeding at 6 months using baby cup,

Home-prepared food is best. Explain how to prepare food at home.

When to begin:

o At 4-5 months:

o At 5-6 months:

o At 7-8 months:

o At 9-10 months:

o At 11-12 months:

Diluted fruit juice and cereals

Vegetables, soup, egg yolk & soft fruits

Chicken, fish, bread and meet

Continue previous food

At 1 year of age baby can eat regular family diet provided it is

soft, he can swallow.

Continue breast feeding up to age 2 years,

Do not add honey or sugar,

Ensure mother understanding and acceptance of your instruction

Ask mothers if she has any question to clarify.


57

(6) Counseling Mothers About Child with Gastroenteritis (GE) F. Rayes


Explore patient’s ideas, believes, expectations and concerns about the diagnosis.

E.g. can vomiting and diarrhea be dangerous to the child?

Explain the diagnosis (what is gastroenteritis)

o What is dehydration?

o Causes

o Complications

o Prognosis

Advice:

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

Advice mother against clear liquids that commonly prescribed inappropriately

(high osmolality, high glucose, low sodium and low potassium)

o Orange juice

o Apple juice

o Coca-Cola and 7Up

o Tea

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

Educate mother about effective home remedial for dehydration?

o (BRAT) feeding in convalescence period (Banana, Rice, Cooked Apple, Toast).

Inform mother about serious symptoms which need hospitalization

o Severe intractable vomiting

o No urine

o Impaired consciousness

Insure patient’s understanding and acceptance of your advice. Explain others management options e.g. IV therapy and/or investigations.

Reassurance

o GE is a self limiting

o If properly treated it rarely gives complications

Emphasize the importance hygienic measures to prevent diarrhea in future?

Calculation of fluid deficit:

For mild dehydration:

60 mL of oral rehydration solution per kg (60 mL x wt. in kg)

= mL of oral rehydration solution over 2-4 hours

For moderate dehydration:

80 mL of oral rehydration solution per kg (80 mL x wt. in kg)

= mL of oral rehydration solution over 2-4 hours

A toddler with severe diarrhea loses 100-200 ml of fluid with each stool and will

require half to one glass of oral rehydration fluid for each stool


58

(7) Counseling Patient About Obesity H. Al Hajjar, M.Alatta & N. Dashash


Encourage patient’s contribution: o Sympathetic approach

o Discuss patient motives & barriers to change

Provide opportunity for feed back

Patient ideas, concerns & expectations: e.g.

o “I am not obese I am only over weight”

o “Worried about becoming a diabetic”

Family & Social history:

o Smoking

o DM, HPT& heart diseases, high cholesterol level

o Obesity

Obtain enough information:

o Previous trials

o Heart disease risk factors

o Role out secondary causes: hypothyroid, medications, cushing’s, heart failure

Past medical & drug history

Appropriate examination: to rule out secondary causes

BMI= Wt/ (Ht) 2 in meter

Diagnosis explained

Appropriate management:

o General advise: food diary, lifestyle change, gradual

o Behavioral: guidelines for healthy diet, avoid cues

o Dietary: food groups, food exchanges

o Physical activity: ↑daily activity, exercise program

o Follow up: 1 week

o Written health education material

o Share options with the patient

o Other modalities according to BMI as medications and surgery

Referral to dietitian

Advice about Diet

o Enjoy your food

o Eat variety of food

o Eat the right amount prescribed for you by your dietetion.

o Do not eat too much fat

o Do not eat while watching TV

o Eat in small plates

o Do not shop while you are hungry

o Always go shopping with as hoping list

o Eat 5-6 times a day (3 meals small healthy snacks

o Do not eat sugary food too often eat only what is calculated to you by your dietetion

o Look after vitamins &minerals in your food

o Ask for support or advice from you doctor if you have any inquiries.


59

Body Mass Index (BMI) & Obesity

o BMI used to reflect the presence of excess adipose tissue.

o Calculated by dividing measured body weight in kilograms by the height in meters

squared (BMI= Weight in Kg ÷ height in m2)

o Normal BMI is 20-25 kg/ m2.

The National Institutes of Health currently define obesity as: a relative weight over 120%

(BMI > 27.5 kg/ m2).

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.

Health Consequences of Obesity:

o Hypertension

o Type II diabetes mellitus

o Hyperlipidemia

o Coronary artery disease

o Degenerative joint disease

o Psychosocial disability

o Certain cancers (colon, rectum, and prostate in men; uterus, biliary tract, breast, and

ovary in women)

o Thromboembolic disorders

o Digestive tract diseases (gallstones, reflux esophagitis)

o Skin disorders are also more prevalent in the obese

o Surgical and obstetric risks are greater as well

o Greater risk of pulmonary functional impairment

o Endocrine abnormalities

o Proteinuria

o Increased hemoglobin concentration

o Death rate increases in proportion to the degree of obesity.


60

(8) Counseling Patient About Smoking Cessation H. Al Hajjar & M.Alatta


Assess smoking habits:

o Smoking & quitting history (causes of failure).

o Interest in cessation.

o Potential motivating factors.

Motivate the smoker to attempt to quit:

o Emphasize benefits of cessation.

o Disadvantages of smoking: medical, social (children, pregnant wife) religious, risk

of fire.

o Focus on short term changes.

o Tailor to the clinical situation. e.g : asymptotic patient, or patient with acute

respiratory illness, pregnancy or chronic disease (DM, Hypertension, Myocardial

infarction, and/or COPD)..

Explore patient’s ideas, concerns and expectations

Ask for a commitment to quit (set a quitting date within tow months)

Discuss methods to help the smoker to quit:

Behavioral Smoking diary.

Positive reinforcement.

Progressive restriction (during preparation)

Find alternatives to oral and hand activity.

o Pick a date to stop smoking and tell your family and doctor

o Avoid smoking cues.

o Remove all ashtrays from you surrounding environment.

Develop social support.

o Tell you patient that he must be firm about refusing cigarettes from others.

o Avoid situation that will tempt you to smoke (friends, parties).

o Tell your family &friends that they should respect your wish of them not smoking

around you.

o Find and join a support group.

o Pray and ask god to help you.

Self help material.

o Learn to do some fun thing that will distract your craving (which will be short

term).

Pharmacological

o Nicotine replacement therapy (gum & patch)

o Effectivenessand. Side-effects.

Other methods

o Smoking cessation programs.

o Acupunctures, hypnosis.

Anticipate problems:

o Withdrawal symptoms.

o Weight. Gain.

Follow up

o Put smoking on problem list.

o Follow up visits. / Continued monitoring at each visit.


61

(9) Counseling Patient About HRT A. Al Harty


Explore what the patient knows about HRT?

Does the patient have any complaint?

Explore menstrual history

Presence of any complaint:

Hot flushes, Sleep disturbances, Sexual problems, Body ache, others

Diet history (Calcium intake)

Daily activity & exercise

Medical illness, DM, hypertension, Heat disease, DVT, Breast disease, Cancer

Smoking

Family history of Cancer breast

Effect of problem on patient life

Her ideas, concerns, expectations

o Discuss advantages and disadvantages of HRT

o Possible regime of HRT, for How long will use?

Importance of:

o Regular follow-up during HRT

o Doing proper investigation

o Report of irregular bleeding, leg swelling

Discuss non pharmacological measures for prevention of osteoporosis:

o Enough intake of calcium, exercise, other alternative drugs.

o Consider the patient willing to undertake risk in exchange with benefits

Examine: Wt, Bp, Breast, abdomen, pelvic exam.

Investigation: Pap smear, mammogram, + lipid profile.

Management:

o Give her time to explore any idea or questions

o She can take enough time to decide if not today

Refer her to health educators

Prescribe HRT

Give appointment for follow up

Patient Education about Menopause

What is the patient knowledge about menopause?

What is menopause?

It’s symptoms (Not necessary all women will have symptoms).

Menstrual irregularity then cessation of menstruation.

Need of contraception in per menopausal stage.

Clarify importance of positive thinking about this stage of life.

Possible occurrence of annoying symptoms & It’s management: Patient ideas, concerns, expectations.

Risk factor for osteoporosis and how to deal with it?

Importance of non pharmacological measures for prevention of osteoporosis:

o Diet (enough intake of calories)

o Exercise (physical activity & sun exposure)

HRT: It’s advantage, disadvantage, and possible regimen for use.


62

(10) Hepatitis B Chronic Carrier H. Al Hajjar & M. Alatta


Skills needed in breaking bad news

o Prepare patient that bad news is coming

o Show sympathy

o Lay out news simply & honestly

o Maintain eye contact, proper body language

o Discuss results of tests one at a time

o Acknowledge your short coming & emotional difficulty

o Encourage patient to express feelings

o Offer help to tell family, employer

Obtain enough information

o Symptoms of liver failure, complications

o Past Medical History: e.g. “jaundice, contact, blood transfusion” o Social history: e.g. “smoker, married & how many children, what occupation?”

Exploration of patient Ideas, Concern & Expectations

Examples:

o How did I get it?

o Will this affect my family?

o What about my work?

o Will I die from if?

o What should I eat?

Appropriate counseling

o Assess patient understanding

o What does chronic HB means? (e.g. drawing of virus)

o Mode of transmission: Blood, sexually, body secretions

o Symptoms: asymptomatic or malaiseand abdominal discomfort

o Prognosis: chronic active hepatitis, cirrhosis, hepatocellular carcinoma or other viral

hepatitis

o Treatment :Interferon, cytotoxic medications or surgery (indication & response)

Family protection:

o Active & passive immunization

o Sexual intercourse & contraception

o Use of tooth brush, razor

Respond to patient questions

Health education materials, where to get more information

Appropriate follow up:

o Need to refer to specialist for US, liver biopsy, treatment

o Shared follow up with specialist, ensure continuity of care

o Regular monitoring by LFT, liver enzymes, α -fetoprotein


63

Guide to Post exposure Immunoprophylaxis for Hepatitis:

Accidental Vaccination + HBIG

Percutaneous or permucosal

Household contact Vaccination

Chronic carrier

Household contact Vaccination + HBIG

Acute case with identifiable

Blood exposure

Prenatal Vaccination + HBIG

Sexual acute infection Vaccination + HBIG

Sexual, chronic carrier Vaccination


64

(11) Counseling Patient With Insomnia N. Dashash & F. Rayes


Explain the nature of insomnia and reassure.

Identify the cause of insomnia and discuss the management options:

1. Chronic sleep problem: advice patient on sleep hygiene and avoid prescription

2. Sleep difficulties as part of physical or psychological illness: treat the cause (e.g. if

the patient has depression explain the specific treatment)

3. Acute or situational sleep difficulties: consider hypnotic prescription and advice on

sleep hygiene

o Prescription of hypnotic Drugs:

- Discuss side effects of drugs.

- Used for a short period of time.

- Should be used only if patient fails to respond to the initial measures.

Sleep Hygiene:

o Establish regular bedtime and regular waking time.

o Avoid all naps.

o Regular exercise but not at night.

o Use bed only when ready to sleep and leave bed if sleep is not forthcoming.

o Avoid all of caffinated drinks/food, stimulants, cigarettes and alcohol.

Healthy environment in the bedroom:

o Dark or weak lighting

o Quiet no TV

o No books

o Comfortable bed ... etc.

Health promotion according to age.

Keep a sleep diary for next visit.

Set up a near appointment.

The help of a psychiatrist can be obtained.

Ask if he has any question?

Offer the patient an educational leaflet.

Offer the patient a referral to a health educator, psychologist and/or psychiatrist if

he wishes.

Thank him for cooperation.

Causes of Insomnia Psychiatric disorder 50 %

Drug & Alcohol abuse 10-15 %

Medical /Surgical problem 10 %

Primary sleep disorder 10-20 %


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General Therapeutic Recommendations in Insomnia Depression Sedative Antidepressant

+ BZDs for the first 10-14 days, then PRN.

Anxiety Long acting BZDs 2ws, if not responding --> Refere.

Pain Treat underlying medical problem aggressively

+ Short course BZDs to establish a normal sleep.

Personality Disoder : Refere

Facts About Insomnia and Benzodiazepine Medications (BZDs) Adiction to BZDs develop after 1-3 months of regular use.

Only 30-45% experienced true withdrawal symptoms.

BZDs are very effective drugs when use appropriatly for short term and low dosage.

No value in long term (>4ws) prescribing of BZDs.

Antidepresant/ Psychotherapyand/or behavioural therapy are more effective than long term

BZDs.

Patient on long term BZDs and review the diagnosis.

Elderly patient happy with small dose BZDs and don’t be dogmatic with him.

Prescribing Of BZDs

Short acting Insomnia Lorazepam 1-2 mg.

Oxazepam 15-30 mg.

Long acting Day time anxity Diazepam 5-10 mg.


66

(12) Family Planning Counseling

F. Rayes


Explore patient’s ideas concern and expectation about family planning

Explore factors that influence the choice of method:

o Age and parity

o Frequency of intercourse

o Lactation

o Degree of desirable effectiveness

o Any contraindication to contraception

o Personal preferences & acceptability

o Concern and previous experience

o Risk of STD or PID

o Compliance

o Marital status

o Cost and ethical consideration

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.

With the patient chose contraceptive method suggested by her type:

Patient factors Contraceptive method

Very young, newly married

Smoker >35 years of age

Diabetic

Lactating

PID

Hypertensive

Toxic shock syndrome

Permanent contraception

Long-term reversible method

HIV risk

- Oral contraceptive (mid-strength)

- Condom, Depo-Provera, diaphragm

- Barrier form or Norplant

- Norplant, Depo-Provera

- Barrier form or oral contraceptive

- Barrier form,or IUD if multiparous

- Condom, oral contraceptive or Norplant

- Vasectomy or tubal ligation

- Norplant or IUD (in monogamous women), Oral

contraceptive

- Condom plus any other form of contraception

Discuss and arrange for follow up according to the following schedule:

Contraceptive method Follow-up

Combined oral contraceptive,

Progestin-only pill

Sponge or Diaphragm

IUD

Progestasert

Norplant

Depo-Provera

Cervical cap

Three months after initiation, then yearly

Three months after initiation; call physician

when discontinuing breast feeding, then yearly

Yearly ; some advocate three-week follow-up visit after

first fitting

Yearly for removal and reinsertion

Yearly for pap smear

Nurse visit every three months; physician visit yearly

Three-weak follow-up visit to check fitting, then Yearly

for pap smear

Three months for Pap smear, then yearly


67

Topics for discussion if combined oral contraception is chosen:

o For the first time start at day one of the period

o Then every month stop the pill for 7 days (to allow menstruation)

o If you miss a pill:

- If you missed only one day, take the missed pill and you don’t need to do any extra contraception precaution

- If you missed more than one pill, you don’t need to take the missed pill, but

extra contraception precaution is needed for at least one week

o Report to your doctor if you have any warning signs:

E.g.: Severs headache, visual disturbance, severe abdominal or chest pain, leg

pain or leg swelling

o Mention that you are on the pill if you need any medication or hospitalization

(13) Emergency Pill Education N. Dashash


Ask about her age and LMP.

When was her unprotected intercourse?

Explain that emergency contraception is riot effective if

o >72 hours for combined oral contraceptive pill

o >5 days for IUCD

The pill:

o Better to give an anti-emetic with the pill

o How? A high estrogen (50 µg) compind pill e.g. ovran

(2 tablets at once, then 2 tablets after 12 hours).

o OR: (50 µg estrogen alone BID for 5 days)

N.B. If vomiting started within 2-3 hours, repeat dose with an antiemetic

Exclude absolute contraindications:

o Thromboembolic disorders e.g. DVT, Pulmonary embolism, CVA

o Active liver disease markedly impaired liver function.

o Known or suspected estrogen dependant neoplasm (e.g. breast or endometrial cancer)

o Undiagnosed vaginal bleeding.

Ask about relative contraindications

o Migraine, epilepsy

o DM, HTN, familial hyperlipidemia

o Smoking

IUCD: (a more effective alternative)

Exclude contraindications:

o Active PID, undiagnosed vaginal bleeding, previous ectopic pregnancy, Valvular heart

disease

Her next period may be early or late.

Should use a barrier method until the next period

She should attend to the physician if she complains of any of the following:

o Lower abdominal pain

o Heavy vaginal bleeding

o Changes in period (heavy, little or missed)

o If she is concerned or needs any clarification or help

The failure rate ranges from 2 to 5 %.

She needs to have an arrangement for future contraception.

Ask if she has any questions.


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(14) Travelers Advice F. Rayes & M. Alatta


Information about travel

o When & for how long?

o Where & which area in the country?

o Why is he traveling?

History (medical illnesses, drug history, allergic history, Vaccination history)

Medico-legal certificates

Invite patient to present his complain and/or ask questions

Take feedback frequently and insure that you are answering all his queries

Important information for travelers:

Information about motion sickness:

o No eating fried or fatty food before departure.

o Set between the wings.

o No reading, close your eye, no tight clothes.

o Antihistamine e.g. (Phenergan) 30-60 min before departure.

Endemic diseases in the area the patient is traveling to

E.g. patient traveling to Africa he need to have some information about the following

diseases: Typhoid, Yellow fever, Hepatitis, Malaria, AIDS

Patient needs to know if there is any Specific Prophylaxis

General measures against GIT infections:

o Unless the traveler is sure of the purity of the local water, he should not drink it without

boiling first. This also applies to water for ice cubes and for cleaning teeth.

o Unpasteurised milk should be boiled before use, and care should be taken with local

cheeses and ice cream, which are often made from unpasteurised milk.

o Advise the traveler to eat only cooked vegetables and avoid salads.

o To peel all fruit, including tomatoes.

General measures against mosquito bites:

o To take measures to avoid mosquito bites, especially after sunset.

o If you are out at night wear long-sleeved clothing and long trousers.

o If sleeping in an unscreened room, or out of doors, a mosquito net (which may be

impregnated with insecticide

o Insect repellents that contain deet work the best.

o Wear permethrin-coated clothing and use bed nets while you sleep.)

o Net is a sensible precaution and portable. Lightweight nets are available.

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.

How to find a doctor In under developed countries university hospital is reasonably the best choice to consult if

the traveler develop any health problem

The Traveler’s Medical Kit Advice patient to take the essential first aid treatment and the prophylactic drugs, e.g.

Chloroquine, Bactrim, Paracetamol, Oral rehydration, Insulin & Syringe, Phenergan.


69

Traveler’s 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

Specific prophylaxis for travelers:

Typhoid: First dose Now 28 day later booster dose.

Yellow fever: 5 days later from specialist center

Hepatitis A vaccine: May be needed + Precaution.

Malaria: Chloroquine one tab. once a week. 2 ws prior to entering, 4-6 ws after

leaving.

AIDS & Other STD: Avoidance of risky behavior completely.


70

5.

Approach to Simulated Clinic Exam F. Rayes

The main objective of the simulated clinic is to evaluate the candidate’s 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 patient’s 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

Doctor-Centered

Consultation

Use of patient’s Knowledge and experience

Use of doctor’s

Special knowledge and experience

Silence Clarification Analyzing Gathering

Information Facilitation Interpretation Probing

Skills used by physician in patient-centered against

Doctor-centered consultation

Scott and Davis (1979) The Expanded Model of Consultation:

Management of Presenting Problem

Management of Continuous Problem

Modification of Help Seeking Behavior

Opportunistic health Promotion

Pendleton 7 Tasks (1982):

1. To define the real reasons for patient attendance;

2. To consider other problems;

3. To choose appropriate action for each problem with the patient;

4. To achieve a share understanding;

5. To involve patient in the management;

6. To use time and resources effectively;

7. To establish and maintain doctor-patient relationship

Neighbour (1992), The Inner Consultation:

Connecting (establishing relationship)

Summarizing (physical, social & psychological diagnosis)

Handing – over (management of presenting problem)

Safety – netting (Anticipatory care)


71

The main skills assessed during simulated clinic exam

Interview and history taking:

1. Introduces self to patients

2. Encourage patients to elaborate presenting problems fully

3. Identifies patients’ reasons for consultation

4. Listens attentively, Puts patients at ease

5. Recognizes patients’ verbal and non-verbal cues

6. Uses silence appropriately

7. Phrases questions simply and clearly

8. Considers physical, social and psychological factors as appropriate

9. Seeks clarification of words used by patients as appropriate

10. Elicits relevant and specific information from patients and/or their

records to help distinguish between working diagnoses

11. Exhibits well-organized approach to information gathering

Behavior and relationship with patients:

1. Conveys sensitivity to the needs of patients

2. Demonstrates an awareness that the patient’s attitude to the doctor (and vice versa) affects management and achievement of levels of cooperation and compliance

3. Maintains friendly but professional relationship with patients

with due regard to the ethics of medical practice

4. Considers ethical issues in his practice, particularly patient confidentiality, and is

able to offer reasons for his action

Physical Examination:

1. Uses the instruments commonly used in general practice in selective, competent and

sensitively manner

2. Performs examination and elicits physical signs correctly and sensitively

Patient Management:

1. Formulates management plans appropriate to findings and circumstances in

collaboration with patients

2. Checks patients’ level of understanding

3. Makes discriminating use of investigations, referral and drug therapy

4. Arranges appropriate follow up

5. Demonstrates understanding of the importance of reassurance and

explanation and uses clear and understandable language

6. Is prepared to use time appropriately

7. Attempts to modify help-seeking behavior of patients as appropriate

Problem Solving:

1. Correctly interprets and applies information obtained from patient records, history,

physical examination and investigations

2. Generates appropriate working diagnoses or identifies problem(s) depending on

circumstances

3. Is capable of recognizing limits of personal competence

4. Seeks relevant and discriminating physical signs to help confirm or refute working

diagnoses

5. Is capable of applying knowledge of basic, behavioral and clinical sciences to the

identification, management and solution of patients’ problems

Anticipatory care:

1. Acts on appropriate opportunities for health promotion and disease prevention

2. Provides sufficient explanation to patients for preventive initiatives taken

3. Sensitively attempts to enlist the cooperation of patients to promote change to

healthier lifestyles


72

Possible difficulties and pitfalls in simulated clinic exam:

1) Common difficulties in communications:

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:

Use of open-ended question at the start only

Talking continuously and not listening

Forgetting to explore patient’s health beliefs

Being very anxious and couldn’t express any empathy

Being reactive and getting angry

Losing control.

2) Common difficulties in information gathering:

Atypical presentation of common disease: E.g. MI presenting as epigastric pain.

Indirect presentation: E.g. depressed patient present with backache.

Many problems at a time E.g. DM + infections + social problems, and difficulty in

prioritization

Multiple somatic complain E.g. somatization, masked depression or anxiety

Possible serious diagnosis: E.g. elderly patient with palpitation.

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

3) Common difficulties in management:

Controversial management issue

Complicated social problem

Complicated diagnosis

Uncertain diagnosis

Risk of complication e.g. ethical dilemma, marital problem, demented patient with

no family support,?? MI. !?? Ca.

Unhealthy life style, e.g. smoker or obese patient needing health education

Risk of complication, e.g. severely depressed patient at risk of suicide

Common Pitfalls:

Forgetting to discuss different management options

Forgetting to make use of other primary health care team members

Forgetting your limitation and to make good use of referral system

Helpful strategies in dealing with difficulties in simulated clinic exam:

1) Read the preliminary information carefully:

Concentrate on the key words, e.g.:

o Infrequent attender or

o DM+ high fasting blood sugar (FBS) or

o Medical student, Follow-up visit, Significant past history…etc

Speculate possible objectives from the given scenario, and at the same time be open

minded and ready to conceder patient’s objectives

2) Have systematic approach to your objectives:

Full focused history

Listen and watch carefully for any verbal or nonverbal cues

Use hypothetical deductive reasoning methods to test your hypotheses

Think loudly to give the examiner the chance to understand how you think, and

give you the desirable evaluation mark

Concentrate on your provisional hypothesis by asking relevant and specific

questions to reach clear and positive diagnosis

Remember: Psychological diagnosis by positive criteria not by exclusion

Eliminate possible deferential hypotheses by asking relevant and specific questions

Use open-ended questions when ever possible

Complete your exploration by asking specific questions

Assess the degree or risk (look for red flags) e.g.:

o Suicidal risk factors in depressed patient or

o Risk factors in hypertensive patient

Explore continuous problems e.g.:

o Chronic illness

o Continuous medications

o Smoking, obesity…etc.


74

3) Remember the basic skills to obtain information and try to avoid habits which

block communication:

Basic skills to obtain information Habits which block communication

General Attitude:

Respect

Empathy.

Touch (if appropriate)

Eye contact.

Body language

Social smile.

Encouraging.

General Attitude:

Patronizing

Tenseness and nervousness

Coldness and unfriendliness

Defensiveness

Appearance of too relax or casual

Appear preoccupied

Questioning:

Open-ended questions

Facilitating verbal & non verbal

Reflecting questions.

Questioning:

Direct questions,

Why question,

Suggestive question,

Yes or No questions.

Many questions at a time.

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

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) Improve your explanation skills:

Ask the patient about what he already knows

Invite patient to ask questions

Continuously ask for feedback to make sure that you and the patient have a shared

understanding of the problem

Use simple language

Use varities of methods, e.g. demonstration or written materials


75

5) Improve your negotiation skills:

Establish and maintain adult to adult relationship

Show good listening

Show empathy and care

Do logical analysis of the problem

Offer alternative solutions

Deviate the conversation to other issues; examples:

o Take more history

o Discuss psychosocial component of the problem

o Perform physical examination

o Give health education

o Discuss health promotion issues

Be flexible and respect of patient autonomy

If patient is insisting make a contract of limited agreement

6) Remember the basic skills for reassurance:

Adult to adult relationship (Respect and honesty)

Appropriate exploration of patient’s problem: o Physical, social and psychological component of the problem

o Exploration of patient health beliefs about the problem

Examination:

o Appropriate o May be over doing some extra examination to show how much you care.

Clear and objective explanation:

o Summarizing the problem

o Naming the diagnosis

o Prevalence of the problem (how common is this problem)

o Natural history (how rare are the complications)

o Management options (how they are safe and acceptable)

o Prognosis (how benign, treatable or at least controllable)

Taking feed back:

o The patient understands the explanation

o The patient accepts the explanation

Assurance of accessibility


76

7) Remember the comprehensive and holistic style of management in family

medicine:

Shared understanding

Comprehensive diagnosis (Physical, social & psychological)

Reassurance and explanation may be the only treatment

Appropriate use of nonpharmachological treatment

Appropriate prescribing: right drug and right dosage & right frequency

Explanation of effects and precautions of the medication

Modification of help seeking behavior

Awareness of limit of personal competence

Appropriate use of resources

Health promotion

Disease prevention

Appropriate follow-up arrangement

8) How to break bad news

(Dr. Hana Al Hajjar)

The setting:

Tell the patient when you are certain

No interruption

Comfortable physical setting

Family support

The patient:

Right to know

How much patient knows?

How much patient wants to know?

Encourage feelings expression

Listen to patient concerns

Beliefs & social background

The telling:

Warning shot, simple & honest

Eye contact, body language

Sympathy, encouragement, reassurance

Explain (diagnosis, prevalence, treatment and prognosis)

Reinforce & clarify frequently

Acknowledge your difficulties in breaking the news

Follow up:

See next day

Offer help to tell family & employers

Support groups

Documentation


77

9) Strategies for dealing with some difficult patients:

Rambling, circumstantial patient: directed interview; closed questions;

permission at outset for frequent interruptions; frequent summarizations.

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.

Violent, berserk patient: prevention: re-channel anger before it becomes

explosive; call for help, plenty of manpower – police if necessary; a show of force can be

reassuring to a person terrified of his own lack of control; not too close – do not violate

patient’s territory; interviewer closer to exit than patient; calm, comforting voice; sedative chemicals, seclusion room, restraints may be needed.

Malingerer: confrontation usually ineffective; diagnosis by inconsistencies in

history and examination.

Seductive patient: deal with issue underlying seductiveness; what does patient

really want; be aware; doctor’s fantasy or needs for omnipotence. Mute non-comatose patient: non-verbal communication is necessary (hold

hands); do not talk about mute patient in his or her presence; patient sometimes can

respond by nods or eyelid movements to closed questions.

Psychotic or thought disordered patient: closed questions; directed interview;

simple short sentences; concrete rather than abstract questions; avoid colluding with

patients about delusions or hallucinations (neither deny nor agree, if possible).

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

10) Organization and time management in simulated clinic exam:

For organization and effective time management in simulated clinic exam, remember the

three stages of the consultation and the tasks you need to fulfill in each stage, and in each

consultation and according to the priorities distribute your time.

Take enough time in stage one (building good relationship), and do not forget to save

enough time for stage three (finishing the interview).

See the table below:

Stages of the consultation and your main tasks in each stage:

Your Main Tasks Stages

Building effective relationship with the patient

Stage I: Starting the interview

Prioritizing between patient’s problems Reaching a provisional diagnosis

Excluding the differential diagnoses

Stage II: Hypothesis formation

Identifying factors that affect management and

prognosis

Explaining management options

Closing the encounter

Stage III: Finishing the Interview

“During training identify your difficulties and work on them specifically,

and if possible ask your trainer to help you to over come your difficulties”

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………

………………………………………………………………………………………………


79

6.

Examples of Simulated Clinics F. Rayes, N. Dashash, H. Hajjar, M Alatta, A. Assaggaf & A. Al Harthy

The following are examples of common simulated patient’s 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 patient’s ideas, concerns and expectations, he also should be sensitive to any verbal or nonverbal cues and respond

to them appropriately and immediately.

(1) Approach to Patient with Chest Pain Dr. Fayza Rayes

Causes include musculoskeletal, gastrointestinal, neurological, functional, cardiac and

pulmonary.

The following items may need to be considered.




Look for recent precipitating event

History of pain: onset, duration and radiation of pain

Characteristics of pain

Aaaociated symptoms: e.g.

o Cough

o Breathlessness or sweating

o Gastrointestinal symptoms

o Palpitations or anxiety

Social and psychological context of the problem

Precipitating factors, e.g. fears or exertion

Relieving factors: rest, medications

Smoking habit

Examination:

Pulse, blood pressure

Cardiovascular system

Chest

Chest wall

Abdomen

Management:

Share diagnosis and share prognosis

Agree management: behavior, drugs or referral

Reassurance and follow-up arrangement if necessary


80

Management of acute MI Rapid history and physical examination IV access Administration of oxygen

Cardiac monitor: ECG Blood studies Aspirin, 1 tablet crushed & swallowed Morphine sulfate, 2-4mg IV every 15-20 min. Transfer to hospital.

Indication to Thrombolytic Therapy o Within 12 hrs. onset of chest pain lasting for at least 30 min.

o ECG changes of ST elevation at least 1 mm in two, Or more contiguous leads of

left bundle branch block.

Contraindications to thrombolytic therapy o A history of active GIT bleeding within 2 months.

o Uncontrolled hypertension.

o CVA having occured within the last 6 m.

o Recent history of serious injury within 1month.

o Non-compressible vascular puncture

See Data interpretation: ECG for more details


81

(2) Approach to Patient with Cough. A. Assagga , A. Al Harthy & F. Rayes

Causes include infection (URTI or pneumonia), inflammation (including smoking),

asthma, cardiac failure, chronic chest disease, foreign body, and malignancy.





Duration of complaint

Predisposing factors (night-time, exercise)

Clarification of the symptom:

o Is the cough tickle in the throat or from the chest, it’s onset and course (Continuous or intermittent, at daytime or at night).


o Wheezing,

o Chest pain

o Shortness of breath, or orthopnea

o Fever, night sweating, weight loss

o Heamoptysis.

Presence of sputum: From throat or chest, quantity, color, relation to position.

Past history of similar problem or T.B.

Family history of T.B. or bronchial asthma.

Continuous problems & at risk factors: bronchial asthma, DM or heart disease

Social history & occupation.

Allergy history

Drug history

Smoking habit

Therapies already tried

Social & psychological context of the problem

Examination:

Examination of respiratory system

Examination of cardiovascular system

Peak flow, before and after Beta agonist

(If the patient is a child exam his throat and ears)

Possible investigations:

Chest X-ray

Sputum culture

Specific investigations according to the differential hypotheses, e.g. TB skin test

Management:


Advise against smoking

Use of medication:

Cough suppressant or expectorants, antibiotics, brochodilators or steroids.

Agree referral if indicated

Arrange follow-up if indicated


82

Important diagnoses not to be missed in a childe presenting with cough:

Differential features of Epiglottitis, Croup & Bronchiolitis

Epiglottitis Croup Bronchiolitis

3 – 7 years

Sudden onset, fulminating

Dysphagia, drooling

Fever

Respiratory stridor

Muffled voice / cry

Minimal cough

Toxic appearance

H. influenza

Emergency protocol

Avoid exam the pharynx

Cefluroxime (150 mg/kg)

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

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


83

(3) Approach to Patient with Diarrhea F. Rayes

Causes include infection, food intolerance, inflammatory, obstruction, functional.





Explore patient’s ideas, believes, expectations and concerns about the diagnosis,

o E.g.: Worms or food poisoning

o Cholera or dysentery

o Cancer or HIV

o Request for investigations or drug treatment or admission to hospital.

Details of the complain:

o Duration of complaints

o Frequency and consistency of stool

o Associated blood and mucus.

o Associated symptoms: E.g. fever, vomiting, abdominal pain, weight loss, fatigue

nervousness.

o Recent events or foreign travel

o Dietary indiscretion

o Family contact, occupation

o Drug history e.g. laxative, antacid, endomethacin diuretics, theophylline or

colchicin.

Other affected family members

Occupation, e.g. food worker

Examination:

General impression

Signs of dehydration

Examine abdomen

Per rectum examination may be indicated, if serious diagnosis is suspected

Possible Investigations: Stool analysis

Culture faeces: if specific infection is suspected

Faecal occult bloods: if malignancy is suspected

Blood tests: for evaluation of general well being of the patient

Barium studies or endoscopy: for chronic diarrhea

Management:


Advise about diet and fluids

Use of medication:

o Electrolyte replacement (rehydration solution)

o Anti-diarrhea agents?!

o Antibiotics?!

Specific therapies

Referral if indicated

Follow-up arrangements if indicated

* See traveler advice for more details in management of diarrhea


84

(4) Approach to Patient with Anemia F. Rayes

Causes include nutritional, hemolytic, chronic GIT bleeding, or chronic diseases.





Look for possible complications of anemia:

o Dyspnoea, palpitation, heart failure, or fainting attack (in case of acute internal

bleeding)

Look for possible causes of anemia:

o Family history of anemia, e.g. thalassemia, G6PD or sickle cell anemia

o Drug (NSAIDs, Steroids)

o Blood per rectum / Black stool

o Dyspepsia (bleeding peptic ulcer)

o Hemoptasis, hematuria or menhorragia

o Regular blood donor

o Past history of chronic disease e.g. TB, Chronic UTI, RA, SLE or subacute

bacterial endocarditis

o Alcoholism

Explore patient ideas believes and expectation

Examination Pallor: (Conjunctive, Lips, Nails)

Nails changes, e.g. Koilonychia (chronic severe anemia)

Evidence of haemoragic talangectasia

If anemia is severe or acute, look for evidence of heart failure.

Abdominal examination:

o Epigastric tenderness

o Renal tenderness

o Mass (cancer)

o Rectal examination:

o Piles or melena

Management and Education:

According to the type and the etiology of the anemia

Explanation and reassurance

Step-care investigations in patient with anemia:

Confirmatory test CBC Findings Suspected anemia

Low serum iron

Low transferin saturation

Low ferritin

Microcytic hypochromic

anemia

Iron deficiency anemia

Low serum iron

Normal ferritin

Microcytic hypochromic

anemia

Anemia of chronic

disease

Normal serum iron

Haemoglobin electrophorisis

Micricytic or normocytic

Hypochromic anemia

Beta thalassemia

Serum B12 level

And/ or serum Folic acid

Macrocytic anemia B12 or Folate deficiency

* For more details see (Data Interpretation: Lab Tests)


85

(5) Approach to Patient with Headache H. Al Hajjar, M Alatta & F Rayes

Causes include tension headache, migraine, referred - pain (e.g. sinus, teeth, cervical

spine). Intracranial pressure (hypertension, tumor, meningitis), temporal arteritis.





Identify the characteristics of pain (Classical history of pain)

o Onset & time, duration, site of pain and nature of pain.

o Continues or intermittent.

o Course (severity &, frequency)

o Triggering or aggravating factors and reliving factors.

o General health and well-being

Ask specific questions: e.g.

o Prodrome, aura of migraine, e.g. visual or sensory aura,

o Respiratory tract infection in sinus pain…

Associated symptoms, e.g. neurological symptoms, fever, eye symptoms, nausea,

vomiting…

History of head trauma or history of lumbar puncture.

ENT problem, any dental or vision problem, e.g. acute viral infection, COPD

Drug history:

o For the headache.

o For other medical causes.

Effect of the headache on patient’s life. Psychosocial problems:

o New stressful events.

o Marital problems or problems at work.

Family history.

Exploration of any continues problems.

Exploration of patient’s concerns, worries, ideas and expectations. Examination:

Blood pressure

Local possible sources of pain:

E.g. sinuses, temporal arteries, teeth, cervical spine, ears

Neurological examination

Management and education


Discussion of self-help, e.g. relaxation

Use of medication:

o Analgesics, anti-migraine or anti-depressant

o Specific medication for primary cause

Agree referral if indicated: “Counselor or specialist”

Follow-up arrangements if indicated

Possible investigations: o Blood tests, e.g. erythrocyte sedimentation rate

o X-ray chest, cervical spine or CT scan


86

Factors in the development of chronic daily headache from episodic migraine

o Analgesic/ergotamine overuse

o Abnormal personality profile, including depressive trait

o Stress

o Traumatic life events

o Non-headache medications, including sex hormones

Alarm symptoms pointing to more serious disease headache

o Aura symptoms associate always with the same body side or with acute onset

without spread, or having either very brief (<5min) or unusually long (>60min)

duration

o Sudden change in migraine characteristics or a sudden substantial increase in attack

frequency

o Headache emerging after exercise (may indicate subarachnoid hemorrhage)

o Onset above age 50 (migraine and cluster headaches are not usually late onset)

o Aura without headache

o High fever

o Abdominal pain (could suggest acute ketoacidosis)

o Recurring neurological symptoms between headaches

o Abnormal neurological examination

o Increase intensity after 24 hours from onset.

o Change in cognition, level of consciousness or focal neurological findings.

o Neck rigidity.

o Abnormality in vital signs

Differential Diagnosis of headache

Tension Headache Migraine Subarchinoid Hge Cluster headache

- Young adult and

middle age

- Recurrent

- Almost daily

- No significant

associated

symptoms

- Triger factors

-Normal

examination

- Common in

young adult

- More in female

- Recurrent

- Once a week

- Lasting from 8

to 12 hours

- Left side of the

head.

- Associated with

malaise, nausea,

vomiting and

photophobia.

- Normal

examination

- Severe headache

(the worst headache

of patient’s life)

- Associated with

exertion & vomiting

- ECG: similar to

IHD

- CT scan then LP

presence of blood

- 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

(6) Approach to Patient with Acne N. Dashash





Identify the present complaint “Acne”

When has it started? Why now (E.g. preparation for social event)?

Is there any aggravating factor (E.g. stress, exams)

Previous treatments:

What sort of treatment? How long was each one used? Compliance?

Patient ideas: what he/she knows about “acne”

Patient concerns and fears:

(E.g. losing friends, scars, discolored skin, not getting married.)

Expectations: (E.g. referral to a dermatologist)

Effect of Acne on the patient (E.g. Relationship with friends)

Exploration of continuous problems:

DM, asthma, smoking …

Examination:

Inspection of the face, shoulders, back, upper arms and chest looking for acne

Management:

Shared understanding of the problem:

Summary of what the doctor understood

Shared management & health education:

o Acne is a common problem, up to 80% of people had acne sometime in their life

o What is acne? Enlargement of the sebaceous gland (oil producing gland in the

skin), with blocking of its outlet and over growth of bacteria.

o It has no relation with being clean or not

o Chronic problem, needs patience in and tolerating the treatments

o It increases at times of stress such as exams, and is related to hormonal changes

(seen in women)

o Black heads and white heads are not dirt

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.

Candidate needs to show skills in dealing with demanding behavior:

o Empathy and caring attitude

o Logical negotiation of advantages and disadvantages of patient’s demand (referral or medications)

o Nonjudgmental attitude

o Flexibility and respect of patient autonomy


88

o

(7) Approach to Patient with Urinary Tract Infection F. Rayes





Explore the nature of symptoms:

o dysuria

o frequency and pattern

o Haematuria

o Pain

o Fever

General well-being

Recurrent symptoms?

Symptoms in sexual organs or pain related to sexual activity

Examination:

Palpate kidneys and lower abdomen

Vaginal examination may be indicated

Investigations:

Urine dipstick nitrite

Urine bacteriology (MSU)

Vaginal swabs

Renal x-ray ultrasound

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

Discuss nature and prognosis of complaint

Discuss management plan

Check self-care and lifestyle

o Adequate fluid intake

o Voiding after intercourse

Follow-up arrangements if necessary

Presentation of UTI in children:

Failure to thrive, fever, enuresis, frequency and dysuria

Management and follow -up:

MSU 2-4 days after starting antibiotic, if positive, patient need urgent referral for

possible obstruction

MSU 2 weeks after antibiotic, if positive repeat the course of antibiotic

MSU 3 months late if positive, patient need maintenance of antibiotic

All proves UTI in children under 5 should be referred for further investigations.

For more details see (Data Interpretation: Lab Tests)


89

(8) Approach to Patient with Sore Throat F. Rayes

The following items need to be considered in managing any episode:




Explore the nature of the complaint:

o Duration

o Associated symptoms: fever, malaise, rash

o Prior medication

o Smoking habit

o Immunocompromised?

o Relevant past history or family history of rheumatic fever

Explore the patient’s concerns, worries, ideas and expectations. Look for possible hidden agenda

Explore continues problems: e.g.

o DM, asthma or malnutrition vaccination coverage …

Examination:

Inspect neck and throat

Palpate cervical glands

Other examinations:

o E.g. rash and spleen (Infectious mononucleosis)

Investigations:

Throat swab rarely indicated

Infectious mononucleosis blood test if it is highly suspected

Complete blood count may be indicated


Use of:

o Analgesics: use enough dose and right frequency

o Antibiotics if bacterial infection is highly suspected

o Encourage symptomatic home remedies

Discuss disease and its cause

Discuss patient’s concerns (sick leave, wary about possibility of rheumatic fever) Discuss management plan

Follow-up arrangements if necessary

Usually simulated patients with minor illness appear in the exam for testing certain skills,

E.g.: Patient demanding referral for tonsillectomy

Patient with mild pharengitis demanding antibiotic

Simulated patient is a smoker and need counseling

Simulated patient has a hidden agenda, E.g. marital problem or parent may be using

the child as presenting complain

Malingering patient requesting sick leave


90

Possible serious differential diagnosis:

Possible Diagnosis Comments

o Epiglottitis

o Meningitis

o Quinsy

o Streptococcal sepsis.

o Rheumatic fever

o Palatal cellulitis

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.

Facts about use of antibiotic in tonsillitis:

o 20-40% of sore throat caused by GABHS

o Incidence of rheumatic fever has no correlation with the use of antibiotic

o Rheumatic fever runs in family, more in low social class

o 50% of +ve culture for GABHS have no serological evidence of infection (Carrier)

o Treatment shorten the duration of illness by 24 hr & prevent supportive

complications.

o Antibiotic does not prevent development of glomerulonephritis

Indications for antibiotics

o GABHS more likely

o Peritonsillar abscess

o Sinusitis

o Prophylaxis in case of associated chronic diseases e.g.

o DM, Asthma or cystic fibrosis.

Indications for tonsillectomy and admission

Tonsillectomy:

o Grossly enlarged tonsils with sleep apnoea.

o History of peritonsillar abscess.

o Frequent tonsillitis with otitis media.

Admission:

o Airway obstruction


91

(9) Approach to Patient with Acute Otitis media

F. Rayes

The following items may be considered in managing any episode:




Explore the nature of complaint:

o Pain , discharge from ear, and/or fever

Recent upper respiratory tract infection

Frequnecy of episodes

Hearing between episodes

At risk factors:

o Age or Down’s syndrome,

o Immunocopromised

Explore the patient’s concerns, worries, ideas and expectations. Explor continues problems: e.g.

o DM, asthma or malnutrition, vaccination coverage …

Examination:

Examine both tympanic membranes

Examine nose and throat for congestion

Assess level of distress

Investigation:

Bacteriology swab if discharge

Management and education:

Prescribe antibiotic and pain killer

Discuss disease and its course

Discuss immediate concerns

Discuss current management

Follow-up arrangements made

Advise lifestyle and self-care: water and swimming

Management of Acute Otitis Media

o Amoxycillin 5-14 days

Review in 48 hours. if symptomatic :

o Insure compliance

o Exclude complications

o Change antibiotic.

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

Treat each episode with antibiotics

Use long term low dose antibiotic prophylaxis !

Insert ventilating tubes (grommets) !

Perform adenoidectomy !


92

(10 )Approach to Patient with Dyspepsia F. Rayes

Dyspepsia is a vague term; patient may has upper abdominal pain, heartburn, anorexia,

nausea, vomiting, flatulence and/or dysphagia. It includes a wide spectrum of differential

diagnosis, starting from functional disorders to malignant disorders

History:

Establish doctor-patient relationship



Explore the nature history of the problem:

o Onset of dyspepsia;

o Chronic: most probably benign etiology

o Site of pain and radiate

o Frequency: cyclic (reflux or ulcer), continuous (dismotility)

o Severity and nature of pain: dull ache, colicky or staping

o Timing: worse at night or hungry (PU)

o After heavy meal or fatty meal: dysmotility or biliary colic.

o Continuous: could be malignancy

o Relieving factors: antacid, rest, strong analgesia, eating

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

Drugs history: aspirin, steroids, NSAID, antacid or tagamet.

Exploration of patient ideas, concerns, expectations and believes

Examination:

o Abdominal examination: may be mild tenderness


Work-up strategy based on risk stratification:

o Patient judged to be low risk: start empirical treatment

o Patient judged to be high risk: refer the patient for investigation

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


93

Advice in peptic ulcers:

o Stop smoking

o Avoid drugs like NSAIDs (explain)

o Cola, coffee & tea with moderation and avoid alcohol

o Milk & diary product with moderation

o Inform patient about warning sign in PU e.g. black stools

o Insure patient’s acceptance & understanding of your advice

o Explain others management options e.g.

o (Medications, dosage, frequency, side effect and any relevant precautions).

o Reassurance: It is common disease and treatable

o Availability of the doctor (you) for any problem or any questions any time.


Drug treatment in patient with peptic ulcer

H2 - antagonist e.g. Cimetidin 800 mg at night, 400 mg BD.

Or Proton Pump Inhibitors

e.g. Omeprazole 200 mg OD

Or Sucralfate 1 g before each meal and at night

Antacid 30 - 45 mmol QSD after meals.

Management of dysmotility

8 weeks course lead to healing of 95% peptic ulcer Drug treatment in patient with dysmotility:

o Metoclopramete: Short term Or Cisapride

o Antiulcer treatment might be tried but for a limited time and not to continue if

symptom fail to resolve Drug treatment in gastro- esophageal reflux disorder

o Mild disease:

Antacid after meal & at bedtime

H2 - antagonist e.g. Cimetidine 400 mg QID

Or Ramtidine 300 mg BD (3 months)

o Resistant cases:

Omeprazol 20-40 mg OD / 8 weeks

Maintenance treatment H2 - antagonist

o In case of failure of medical treatment, refer patient for surgery

Indication for referral & investigations:

o If diagnosis is in doubt

o If malignancy need to be excluded, e.g. patient has weight loss, dysphagia, vomiting

o Patient age over 45 years

o The patient’s symptoms change, possibly indicating a new pathology or malignancy.

o Failure of empirical treatment


94

(11) Approach to Patient with Irritable Bowel Syndrome

F. Rayes

History:

Establish doctor-patient relationship



Explore the nature history of the problem

o Abdominal distention

o Pain eased after bowel movement

o Altered stool frequency, alter stool form and alter stool passage

o Urgency and feeling incomplete evacuation

o Passage of mucus

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

Explore the patient’s concerns, worries, ideas and expectations. Explore any continues problems: e.g. psychosocial problem

Examination and Investigation:

o Abdomen and per rectum examination

o Sigmoidscopy may be needed

Management:

o Develop effective Pt-Dr Relationship

o Acknowledgment of pain and treat with empathy

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

Don’t overreact & set reasonable treatment goal Negotiate treatment & know your limitation

Education and counseling:

o Explain the diagnosis:

o The intestine squeeze food too hard or not hard enough to cause food to move too

fast or too slowly.

o Advice patient to increase high-fober foods like vegetables and fruits, whole grain

braed and cereals

o Drink plenty of water

o If gas is a problem to avoid beans, cabbage and some fruits

o Avoid food that increase the symptom, if milk and other dairy product bothers, the

patient may have lactose intolerance

o Stress management

Follow up arrangement


95

Differential Diagnosis of IBS

With Diarrhea And/or Constipation:

o Colorectal Cancer

o Polyps

o Inflammatory bowel disease

o Chronic intestinal infection(e.g.

giardiasis)

o Coeliac disease

With Upper Abdominal Pain:

o PU

o Cholelithiasis

o Chronic pancriatitis

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 of Colorectal Cancer

It is the second most common cancer in both males and femals

Risk factors :

o Familial adenomatous polyposis

o IBD > 20 Years

o Family history of colorectal cancer

Risk of colorectal cancer with an affected first -degree relative :

o One relative: risk 1 in 17

o Two relatives: risk 1 in 6

o Three relatives: risk 1 in 2


96

7.

Data Interpretation: Lab Tests A. Assaggaf & N. Dashash

Laboratory Findings in Selected Anemias

Thalasemias

Laboratory

Finding

Iron

deficiency

Folate deficiency

anemia

GRPD Sickle cell trait Alpa Beta

Hemoglobin

Hematlcrit

Mean

corpuscular

volume

Mean

corpuscular

Hemoglobin

concentration

Transferrin

saturation

Serum iron

Ferritin

Total iron

binding

capacity

Serum folate

Serum B12

Sickledx

Hemoglobin

A2

Perihpheral

smear

Decreased

Decreased

Decreased

Decreased

Decreases

Decreases

Decreases

Increased

Normal

Normal

_

Normal or

decreased

Microcytosis,

hypochromia

Normal or

slightly decreased

Normal or

slightly decreased

Increased

Normal

Normal

Normal

Normal

Normal

Decreased

Normal

_

Normal

Macrocytosi,

Neutropenia,

thrombocytopenia

Decreased

Decreased

Norma (?)

Norma (?)

Normal

Normal

Normal

Normal

Normal

Normal

_

Normal

Normal

Normal or

slightly decrease

Normal or

slightly decrease

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Positive

Normal

Normal

Normal or

decreased

Normal or

decreased

Normal or

decreased

Normal or

decreased

Normal

Normal

Normal

Normal

Normal or

decreased

Normal

_

Normal

Microcytosi,

Neutropenia,

poikilocyosis

Decreased

Decreased

Slightly

decreased

Slightly

decreased

Normal

Normal

Normal

Normal

Normal

Normal

_

Increase

Microcytosi,

Neutropenia

Target cells


97

History and Physical Examination Findings in Macrocytosis Anemia:

History:

Medications

Alchol use

Nutrition

o Strict vegetarianism (B12

deficiency)

o Predominantly carbohydrate diet

(folate deficiency)

o Advanced age

o Poor dentition

o Financial trouble

Neurologic symptoms

o Gait disturbance

o Parestjesoa

o Loss of taste

o Tongue paresthesia

Hepatic symptoms o Pruritus

o Dark urine

Occupational

o Radiation exposure

o Chemical exposure

Hypothyroid symptoms o Cold intolerance

o Fatigue

o Change in voice

o Constipation

o Change in hair

Surgery

o Total or partial gastrectomy

Physical examination

Signs of liver disease

o Jaundice

o Spider angiomas

o Ascites

o Hepatosplenomegaly

Neurologic signs

o Ataxia

o Loss of vibratory sense

o Loss of position sense

o Weakness

Other

o Glossitis

o Vitiligo

Common Causes of Macrocytosis

Cause Percentage of cases *

o Alcohol abuse

o B12 or folate deficiency

o Chemotherapy or drugs

o Hemolysis or bleeding

o Liver disease

o Primary bone marrow disorders

o Hypothyroidism

o Others

36

21

11

7

6

5

5

12

* Percentages total more than 100 percent because of rounding

Reference: American Family Physician CD


98

Causes of Vitamin B12 Deficiency

Malabsorption:

o Inadequate intrinsic factor

o Pernicious anemia (gastric atrophy, lack of intrinsic factor secretion)

o Gastrectomy

o Gastric bypass surgery

o Ileal disorders (sprue, regional enteritis, surgery, neoplasm)

o Competition for B12 (fish tapeworm, blind loop syndrome)

o Drugs (cochicine,neomycin)

Inadequate intake:

o Strict vegetarianism

Other rare causes:

o Congenital absence or dysfunction of intrinsic factor

o Transcobalamin II deficiency

Causes of Folate Deficiency:

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:

o Hemolytic anemia

o Pregnancy

o Exfoliative dermatitis

o Infancy and growth

Loss:

o Dialysis

Chemical interference:

o Methotrexate


99

Criteria for Diagnosis of Diabetes and ImpairedGlucose Hmoeostasis

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

Impaired glucose homeostasis:

o Impaired fasting glucose = FPG from 110 to < 126 mg per dL (6.1 to 7.86 to < 11.1

mmol/l)

Normal glucose homeostasis:

o FPG < 110 mg per dL (6.1mmol/l)

o 2 hr PPG < 140 mg per dL (7.75 mmol/)

FPG = fasting plasma glucose; 2hrPPG = two hour postprandial glucose

Guidelines call for symptoms of diabetes mellitus plus positive findings from any two of the three

tests on different days; symptoms include polyuria, polydipsia, and unexplained weight loss; casual

is defined as any time of day without regard to time since last meal.

Recommendations for Diabetes Screening of Asymptomatic Persons:

o Timing of first test and repeat tests

o Test at age 45; repeat every three years of age or older

o Test before age of 45; repeat more frequently then every three years if patient has

one or more of the following risk factors:

o Obesity: more than or equal 20% of desirable body weight or BMI more than or

equal 27 kg per m²

o First-degree relative with diabetes mellitus

o Member of high-risk group (Black, Hispanic, Asian)

o History of gestational diabetes or delivering a baby weighing more than 4.032kg

(9lb)

o Hypertensive (BP > or = 140/90)

o HDL cholesterol level < or = 35 mg per dl (0.90 mmol/l) and/or triglyceride level >

or = 250 mg per dl (2.83 mmol/l)

o History of impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) on

prior testing


100

Liver Function Tests

Physical & Laboratory Findings in Selected Jaundice Syndrome

Jaundice

Syndrome

Hepato-

megaly

Spleno-

megaly

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

5-20 times both

type

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

Evaluation of Patient with Jaundice Syndrome:

Primary Conjugated

Hyperbilirubinemia

Liver enzyme evaluation

Elevated Normal

Clinical evaluation

Suggestive of Suggestive of intra- Depending on

Hypatocellular disorder or extrahepatic biliary clinical presentation

(aminotransferase obstruction consider :

Elevation dominant) (alkaline phosphatase -- Recent sepsis or

elevation dominant; -- systemic infection

history of symptomatic -- Rotor syndrome

cholelithiasis) --Dubin-Johnson

syndrome

Ultrasonograph

Or

Computed tomography

Serological

Evaluation

Consider:

Infection

-- (Especially viral

hepatitis)

-- Drug-induced

Hepatitis


102

Hepatitis B makers: Summary of Interpretation:

HBsAg HBeAg HBsAb HBsAb HBeAb Interpretation

_ _ _ _ _ Never infected or early incubation.

+

_

_ _ _ Early acute hepatitis,

Infectious

+

+ _ _ _ Early acute hepatitis,

Very infectious,

Greatest risk.

+

+ _ + _

Acute hepatitis/chronic carrier,

Still infectious,

>3/12 chronic liver disease

+ + _ + +

Late acute resolution,

Chronic carriers (? Improving).

+ _ _ + +

Infection soon resolving:

Still infectious, Chronic carriers,

Sometimes indicated improvement.

_ _ _ + +

Convalescent, may still be infectious

(Virus not detectable by current

methods)

_ _ + + + Recovery phase,

No longer infectious.

_ _ + + _ 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

Management Strategy for Toxoplasma

Serologic Testing During Pregnancy

1 Serologic testing preferably before conception or the first prenatal visit.

2a If negative lgG, retest at 18-22 weeks.

2b If positive lgG, immediately repeat tests including lgG and lgM

3a If lgG positive, stable, or low titer, IgM negative, suspect old or preconception

exposure. Repeat tests in 2-4 weeks

3b If lgG positive, any titer, lgM positive, suspect recent exposure.

Repeat tests in 2-4 weeks.

4a If repeat lgG positive, titer stable, lgM negative, confirm old

exposure . No further testing necessary.

4b If repeat lgG positive, titer rising, lgM positive, suspect recent exposure.

Repeat tests in 2-4 weeks.

5a If repeat lgG and lgM positive (Stable or declining titer). Suspect

recent exposure 2-6 months before tests obtained. Treat

according to gestational age at time of presumed infection and according to

patient wishes.

5b If repeat lgB and lgM positive with rising titers, suspect active

recent infection. Treat according to gestational age and patient

wishes.

6a If repeat serologic tests negative, repeat tests at 36 weeks.

6b If repeat serologic tests positive, retest as in (3).

2

6

3

4

5

5

3

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

Children: Treat for 6/52:

- Rifampicin 20 mg/ kg/ day once (OD)

- Septrin (TMP/SMZ) 10 mg /kg/ day in 2 divided doses

Alternative treatment for children:

o Children <9 yrs:

-Septin for 6/52 +Streptomycin 20 mg/ kg/ day/ M (OD) max(1gm/day) 2/52

o Children >9 yrs

-Tetracycline 30-40 mg kg/ day max (2 gms/day) in 4 divided doses 6/52

+

Streptomycin 2/52 OR Septrin 3/52

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


104

Thyroid Function Tests

Thyroid disorders T3

T4

Free T4

Index TSH

TRH

test

Subclinical hypothyroidism N

Hypothyroid

Hyperthyroid

Eutyroid Syndrome

N, N, N, N,

Secondary hypothyroidism

(Pituitary hypothalamic disease need

further investigations of hypothalamic

pituitary function

TSH secreting pituitary tumor or

Thyroid hormone resistance


105

Urine Analysis

1. Pyuria: (Pus cell in urine)

o 5 cells

o Differential Diagnosis:

1. Pyelonephritis

2. UTI

3. Urethritis

4. Prostatitis

2. UTI:

Urine:

o Pyuria

o Bacteruria > 105 [in symptomatic female > 102] Hematuria in 30 % of patients

o Nitrate +ve in 80%

o pH alkaline in Proteus and Klebsiella.

Organisms:

o E. Coli (80%) (gm – ve)

o Staph. (gm +ve)

o Klebsiella (gm – ve)

o Proteus (gm – ve)

o Enterococci

o Mixed

Investigations:

o C/S

o Further radiological investigations.

D Dx:

o Cystitis

o Prostatitis

o Urethritis

o Malignancy

Management of Uncomplicated UTI:

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

Drug Management of UTI in Children:

o Septrin 6 – 12 mg / kg / dose BID for 10 – 14 days

o F/U: for C/S & possible referral for radiological investigations.


106

3. Oxaluria: Causes:

1. Ileal dis. (Crohn’s ileal resection) 2. Hereditary (primary)

3. Food, most common: tea, nuts, chocolate, dark green vegetables

Risk: increase renal stone

4. Glucosuria:

Causes:

1. DM

2. Low renal threshold (< 180 mg/ml)

3. Pregnancy

4. Cushing’s

5. Hyperthyroidism

Investigations:

o FBS

Management:

o According to the confirmed diagnosis.

5. Contaminated Urine:

o Epithelial cells > 10 : mainly squamous, transitional cells.

o Pus < 5

o Mixed organism

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. Nephrotic synd. = ++++ (> 2000)

2. G.N. = 2 + 4 + (100 – 2000)

3. Pyelonephritis 1+2+

4. CRF = 1 + 2 +

5. False +ve = in pyuria & epithelial cells

6. Physiological:

Fever

Exercise

Investigations:

o 24 hour collection

o Cholesterol

o U/S abdomen


107

7. Urine Casts:

o Hyaline Non-specific

o Waxy advanced R.F.

o RBC G.N.

o Epithelial cast acute tubular injury, G.N, Nephrotic synd.

o WBC Pyelonephritis, G.N, interstitial nephritis.

o Granular Nephritis

o Faulty (lipid) Nephritic

o Mixed G.N.

8. 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. MSU, CIS, UIE, CBC, ESR

2. IVP, US, Cystoscopy, CT, angiography, biopsy.

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)


108

10. Sterile Pyuria:

Deferential diagnosis: Pyuria with negative culture (Causes):

1. Chlamydia

2. T.B.

3. Stone

4. Malignancy

5. Viral

6. Partially treated UTI

7. SLE

11. False Red Urine:

1. Drug: Rifampicin

2. Food: blackberry, beat root

3. Oxidation of crystals (in children).

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.

Indications for IVP:

o Children under 5 year of age

o Women with persistent bacteruria or 2 function in one year

o Haematuria after eradication of infection

o Persistent pyuria after eradication of infection o Infection with less common organism

o Asymptomatic bacteruria and pyclonephritis in pregnancy

Risk of IVP:

o 1 % may develop anaphylactic reaction

o Mortality rate is 1:10,000 - 1: 40,000 %

Interpretation of MSU:

o No significant growth: < 103 + Pyuria + Symptoms

o Unusual organism

o Anaerobes or viruses

o Analgesic nephropathy

o Antibiotic is taken before the sample.


109

Urine culture (Bacteruria)

o Suprapubic:Any number is significant

o MSU: < 10,000 is suggestive

100,000 is an evidence of infection

If the patient is asymptomatic: It is nesecarily to have 2 consecutive colonies >

100,000 of same organism.

MSU in children:

o Before starting antibiotic

105 /ml pure culture is reliable

< 105 /ml mixed growth is not significant (Becteruria)

Significant Bacteruria:

o > 105 /ml + Pyuria = Infection

o > 105 /ml + No pyuria = False positive

Intermediate bacterial counts:

o 104 - 10

5 /ml + Pyuria = Infection, if pure culture and fresh specimen

o More than one organism + no pyuria = contamination

o High mixed count = contamination.

Treatment of Common Infestations

Schistosomiasis:

o S. Mansoni , S. Japonicum and S. and Haematobium (Urinary tract)

Praziquantel 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

Hookworms (N. americanus, A. duodenal) ‘Nematodes = (Round worms)’ o Mebendazole (Vermox) 100 mg PO BD y 3/7 (children > 2 y)

o Pyrantel Pamoate 10 mg/kg (max. 1 gm) single dose (light infection)

Or 10 mg/kg PO OD y 3/7 (heavy infection)

o Albendazole 40 mg PO once

o Treatment of Anemia Iron treatment F. Fumarate 200 mg Bid for 6/52

o Or F. Gluconate 325 mg Bid for 3/12

Enterobius Vermicularis (Pinworm, threadworm)

o Mebendazole 100 mg PO once

Repeat at 2 weeks one dose (age 2 yrs or more)

o Pyrantel Pamoate 10 mg/kg PO once (tab. = 125 mg)

Repeat at 2/52 and 4/52 (0, 2, 4/52).

Note: * Hygiene, cutting nails, bath after rising in the morning

* Treat whole family

* Continued symptoms. means reinfection

* Adult worm die after 6/52

o Albendazole (Alternative) 400 mg PO once (repeat in 2/52).


110

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)

Ascariasis (Nematodes ‘roundworms’) o Mebendazole 100 mg PO BD x 3/7

o Levamisol 120 – 150 PO once Drug of choice for mass treatment

Amoebiasis (E. histolotica)

o Metronidazole 800 mg PO Q 8 hr x 10 days

o In case of liver abscess: aspiration.

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


111

8.

Data Interpretation: Slides N. Dashash

General Guidelines for Slide & Data Interpretation

1) Read questions carefully.

2) If interpreting Data: Comment on the abnormal as well as the abnormal

3) If you are asked to describe lesion

Describe it fully:

o Shape: e.g.: round, regular or irregular, location and Distribution… o Colour:e.g : erythematous, brownish, pearly… o Ulceration

o Crusting and colour of scales

o Lichnification, Bullae, bleeding points…etc. 4) Helpful Hints in Studying slides:

Approaching slides on infectious disease:

o What is the caustic organism

o How can you diagnose it?

e.g.-Micros-copy and culture of scrapings

-Woods light examination. color change.

-Special tests for some disorders.

o What is the distribution of the Rash.

o How is it prevented eg: hygiene, eradication of vector…etc. o What is your management or action?

A good approach is to mention what you would actually do in your practice. eg. o Explaining the problem to the patient.

o Investigation (if you need further information such as culture).

o Advise : eg: hygiene, treating other members of the family if disease is contagious.

o Preventing and treating complication.

o Prescription of medication, including generic name (best), dose, how to use,

frequency and duration

o Referral

Dermatology & General Medicine

Acute candidiasis of the oral cavity (thrush):

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.


o Diabetes mellitus

o Hypothyroidism

o Hypoparathyroidism

o Drugs e.g. contraceptive pill, antibiotic therapy, systemic steroids.


112

Pitryasis Vesicolor:

Appearance:

o The eruption manifests itself either as pink or brownish patches on a pale

background, or as hypopigmented patches on a dark background

o The organism produces azaieic acid which bleaches melanin.

Causative Organism:

o The yeast malassezia furfur. Differential diagnosis: Vetiligo

Treatment: Refer to handout.

o With topical agents e.g. benzoic acid compound ointment BPC (Whitfielf’s 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:

o By two application of an anti-scabetic lotion (benzyl benzoate or gammabenzene

hexachloride) to the whole skin surface below the chin, on two occasions 24 hours

apart for patient and close contacts. Pruritus can take up to two weeks to settle,

during which time no further anti-scabetic treatment should be used.

o Children and pregnant woman Benzyl benzoate

o Wash the drug off after 24 hours

o After treatment, wash clothes and bed linen in hot water.


113

Systemic Lupus Erythematosus (SLE):

Appearance: Butterfly (Malar) rash of face of young females.

Other features of SLE: - Pleuritis, pericarditis,

- Nephritis, Anemia

Diagnostic test:

o Antibodies to double stranded DNA, are found in over 80 per cent of patients.

Cutaneous Leishmaniasis:

Transmitted by: The sandfly

Causative organism: The protozoan leishmania tropica

Diagnosis: Smear demonstrates the organism with Wright’s or Giemsa stain.

Pyogenic granuloma:

Often a result of trauma.

Differential diagnosis:

Amelanotic melanoma: The lesion after removal should be sent for

histological examination.

Treatment: - Silver nitrate application.

- Curettage

- Diathermy under local anaesthetic

Kobner’s Phenomina:

Seen in:

Lichen planus

Proriasis

Vetiligo

Warts

Moluscum contgiosum

Acanthosis nigricans:

Associated with: Malignancy of an internal organ:

o Occurs in almost 100 per cent of cases of the acquired type in

non-obese adults.

o Commonly adenocarcinomas.

o 85 per cent being intra-abdominal.


114

Nail Changes in Psoriasis:

1) Pitting

2) Onycholysis

3) Discoloration

4) Thickening

5) Subungual Hyperkeratosis

Differential Diagnosis:

1. Trauma

2. Eczema

3. Onychomycosis

Treatment of psorisis:

Dithranol, tar, corticosterods

Emoliants

Systemic PUVA, UVB

Methotrexate, etretinate.

Basal cell carcinoma:

Associated with:

Excessive sun exposure

X-ray treatment of the area

Contact or medication with arsenic

Treatment: By curettage, cryotherapy or excision

Insulin induced fat hypertrophy (lipodystrophy):

Dermatological side effects of insulin:

Local reactions: o Immediate or delayed erythema, keloid formation

General reactions: o Erythema multiforme, urticaria, purpura.

Palmar Erythema:

Causes: i) Cirrhosis (especially alcoholic)

ii) Normal pregnancy

iii) Rheumatoid arthritis

iv) Thyrotoxicosis

v) Dermatological disorders – eczema, psoriasis, pityriasis rubra pilaris.

vi) Others include polycythaemia, diabetes mellitus, mitral valve disease, beri-

beri.

vii) May occasionally be inherited


115

Henoch-Schonlein Purpura:

Complications: Bleeding from the gut and nephritis

Causes:

Usually none is found.

In former years streptococcal infection was thought to be important.

It is now regarded as an immune complex disease but the antigen is

usually difficult to identify.

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)

Stevens – Johnson Syndrome:

Causes:

Infections: -Herpes simplex

-Mycoplasma

-Streptococcal

-T.B.

Drugs: Barbitarates, penicillin, sulphonamides

Neoplasia: e.g. Hodgkin’s disease

Connective tissue diseases

Malignant Melanoma:

Differential Diagnosis:

Seborrheic keratosis

Compound melanocytic nevus


116

Moluscam Contagiosum:

Tiny white (pearly), umbilicated papules

Common in - Children

- Atopics

- Immune suppressed

Caused by Pox virus.

Complications: secondary infections

Treatment: Removal: - By curettage

- Expression of contents

- Phenol or codeine.

Chicken Pox (Varicella):

Complications:

Secondary infection

Thrombocytopenic purpura

Encephalitis

Varicella pneumonia (usually in adults and those with an impaired immune response).

Herpes Zoster:

Commonly affects trunk then cranial nerves

Complications of herpes zoster ophthalmicus:

Conjunctivitis, keratitis, iridocyclitis, optic neuritis (rarely).

Encephalitis.

Secondary streptococcal/staphylococcal infection.

Haemorrhagic zoster (purpura fulminans).

Dissemination (immunosuppressed patients).

Post-herpetic neuralgia.

Treatment:

Acyclovir, vidarabine, or idoxuridine will limit viral replication.

Systemic corticosteroids may reduce the incidence of post herpetic

neuralgia (contraindicated in the immuno-compromised host).

Local corticosteroids and atropine if anterior uveitis has developed.

(immunosuppressed patients).

Post-herpetic neuralgia.


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Lesions on the shin

1) Erythema nodosum:

A common vasculitis reaction of larger subcutaneous vessels. In many cases no causes is

found.

Causes: 1. Sarcoidosis

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, Behchet’s disease

5. Lymphoma

Clinical features:

Erythematous, tender, nodules appear on shins and occasionall thighs and forearms.

Associated pyrexia, malaise, oedema and aching of legs

Color bright red to purple to brownish

Recurrences may occur

Most attacks settle within 2-12 weeks

Treatment:

Bed-rest

Anti-inflammatory analgesics

Support stockings or bandages

Systemic steroids may be required for severe cases

2) 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.


118

3) Pretibial myxoedema:

Caused by Graves’ disease

Other dermatological signs of throtoxicosis:

Vitiligo or diffuse hyperpigmentation

Diffuse alopecia

Clubbing of the fingers and toes

Soft tissue swelling (i.e. thyroid acropachy)

Onycholysis

Urticaria

Treatment:

Corticosteroids:

Under occlusive plastic dressing

Injected intralesionally

Angioedema

Aetiology

Hereditary angioedema is an autosomal dominant condition due to C1 esterase inhibitor

deficiency in the complement cascade.

Angioedema may also occur in urticaria.

Clinical features

Swelling of the lips, periorbital area, neck and joints.

The larynx may be affected and this can be fatal.

Gut involvement may produce abdominal pains.

Investigation

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

Causes of Mouth Ulcers:

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: Behccet’s, Reiter’s, Steven- Johnson syndrome

5. Skin conditions: pemphigoid, pemlphigus vulgaris, Lichen planus

o Vitamin deficiency:

o Vitamin C, Riboflavin, Nicotinic acid


120

Ear, Nose and Throat

Interpreting Rinne and Weber Hearing Tests:

Interpretation Rinne Weber

Tunning fork in front

of Pinna

Tunning fork (512 – H2 ) on

skull in midline

Normal Positive AC > BC No Lateralization

Conductive hearing loss

(e.g. perforation, cyromette tube)

Negative BC > AC Lateralizes to the abnormal

ear

i.e. Sound perceived louder in

abnormal side.

Sensorineural hearing loss

Positive AC > BC Lateralizes to the normal ear

i.e. Sound perceived louder in

the normal unaffected ear.

N.B.: AC = Air Conduction, BC = Bone Conduction.

Tympanosclerosis:

Appearance: White patches “chalk patches”

Causes: Past otitis media

T.M. Trauma or perforation

Complications: T.M. and ossicular immobility conductive deafness.

Tympanic Membrane Haematoma (Bleeding):

Causes: Barotrauma: from common cold or airplane descent injury, e.g. slap

on check.

Treatment: Usually no treatment is required as it is self limiting.


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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):

The retinal findings of mild and moderate NPDR include-micro-aneurysms (fine

red dots)

o Retinal haemorrhage (‘blots’) Hard exudates (yellow lipid deposits. o Macular Oedema

Severe NPDR: increased vascular tortuosity

o Venous beading, (widespread intraretinal micro-aneurisms) micro-infarctions of the

nerve fiber layer, or Soft (‘cotton wool’) exudates o 40% will develop proliferative diabetic retinopathy within 1 year.

2. Proliferative diabetic retinopathy (PDR):

o Responsible for most of profound visual loss from diabetes.

o New blood vessels (neovascularization) in the area of the optic disc and elsewhere

on the retinal surface or elsewhere in the eye; for example, on the surface of the iris

(rubeosis iridis), causing severe glaucoma.

o If not treated, these fragile new vessels bleed into the vitreous. Fibrous tissue in the

new vessels will contract and cause retinal detachment.

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 Grade IV

A/V ratio*

Flame hemorrhages

Exudates

Papilledema

Copper wiring

Silver wiring

AV nipping

¾

-

-

-

-

-

-

½

-

-

-

-

-

Slight

1/3

-

-

-

Present

-

-

¼

Present

Present

-

-

Present

Right-angle

Fine cords

Present

Present

Present

-

-

Same as grade

III

*A/V ratio refers to the ratio of the diameter of the arteriole to the venule.

Management of hypertension retinopathy:

o The primary goal is adequate control of the blood pressure General principles

weight reduction,

o Reduced salt intake lipid-lowering

o Direction of smoking reduction of alcohol consumption

o Anti-hypertensive drugs


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- Absorbable sutures

Organic: Catgut is the commonest example

o Useful in intestinal anastomosis

o closure of peritoneum

o stitch7 of fat or subcutaneous tissues.

Synthetic (Dexon, Vicryl):

o Synthetic absorb-ables cause less reaction and are superior.

o Stronger than catgut handle and tie better than catgut, but take a longer duration

before absorption.

2- Non-absorbable sutures:

o Organic (silk). Tie and handle easily, may precipitate infection (i.e. not preferred)

o 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

o Cutting needles used for skin or tendons.

o Round-bodied needles for anastomosi of the GI tract and vascular work.

Guidelines for suture removal:

o Face and neck: 3-4day

o Scalp: 5-7 days

o Abdomen and chest: 7-10 days (up to 14 days after aortic surgery)

o Limbs. 5-7 days.

o Feet: 10-14 days.

o N.B. Sutures can be removed earlier than these times for cosmetic reasons.

Steristrip may be used as an alternative especially in children.


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9.

ECG Interpretation A. H. Hassan

Contents:

Part I: Basic ECG Principles.

PART II: Practical Applications:

o Ischemic Heart Disease.

o Chamber Enlargement.

o Conduction Defects.

o Digitalis Effects and Electrolyte Disturbances.

o Arrhythmias: -

- Ventricular Fibrillation (VF) and Ventricular Tachycardia (VT).

- Atrial Fibrillation (Afib) and Atrial Flutter (AF).

- A-V Heart Blocks.

Objectives:

Every physician is expected to be able to:

o Appreciate the difficulties in mastering ECG interpretation,

o Differentiate between normal and abnormal ECG tracings,

o Interpret properly abnormal ECG findings,

o Master efficiently the topics covered, and

o Improve in the future his basic knowledge and skills about ECG interpretation

discussed here.

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.

PART 1: Basic ECG Principles (14 points to analyze)

1) Standardization

o 1 m Volt = 10 mm.

2) Rate

Regular Rhythm:

o 300 / number of large squares.

o 1500 / number of small squares.

o 300 / 150 / 100 / 75 / 60 / 50.

Irregular rhythm:

o Number of cycles in 6 sec. x 10.


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3) Rhythm

Normal Sinus Rhythm:

o Rate = 60 - 100 / min.

o Regular rhythm.

o + ve P II.

o - ve PaVR.

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.

6) Mean Electrical Axis Deviation of the QRS Complex

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.

Normal Axis: (-30o) to (+110

o) degrees.

Abnormal Axis Deviation:

Right Axis Deviation (RAD):

o Normal,

o Right Ventricular Hypertrophy (RVH).

o Lateral Myocardial Infarction (MI),

o Chronic Obstructive Pulmonary Diseases (COPD),

o Acute Pulmonary Embolism.

Left Axis Deviation (LAD):

o Normal,

o Left Vevtricular Hypertrophy (LVH),

o Left Bundle Branch Block (LBBB),

o Left anterior hemi-block.


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7) QRS Duration

Normal: - 0.1 sec. or less.

Wide QRS complex:

o Bundle Branch Blocks (BBBs),

o Premature Ventricular Contractions (PVC),

o WPW,

o Hyperkalemia,

o Toxicities: Tricyclic Antidepressants (TCAs), Procainamide, quinidine.

8) QRS amplitude

Short:

o Normal,

o Obesity,

o Pleural Effusion,

o Extensive MI,

o Emphysema

o Myxedema.

Tall:

o Young adults.

o Thin chest wall.

o Ventricular Hypertrophy

9) R wave Progression

Poor Progression:

o COPD.

o LVH.

o Anterior MI.

o LBBB.

Prominent RV1

o Infants and children.

o RVH.

o Posterior MI.

o RBBB.

o WPW.

10) ABNORMAL Q-WAVE

o Width: - > 0.04 sec.

o Amplitude: - > 25% R wave.


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11) QT interval

Normal duration: - 0.4 sec; (should be corrected for the heart rate).

Prolonged:

o Hypocalcemia.

o Hypokalemia.

o Ischemia.

o Hypothermia.

o Subarachnoid Hemorrhage.

o Procainamide.

o 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.

Abnormal:

o Ischemia.

o MI.

o Ventricular Strain.

o Pericarditis.

o BBBs.

14) U-wave

o Hypokalemia.

o Toxicity.


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PART II: Practical Applications

1) Ischemic Heart Disease

Transmural MI.:

Acute:

o Persistent ST elevation,

Evolving:

o Q wave.

o Deep T- wave inversion.

Sub-endocardial (non-Q.) MI.:

o Persistent ST depression, &/or

o T-wave inversion.

Transmural Ischemia (Prinzmetal angina):

o Transient ST elevation, or

o Increased T wave positivity.

Sub-endocardial Ischemia (classic angina):

o Transient ST depression.

Site:

o Ant.: - V2-4.

o Ant.-septal: V1-3.

o Ant.-Lateral: I, aVL, V4-6.

o High Lat.: I, aVL.

o Extensive Ant.: V1-5.

o Inferior: II, III, aVF.

o RV: - Right Chest Leads.

o 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

RBBB:

o Wide QRS, (if narrow incomplete BBB).

o Prominent R V1.

o Wide slurred R’ V1,2. o Wide slurred S I,aVL, and V5 or 6.

o ST-segment depression, and T- wave inversion V1-3.

LBBB:

o Wide notched QRS.

o Prominent notched R I, aV L, V5,6.

o Wide S V1.

o ST-segment depression, and T- wave inversion I, aVL, V5-6.

o No Q-wave in I and V5,6.

Digitalis Effects and Electrolyte Disturbances:

Digitalis Effects: Bradycardia, “Coved concave, or scooped” ST-segment

depression, and Short QT interval.

Digitalis Toxicity: 1st., 2 nd., or 3 rd. Degree Heart Block, Marked Sinus

Bradycardia, 1st., AT, AF, Afib, PVCs, VT, and/or VF.

Hyperkalemia: Tall (peaked, slender, tented) T, flattened P wave, wide QRS, ST-

segment elevation, A-V conduction defects, VT., VF, asystole.

Hypokalemia: U wave, ST- segment depression, flattened or inverted T wave,

increased amplitude and width of P wave, prolonged PR interval.

Hypercalcemia: Markedly short QT interval (even absence of ST- segment).

Hypocalcemia: Prolonged QT interval.

4) Arrhythmias

If There is no Normal Looking QRS Complex:

o Ventricular Fibrillation.

o Ventricular Tachycardia.

If There is no Normal Looking P Wave:

o Atrial Fibrillation.

o Atrial Flutter.

What is the Relationship Between P Wave and QRS Comples?

o Fixed Prolongation of the P-R Interval: 1st Degree HB.

o Progressive Prolongation of the P-R Interval: 2st Degree type I HB.

o No Relation:

- 2nd Degree type II HB: No complex without P-wave before it.

- 3rd Degree HB: Complex appears without P- wave before it.


129

10.

Data Interpretation: Radiology M. Al atta

General Advice on X-ray interpretation

Basic interpretation of the chest X-ray is easy. It is simply a black and white film and any

abnormalities can be classified into:

1. Too white.

2. Too black

3. Too large.

4. In the wrong place.

To gain the most information from an X-ray, and avoid inevitable panic when you see an

abnormality, adopt the following procedure:

1. Check the name and the date.

2. Check the technical quality of the film.

3. Scan the film thoroughly and mentally list any abnormalities you find.

4. When you have found the abnormalities, work out where they are:

5. Always ensure that the film is reported on by a radiologist.

6. Finally do not forget the patient. It is possible and indeed quite common for a

very sick patient to have a normal chest X-ray.

Exams and the normal X-ray

Spotting the abnormality in an apparently normal chest X-ray is a common question in

postgraduate exams. If confronted with such an X-ray, then think of the following

possibilities:

o Apical shadowing

o Left lower lobe collapse

o Hiatus hernia (fluid level behind the heart)

o Dextrocardia (with the X-ray shown the wrong way around)

o Mastectomy

o Air under the diaphragm


130

Chest X-Ray

Causes of a pleural effusion

Transudate <30 g/l of protein

o Heart failure, e.g. congestive cardiac failure, pericardial effusion

o Liver failure, e.g. cirrhosis

o Protein loss, e.g. nephritic syndrome, protein-loosing enteritis

o Reduced protein intake, e.g. malnutrition

o Iatrogenic, e.g. peritoneal dialysis

Exudates >30 g/l of protein

o Infection, e.g. pneumonia, tuberculosis

o Infection

o Malignancy, e.g. bronchial carcinoma, mesothelioma, metastasis

o Collagen vascular disease, e.g. rheumatoid arthritis, SLE

o Abdominal disease, e.g. pancreatitis, subphrenic abscess

o Trauma/surgery

The coin lesion

The term coin lesion is used to describe a discrete are of whiteness situated within a lung

field. It is not necessarily strictly circular. The main worry is that it may represent a

carcinoma

Causes of single coin lesions

o Benign tumor, e.g. hamrtoma

o Malignant tumor, e.g. bronchial carcinoma, single secondary

o Infection, e.g. pneumonia, obsess, tuberculosis, hydatid cyst

o Infarction

o Rheumatoid nodule

Fine nodular shadow or

Reticulonodular shadow in a Chest X-Ray:

Differential Diagnosis

o Miliary T.B.

o Sarcoidosis

o Pneumoconiosis

o Haemosiderosis

o Miliary carcinomatosis

Cavitating lung Lesion

Some coin lesions may cavitate and if you have identified a coin lesion it is important to

look for features of cavitation

Causes of Cavitating lung lesions

o Abscess

o Neoplasm

o Cavitations around pneumonia

o Infarct

o Rheumatoid nodules (rare)


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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.

Causes of bronchiectasis

o Structural, e.g. Kortagener syndrome, obstruction (carcinoma, foreign body)

o Infection, e.g. childhood pertussis or measles, tuberculosis, pneumonia Immune,

e.g. hypogammaglobulinaemia, allergic bronchopulmonary aspergillosis

o Metabolic, e.g. cystic fibrosis

o 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.

Causes of numerous calcified nodules

o Infection, e.g. TB, histoplasmosis, chickenpox

o Inhalation, e.g. silicosis

o Chronic renal failure

o Lymphoma following radiotherapy

o Chronic pulmonary venous hypertension in mitral stenosis


132

Pneumothorax

When you see a unilateral black lung you need to:

1. Check the technical quality of the film.

2. Determine which side is abnormal

Causes of Pneumothorax

o Spontaneous

o Iatrogenic/trauma, e.g. pleural tap, transbronchial biopsy, central venous line

o Insertion, mechanical ventilation

o Obstructive lung disease, e.g. asthma, COPD

o Infection, e.g. pneumonia, tuberculosis

o Cystic fibrosis

o Connective tissue disorders, e.g. Mar fan’s, Ehlers-Donlos

Unilateral Hilar Enlargement

Hilar enlargement always warrants further investigation

Causes of hilar lymphadenopathy

o Neoplastic e.g. spread from bronchial carcinoma, primary lymphoma

o Infective, e.g. tuberculosis

o Sarcoidosis (rarely unilateral)

Causes of hilar vascular enlargement

o Pulmonary artery aneurysm

o Poststenotic dilatation of the pulmonary artery

Bilateral Hilar Enlargement

As with unilateral hilar enlargement bilateral hilar enlargement can be due to enlargement

of pulmonary arteries, veins or lymph nodes.

The commonest causes of bilateral hilar enlargement are pulmonary hypertension and

Sarcoidosis.

Causes of bilateral hilar lymphadenopathy

o Sarcoid

o Tumors, e.g. lymphoma, bronchial carcinoma, metastatic tumors

o Infection, e.g. tuberculosis, recurrent chest infections, AIDS

o Berylliosis

Causes of pulmonary hypertension:

o Obstructive lung disease, e.g. asthma, COPD

o Left heart disease, e.g. mitral stenosis, left ventricular failure

o Left to right shunts, e.g. ASD, VSD

o Recurrent pulmonary emboli

o Primary pulmonary hypertension


133

Causes of pericardial effusions:

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.

Diagnosis of rib fractures

Rib fractures can be missed on a chest X-ray. The diagnosis is therefore clinical and the

chest X-ray is usually performed to look for potential complications.

Surgical emphysema

At first sight surgical emphysema gives a very messy appearance, which is sometimes

confined to the obvious soft issue areas but may spread over the whole X-ray.

Causes of surgical emphysema

o Trauma

o Iatrogenic, e.g. surgery, chest drain insertion

o Obstructive lung disease, e.g. asthma

o Esophageal injury

o Gas gangrene


134

Pancoast’s 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 radiologist’s 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 Paget’s disease

o Hyperparathyroidism

Generalized Skull Rdiolucencies

o Renal osteodystrophy

o Fibrous dysplasia

o Fluorosis

o Acromegaly

o Drugs-for example,

o Phenytoin

o Hemolytic anemia’s

Multifocal Skull Radiolucencies

o Sclerotic metastases

o Paget’s disease Multifocal o Paget’s disease

Localized Skull Radiolucencies o Foreign body

o Hyperostosis frontalis interna

o Osteroma

o Meningioma

o Hair bunch


135

Bone and Joints

Hyperparathyroidism / Findings in hand X-Ray:

o Eroded tufts of terminal phalanges

o Subperiosteal cortical resorption

o Fine lattice like pattern of bone

o Generalized loss of bone density

Supracondylar fracture

Complications

Early:

1. Volkman’s Ischemia: (4 P’s : 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. Volkman’s 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 Early: difficult to interpret, as so much of the joint is cartilage.

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.


136

The Joint Program of Family and Community Medicine - Jeddah 136

11.

Data Interpretation: Self-assessment Exercise Hana Al Hajjar

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) What is the diagnosis ?

B) What is your management ?


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 Patient’s value Normal value

Fasting 94 mg/dl 105 mg/dl

1 hour 180 mg/dl 190 mg/dl



A) What is your diagnosis ?

B) Out line your management plan?


Question (3)

A four-year-old child presents for audiogram and tempanometry testing . his results

are shown as

صورة السمع

A) What is your interpretation ?

B) List three possible causes ?


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 5 795

A) What is the prevalence of hypertension ?

B) What is the prevalence of MI ?

C) Draw 2x2 table


Question (5)

ECG

A) What is the diagnosis?

B) List two possible causes?

C) What is the management


Question (6)

This is the thyroid function test of a 42 year old lady

T4 ………………………. 7 μg/dl ( 5 – 11.5 )

T3 ………………………. 134 ng/dl ( 100 – 215 )

T3 uptake ………………. 19 % ( 25 – 35 )

TSH ……………………. 22 μg/dl ( 0.7 – 7 )

FIT …………………….. 4.3 ( 6 – 11.5 )

A) What is your interpretation?

B) What is the most common cause?

C) What further investigation will confirm your diagnosis?

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 ( 5 – 25 )

Creatinine ………………….... 4 mg/dl ( 0.5 – 1.5 )

Na ……………………...……..146 mmol/l ( 135 – 153 )

K …………………………….. 5.9 mmol/l ( 3.5 – 5.3 )

Cl …………………………..... 110 mmol/l ( 95 – 106 )

Ca …………………………… 8 mg/dl ( 9 – 10.5 )

Phosphate …………………… 7.6 U/L ( 0 - 5.5 )

T. Protein ……………………. 5.6 g/dl ( 6.6 – 8.7 )

Albumin …………………….. 3 g/dl ( 3.8 – 4.8 )

Fasting blood sugar ………… 96 mg/dl ( 70 – 110 )

A) Comment about his serum calcium level

B) What is your interpretation ?


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.

Colour: yellow turbid Blood ( haem ): +++

Deposit : + WBC/HPF: 8 – 10

Ph: acidic RBC/HPF: 15 – 20 (clumps +++)

Odour: normal Epith cells: ++

Nitrate: nil Casts: hayaline casts ( + )

Protein: trace Parasite + ova: nil

Glucose: nil Mucuos thread: +++

Ketones: nil Chemical deeposits: nil

Urobilinogen: N. Trace Others: nil

Bilirubin: n


B) List five most probable causes?

A) What further investigation this patient needs ?


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) Calculate his LDL level.

B. B) What is your management?

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) What are the two most probable causes of such result?

B. B) What further investigation this patient needs?


Answers to the Self-assessment Exercise

Answer (1)


Acute or recent inferior infarct and acute posterior infarct

B) What is your management ?

Assessment in the first ten min of arrival to primary care:

Vital signs, O2 saturation

Cardiac monitor ( 12 leads ECG )

Start one or two IV lines

Draw blood for cardiac enzymes, electrolytes, coagulation studies

Portable CXR ( if available )

Immediate general treatment: (MONA)

Morphine IV 1-3 mg repeated at 5 min interval as needed

O2 by face mask or nasal canula

Nitroglycerin sublingual

Aspirin PO 160 – 325 mg

Adjuvant treatment:

B-blockers ( unless SBP< 100, HR< 60, 2nd or 3rd degree heart

block )

ACE inhibitors ( in 12 – 24 h )

Selected thrombolytic therapy: ( if available )

TPA ( Altepase ) or Streptokinase

Arrange for referral accompanied by doctor or nurse

Answer (2)

A) What is your diagnosis ?

Gestational diabetes

B) Out line your management plan ?

Explanation to the patient

Shared care with the hospital

Diet therapy

May need insulin therapy if FBS > 95mg/dL or 2PP > 120 mg/ dL

Testing for fetal well being by non stress test twice weekly and

by biophysical profile from 32/34 week gestational age

Monitor for maternal , fetal and neonatal complications


Answer (3)


Conductive hearing loss left ear

Type B tympanometric curve

B) List three possible causes

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 MI

History of

hypertension

+ ve - ve Total

+ ve 4 36 40

- ve 1 59 60

Total 5 95 100

Answer (5)


2nd

degree heart block, mobitz type 2

Fixed PR interval then missed beat

B) List two possible causes?

Degeneration

Acute MI

C) What is the management

Needs ultimate ventricular pacing


Answer (6)


hypothyroidism

B) What is the most common cause?

Hashimoto’s thyroditis

C) What further investigation will confirm your diagnosis?

Antimicrosomial antibodies

Antithyroglobuline antibodies

Answer (7)

A) Comment about his serum calcium level

He is having low apparent calcium coz of his low albumin level

His corrected serum calcium is calculated as Ca + 0.8 ( 4 – albumin )


Chronic renal failure plus

Renal osteodystrophy

Answer (8)


Microscopic hematuria

Possible renal parenchymal disease

Urinary tract infection

B) List three most probable causes?

Tumor

Calculus

Infection

Drugs

Systemic diseases

Essential

C) What further investigation this patient needs ?

Referral for biopsy

Urine culture and sensitivity

Ultrasound

Renal function test


Answer (9)

A) Calculate his LDL level.

T. Cholesterol - HDL - TG/5 = mg/dl

236 – 24.6 - 267/5 = 158 mg/dl

B) What is your management?

This patient is high risk for cardiac disease, primary prevention

( DM, smoker, age 52, male, loww HDL, high LDL )

Aim to decrease LDL to < 130 mg/dl

Diet

Medications ( pravastatin or lovastatine )

Exercise

Smoking cessation

Start daily aspirin

Non pharmacological ( garlic, antioxidants, psylium and omega 3 fatty acids )

Follow up

Answer (10)

Raised AST & ALT hepatocellular injury

Raised ALK phosphatase obstruction

GTT is very sensitive to liver insult but is not specific and may increase in : alchohol,

antiepileptic medication , DM and history of MI

A. A) What are the two most probable causes of such result?

Obstructive or infeltrative disease

Consider malignancy

B. B) What further investigation this patient needs?

Drug history

Ultrasound


149

12.

Approach to the Oral Exam F. Rayes

Introduction:

The broad goals of this examination are to provide evidence of satisfactory

completion of the Family Medicine Board Program for Family and Community

Medicine, and to provide evidence of competence to practice.

The oral exam assesses areas of competence not tested in other parts of the

examination

Since the MCQ-type questions test factual knowledge reliably and extensively,

hard facts and figures are not part of oral assessment

During oral examination the examiner will be looking at your problem solving

skills and attitude and your consideration of illness in physical, psychological and

social terms

In the face of critical challenge from the examiners, the examiner will be looking at

your abilities to make decisions and to justify the conclusion they reach.

In general, the type of problem set in Modified Essay Questions type component of

the written paper will not be repeated in oral exam as the oral has its own focus

The range of oral exam questions:

Problem definition: this covers the candidate’s 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 candidate’s 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 candidate’s personal approach to continuing professional development, self-appraisal and evaluation,

stress awareness and burnout management


150

General Approach to Oral Exam Questions

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 problem…etc) and describe to the examiners your analysis of the problem.

This step is very important for the following reasons:

o It helps you to give comprehensive answer

o It demonstrates to the examiner your holistic approach in thinking

Organize your answer according to the different dimensions of the problems e.g.

o You can say” for the physical part of the problem I need to do …..etc. o For the ethical part of the problem I need to do …. etc. o See next table (Systematic Thinking)

The examiner may give you a challenging question:

o Remember the examiner is not looking for a definite answer (yes or no). He/she

will be looking at your abilities to make decisions

o Be flexible and discuss options, advantages and disadvantages and avoid strong

statements.

o 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 patient’s 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


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. don’t 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


o Physical

o Social

o Psychological

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 patient’s 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: Don’t 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, don’t 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

Tips and Pitfalls in Oral Exam

Misunderstanding of the Question:

Formulate the question the way you understand it and ask the examiner: Is this what

you mean by your question?

Thought Block:

o Think of alternative solution

E.g. I can’t 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.

Very short answers and long silence:

o Having system of thinking will help you to be fluent

o Remember it is your stage, express yourself as much as you can

o Instead of keeping silent, think loudly and express your uncertainty

o Proceed in talking unless the examiner stops you.

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.

Odd answer for strange question:

o Reformulate the question in a more logical way, e.g.:

Q1. Health education is not very effective. Why we do health education?

A1. You mean obstacles to health education

Q2. Family doctor is not a social worker. Why you keep asking about

social history?

A2. You mean the role of family doctor towards social problems.

o Always and always remember there is no (yes or no) answer

o Think of probabilities, advantages & disadvantages.

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

If a difficult problem is presented:

o Acknowledge the difficulty of the situation and give reasons for it

o Express your feelings about the situation, e.g. “ This is a difficult situation because I want to maintain a good relationship with the patient and keep his confidentiality,

but on the other hand his wife need to be protected…”

Self-Training For Oral Exam

Answer each of the following questions by writing a short notes, and then rehearsing

presenting your answer to a colleague or even to yourself

1. What is your plan after graduation?

2. How are you going to maintain your CME?

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. What do you understand by EBM?

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. How do you deal with job stresses

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

Risk Assessment Exercise

Q1 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


156

Important Topics in Oral Exam Vital statistics,

Sensitivity & Specificity,

Survey and Surveillance,

P. Value, CI, NNT

Quarantine,

Incidence and prevalence,

Immunization schedule and specific

immunization,

Investigation of an epidemic,

Alma Alta Declaration

Rationale of Well Baby Clinic,

Rationale of routine antenatal visits,

Primary Care Tasks and Principles,

Screening principles / Periodic health

examination,

Family Life Cycle & Family Genogram,

Differences between Family Medicine

& Other specialties,

Endemic diseases in KSA e.g.

Brucillosis, Bilharziasis, TB, Malaria.

Management of chronic diseases,

Diagnosis of asthma in children,

Diagnosis of hypertension / white coat

hypertension,

Elderly hypertensive & Role of anti-

hypertension drugs,

DM: e.g. decision to start insulin in

NIDDM,

Dealing with emergency,

Use of referral system and discussion

with specialist,

Management of common diseases,

URTI and Role of antibiotics,

Otitis media & Glue ear,

Menopause and Role of HRT,

PU and eradication of H. pylori,

Rationale of empirical treatment

(therapeutic trial) e.g.

o Dyspepsia,

o UTI,

o Night cough in children.

Rationale of some preventive care

protocol - e.g.

o Cholesterol screening,

o Pap smear,

o Breast self-examination & Breast

mammography.

Patient scenario testing your index of

suspicion - e.g.

o Depression and risk of suicide,

o Child abuse,

o Drug abuse,

o Dyspepsia in a 50 years old patient

Challenging questions, e.g.

o Rationale of health education, Is it

effective? Why to do it?

Barriers to compliance with advice or

medication,

Models of consultation,

Patient-Doctor Relationship,

Counseling,

Reassurance,

Compliance,

Referral,

Dealing with difficult patients,

Breaking bad news,

Advice and Instructions,

Illness behavior &

Health behavior.

Audit,

Team work, and Relationship with

colleagues

Plan of action,

Management cycle,

Organizing your practice,

Time management

Medical records,

Registers.

CME.

How to read an article?

Burn out.

Audit

Research.

Ethics:

o Confidentiality

o Patient autonomy

o Doctor obligations

o Doctor loyalty


157

13.

Community Medicine Review A.H. Hassan

Objectives of this review

o To perform well in the OSCE examination,

o To satisfy the examiner in the final oral examination,

o To master efficiently the topics covered in the course,

o To master other areas and topics using similar basic principles of thinking and

organization, (apply the same model in other areas),

o To improve the basic knowledge regarding the topics discussed here.

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.


158

Management Cycle

Planning

Define objectives

(General & specific)

Prioritization of Objectives

Organization

Who to do what

Resuorce needed:

Personnel

Equipments

Time

Budget

Implementation

Effective Communications

Effective delegation

Teamwork

Monitoring

(Audit):

Structure

Process

Outcome


159

Planning health education program

Preparation

1) Identify the community health problems.

2) Identify the at risk group (target population).

3) Identify resources.

4) Identify possible barriers.

5) Prioritize health problems.

Basic program planning questions

1) What are the dimensions of the health problem?

– Condition specific?

– People specific?

2) What information, skills, and behaviors must be acquired (learning objectives)?

3) What services needed to enable people to change behaviors?

4) What resources are needed?

5) What changes are expected?

6) Which behavior changes can and should be measured?

7) What support services are needed (training, forms , administrative,…..etc.)?

Organization

1) Identify the message (learning experience)

2) Identify the method of communication

3) Schedule an operational plan

4) Identify monitoring and impact measurement tools

Epidemiology

Control of Communicable diseases,

Control of Non-communicable diseases,

Occupational hazards.

Investigation of an epidemic.

Disaster plan.

Field survey.

Surveillance.


160

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

Control of communicable diseases

A) agent :-

o Eliminate the agent.

o Prevent multiplication.

o Eliminate reservoir.

B) reservoir :-

o Human.

o Animal.

o Soil.

C) portal of exit :-

D) mode of transmission :-

o Direct

o Common vehicle

o Air born

o Arthropods

E) susceptible host :-

o Health habits

o Immunity

o Chemoprophylaxis


161

Control of communicable and non-communicable diseases

A) primary prevention:-

o Health promotion

o Specific protection:- (ig., vaccines, chemoprophylaxis)

B) secondary prevention:-

o Early detection (screening)

o Prompt treatment.

C) tertiary prevention:-

o Limit disability.

o Rehabilitation.

Control of occupational hazards

o Identification of occupational hazards.

o Substitution.

o Enclosure.

o Removal of the source.

o Segregation.

o Ventilation.

o Exhaust system.

o Sound protective equipment.

o Good house keeping.

o Environmental monitoring.

o Worker education.

o Legislation.

o Screening.

Physician role in prevention of occupational hazards

Visiting the work place.

Establishing surveillance (reporting) system.

Monitoring new materials.

Educational programs.

Establishing team:

o Hygienist

o Nurse

o Safety officer.


162

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.


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

Periodic health assessment

Strength of recommendations:

A: good evidence to support the recommendation to include the condition in

a periodic heath examination

B: fair evidence to support the recommendation to include the condition in

a periodic heath examination

C: insufficient evidence to recommend for or against the inclusion of the

condition in a periodic health examination, but recommendations may be made

on other rounds.

D: fair evidence to support the recommendation to exclude the condition from a

periodic health examination.

E: good evidence to support the recommendation to exclude the condition from a

periodic health examination.

Evidence Based Medicine

Quality of evidence:

I: at least one properly randomized controlled trial.

II-1: well-designed controlled trials without randomization.

II-2: well-designed cohort or case-control analytic studies.

II-3: multiple time series with or without the intervention; or

dramatic results in uncontrolled experiments.

III: opinions of respected authorities.


165

General Rules of Vaccinology

Rule Number 1:

o The more similar a vaccine is to the natural disease, the better the immune response

to the vaccine.

Rule Number 2: o Live attenuated vaccines are usually affected by circulating antibody to the antigen.

o Inactivated vaccines are generally not affected by circulating antibody to the antigen.

Rule Number 3:

o There are no contraindications to simultaneous administration of any vaccines.

o Except cholera and yellow fever.

Rule Number 4:

o Increasing the interval between doses of a multi-dose vaccine does not diminish the

effectiveness of the vaccine.

o Decreasing the interval between doses of a multi-dose vaccine may interfere with

antibody response and protection.

Rule Number 5:

o Live attenuated vaccines generally produce long lasting immunity with a single dose.

Inactivated vaccines require multiple doses and often require periodic boosting to

maintain immunity, except OPV and measles

Rule Number 6:

o Adverse events following live attenuated vaccines are similar to a mild form of the

natural illness.

o Adverse events following inactivated vaccines are mostly local with or without

fever, except DPT

Rule Number 7:

There is only one universal absolute contraindication to vaccination:

o Severe allergy to a vaccine component, or

o Following a prior dose of a vaccine


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

Up – date Knowledge in Vaccinology

New vaccines: 7 valent pneumococcal vaccine for infants.

Renewed old vaccines (DTaP, Hep. A 2 doses only).

Vaccine combinations

o Quadri-valent.

o Penta-valent.

o Hexa-valent.

Debate

o Decision making: To include or not (Hib, Hep A, VZ, 7 valent pneumococcal)

o OPV Vs IPV.

o MMR and Inflammatory Bowel Disease.

Poliomyelitis Eradication Vs Tetaneous neonatorum eminationel

New epidemics

RTA, CVD, HIV, Substance abuse


168

14. Basic Statestical Principles for Physicians A.H. Hassan

Objectives of the Review

1) To perform well in the OSCE examination.

2) To satisfy the examiners in the ORAL examination.

3) To master efficiently topics covered.

4) To deal efficiently with similar problems using the same models.

Important Definitions

o Sensitivity.

o Specificity.

o A positive predictive value.

o A negative predictive value.

o Likelihood ratio of a positive test.

o Type 1 error.

o Type 2 error.

o P value.

o Incidence.

o Prevalence. (Point prevalence and Period prevalence)

o Odds ratio.

o Relative risk.

o Absolute risk.

o 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.


169

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 Best for screening.

o Believe negative test.

o Rarely miss a patient.

o Best for common diseases.

o Best for serious diseases.

o Used to rule out a disease.

o Negative test excludes the disease.

o Many false positive.

o Few false negative.

Highly Specific o Best for conformation.

o Believe positive test.

o Rarely include a healthy.

o Best for rare diseases.

o Best for stigma diseases.

o Used to rule in a disease.

o Positive test conforms the disease.

o Few false positive.

o Many false negative.


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 non-

diseased 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

Two by Two Tables

o In a trial to calculate the power of urine testing for glucose to diagnose DM, a family

physician included 38 person in a pilot study. Of them 18 were known diabetics.

Eighteen persons tested positive of them 11 were diabetics.

o Construct two by two table for the urine test.

o Calculate the following:-

– Sensitivity and Specificity.

– Positive and negative predictive values.

– The likelihood ratios of positive and negative test results.

o Of the 231 patients admitted to the CCU with professional diagnosis of acute MI, and

with positive CK test; 16 patients were found not to have MI.

o Whereas, of the 129 patients with negative CK test admitted to the same unit, 15

patients were found to have acute MI.

o Construct the two by two table for the CK test.

o Calculate the following:-

– Sensitivity. Spacivity, positive predictive value, negative Predictive value and

Likelihood ratio of the test.

Example of Two by Two Table

o The prevalence of tuberculosis in a 100,000 population to be screened is

approximately 4%.

o The tuberculin skin test is used for screening. The sensitivity and specificity

associated with this screening are 40.8% and 99.2% respectively.

o Construct a (2×2 table).

o A person in this population was found to have a positive result, What is the

probability that he has TB?

o Calculate the percentage of false positive and negative test results.


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


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


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 & Non-

Nationals due to IHD.

Types Of Epidemiological Studies

A) Your own study.

B) Types of studies.

C) The power of the study.

Your Own Study

Objectives (Aim).

Design.

Sampling:

o Technique

o size.

Conclusion.

Recommendations.


176

Types Of Studies

Observational

o Descriptive

o Analytic

Experimental

Observational Studies

Descriptive studies:

o Ecological (correlational).

o Cross sectional (prevalence).

o Longitudinal.

o Case seires or report.

Descriptive study

o Is designed to give a clear picture of a particular situation

o Describes diseases in relation to person, place, and time.

o It constitutes an important first step to determine risk factors

o It uses the available sources of information

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.


177

Case-control study design

The design is guided by

o The type of the disease to be investigated

o The appropriateness of controls

o The basic assumptions underling the analysis such as:

- Cases are representatives of persons who are being investigated for the disease.

- The control represent the entire non-diseased population.

Advantages and disadvantages

of case-control study

Advantages

o Cheep.

o Quick.

o Small sample size.

o Good for rare diseases.

o Can test several risk factors.

o Odds ratio can be calculated.


of case-control study

Disadvantages

Tests only one disease.

Determination of casual relationship is difficult (can only estimate the risk of

developing the disease indirectly).

Incidence rate, and relative and absolute risk cannot be calculated.

Bias is common: -

o Recall bias.

o Selection (of control) bias.

o Bias by knowing the diagnosis.

Selection of controls

o From the population

o Persons working in the same factory or attending the same school

o Hospital patients

o Close associate of the cases


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


of cohort study

Advantages:

Good for assessing rare exposure

Several out-comes can be measured (investigate multiple effects of a single

exposure).

minimizes selection bias.

Incidence rate, and relative and absolute risk can be calculated.

The methods are standardized and the results are trusted (temporal sequence can be

more clearly established).

Efficacy of the drug or procedure in treatment of certain disease.

Disadvantages:

Longer time.

Expensive.

Larger sample size.

Difficult: -

o Drop-out.

o Changes in diagnostic criteria.

o Changes in other variables.


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.

Strength of Evidence for Causality

1) Experimental: The strongest

2) Prospective cohort:

3) Historical cohort:

4) Case-control:

5) Cross-sectional:

6) Case series:

7) Case report: The Weakest


180

15.

Some Important Topics for Oral Exam F. Rayes, A. H Hassan, M. Alatta, N. Dashash & A. Assaggaf

Primary Health Care A. H. Hassan

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 Equity of distribution.

o Appropriate technology.

o Multisectorial approach.

o Community participation.


181

Instruments of PHC

o Community survey and diagnosis.

o Family health records.

o Plan of action.

o Team approach.

o Information system.

Strategies for PHC implementation

o Expansion of services.

o Better relation with community.

o Encourage comprehensive care (curative, preventive, promotive,

rehabilitative).

o Integration preventive and curative services.

o Promotion of health awareness.

o Coordination with secondary care.

o Multisectorial approach.

o At risk approach.


182

The Team Work Dr. Fayza Rayes

As the effective multidisciplinary teamwork is an essential ingredient of good patient

care, the importance of the teamwork was recognized in the Alma Alta Declaration in

1978 and was further emphasized in recent statement by World Health Organization.

Aspects of Teamwork:

o Pooling of resources

o Delegation of work

o Specialization of function

o Every team need a leader

Common Problems in Teamwork:

Difficulties in communications

Teamwork takes time;

o Meetings take time

o Infrequent or two frequent meetings

3. Confidentiality

4. Common Problems in meetings:

o Interruption

o The setting (the place and time)

o Decision Yes, Action No.

The Members of the Primary Health Care Team:

o The patient is very important member in the team

o Doctors

o Nurses

o Receptionists

o Social workers

o Dietitians …

Who is the Leader?

o The successful leader will have the following criteria:

o The most responsible one in the team

o The most respectable one in the team

o The one with the highest income

o The one with the highest qualification

o The most stable one in the center to insuring continuity of care

Approach to Leadership:

o Initiatives: The leader person is usually the most initiative person in the team,

bringing new ideas and encouraging creativity

o Arrange social activities: Usually he /she makes use of every social occasion

in order to maintain good relationship between team members

o Take care of the new members: Usually he /she takes special care of the new

members, he/she will discuss with him his job description and help him to be

oriented to work environment and to be familial with other team members in

the practice


183

Cholesterol Screening F. Rayes

Cholesterol level mmol / L Action Follow-up

Less than 5.2 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

Indications of screening for hyperlipidemia

o Family history of CHD o Family history of hyperlipidemia o Premature vascular disease o Stigmata of hyperlipidemia o Hypertension o Diabetes mellitus o Obesity o All adults aged over 20 years (Future). o IHD / Referral for coronary angiography o Angina despite full medical therapy o Unstable angina o Angina with features of heart failure o Acute MI with recurrent pain between day two and discharge o Post-infarction angina during the next three months o Valvular heart disease


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

Mass immunization campaign.

o Size of the problem:

- 250,000 cases continue to occur each year.

- Crowding, poor sanitation, inadequate hygiene other enteric

pathogens are believed to facilitate transmission. - In USA 1955 >450 million doses were administer to children

and adults during 5 years

- Incidence declined from 18 cases / 100,000 total population to

2 cases / 100,000.

- 1961 the incidence decrease 1 case / 10 million populate by

1970.

- By 1979 NO cases Eradication in USA.

o Vaccine development and use:

- Salk (Inactivated Poliovirus Vaccine) IPV 1954

- Sabin (Live, Attenicated Vaccine ) OPV 1960


185

Global Eradication :

o WHO called for Global Eradication of poliomyelitis by year 2000.

o Achievement and maintenance of high immunization level.

o Vaccine quality control and availability.

o Training and supervision of in-country personnel.

o Acute Flacid Paralysis ( AFP ) surveillence.

o National Immunization Days ( NID ).

o Research and development to increase the effect of vaccine.

o No more than 14 cases / year, average 8 cases/ year since 1980.

o 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.

Immediate Treatment for Suspected Meningococcal Infections

o Adult and children older that 10 years --> 1200 mg Benzylpenicillin. IM o Children aged 1-9 years ---> 600 mg Benzylpenicillin. IM o Infants aged less than 1 year ---> 300 mg Benzylpenicillin. IM o Pt. with Rash / Warning Presentation o Associated symptoms suggestive of serious illness. o Purpuric or petechial rash o Generalized pustular rash o Infection in dangerous area eg. eyes, dangerous area of the face. o Very toxic patient


186

Tuberculosis F. Rayes & N Dashash

TB in Developed & Developing Countries in comparison to KSA:

Developed Developing KSA

Prevalence of infection in the age

group 0-14 y.

2 - 3 % 60 - 80 % 7 %

Case rate / 100,000

12 - 20 250-500 30 - 40

Mortality rate / 100,000

1 - 2 60 - 100 ---

Percent of TB deaths to total deaths 0.1 % 3 - 10 % ---

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).

TB / Facts

o BCG efficacy 60-80%.

o BCG cause +ve skin test for 6-7 years after immunization.

o False -ve PPD in 20% of active TB.

o False -ve PPD in 50% of HIV.

o Chest x-ray is normal in 50% of extrapulmonary TB.

TB / Diagnosis

o Clinically:

o High index of suspicion

o Screening Tests

o PPD skin test: if positive test = infection has occurred.

o X-ray chest: it is less sensitive than skin test.

o Confirmatory test

o Sputum

T.B. skin test

o 1 in 3 persons affected in the world.

o 20-30 % increase in cases in 1991. In USA 13% increased rate in 1992.

o 8 million new cases annually, 3 million deaths/year from T.B.

New CDC Recommendations

5 mm indurations is considered positive in:

o HIV or high risk for HIV

o Close recent contact TB patient

o CXR consistent with old TB

10 mm is considered positive in:

o Prevalent areas

o IV drug abusers

o Low socio-economic class and homeless

o Patients in long term care institutes

o Other medical conditions: gastrectomy , chronic renal failure, DM, steroid

o Health care employees, day care, schools …


187

Child with Short Stature F. Rayes

Criteria of familial short stature:

o Short parents o Normal birth history and gestational weight o Short stature but with normal growth velocity

o Bone age equal to choronologic age o Normal age for the onset of puberty o Absence of organic or psychogenic disease

Criteria for Constitutional Short Stature

o 50% of cases have history of delayed growth and development is either parent. o Normal birth history and growth for the first months of life. o Absence of organic or psychogenic disease o Bone age less than choronoligic age o Delayed onset of puberty. o Final height is appropriate for genetic potential.

Initial investigation of A child with short stature

X-ray to determine bone age:

o AP & lateral -knee & hand (< 2 ys age).

o AP & lateral - left hand (> 2 ys age).

Bio-chemistry:

o CBC

o Urinalysis

o ESR

o U&E

o LFTs

o Iron concentration

o Calcium, Phosphorus & Alkaline phosphate


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:

Don’t 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 & don’t ignore them.

Finally I ask God to help you to succeed your exams.


190

Internet Resources H. Hajjar

Site name Address

Sites of Interest to Family

Physicians

http://www.uwo.ca/fammed/clfm/sites.html

Internet resources for

family doctors

http://www.wonca.org/resources/journals/wonca_journals.htm

Journals

American Family

Physician

http://www.aafp.org/afp/index.html

Family practice

management

http://www.aafp.org/fpm/index.html

Royal Collage of General

Practitioners

http://www.rcgp.org.uk/

British Journal of General

Practice

http://www.rcgp.org.uk/rcgp/webmaster/bjgp_sub.asp

Electronic BMJ http://www.bmj.com/

Jama http://jama.ama-assn.org/

Royal Australian Collage

of General Practice

http://www.racgp.org.au/publications/

The Collage of Family

Physicians of Canada

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

http://www.aafp.org/

American Medical

Association

http://www.ama-assn.org/

American Diabetes

Association

http://www.diabetes.org/

British Hypertension

Society

http://www.hyp.ac.uk/bhs/

British Thoracic Society http://www.brit-thoracic.org.uk/

Center of Disease Control

and Prevention

http://www.cdc.gov/

Canadian Medical

Association

http://www.cma.ca/eng-index.htm

National , Heart, Lung and

Blood Institute

http://www.nhlbi.nih.gov/index.htm

WHO http://www.who.int/home-page/

http://www.wonca.org/


191

Site name Address

Evidence Based Medicine National Guideline

Clearinghouse

http://www.guideline.gov/body_home_nf.asp?view=home

Primary Care Clinical

Practice Guidelines

http://medicine.ucsf.edu/resources/guidelines/

Evidence-Based Medicine

(Journal)

http://hiru.mcmaster.ca/ebmj/default.htm

The Cochrane Library http://hiru.mcmaster.ca/cochrane/cochrane/cdsr.htm

http://www.mayohealth.org/home

Medscape http://www.medscape.com/

The Emergency

Medicine and Primary

http://www.embbs.com/

Auscultation Assistant http://www.wilkes.med.ucla.edu/intro.html

ي لصحي لسعو صصا للتلهي

http://www.arabcom.net/chp/scfhs/

194

Index

Acne: Approach to patient with acne 87

Anemia: Approach to patient with anemia 84

- Investigations 84, 96

- Macrocytic anemia 97

Ankle Examination 47

Antidepressant prescribing 32

Anxiety History 30

Arthritis: Approach to patient with arthritis 19

- History 19

- Examination 20

- Differential diagnosis and investigations 21

- X-Ray 135

Asthma: Approach to patient with asthma 8

- Advice 9

- Inhaler technique 9

- Peak Flow Meter 10

- Patient education 10

- Asthma traffic light zone 11

Audit 183

B Backache: Approach to patient with backache 23

- Back examination 23

- Counseling patient with backache 25

Body mass index 59

Breast Feeding Counseling 55

C Carpal Tunnel Syndrome 42

Chest Pain: Approach to patient with chest Pain 81

- Management of acute MI 80

- ECG findings 127

Cholesterol Screening 184

Community Medicine Review 157

Cough: Approach to patient with cough 81

- Differential diagnosis of child with cough 82

Contraception counseling 66

Contraception: Emergency Pill Counseling 67

Control of Communicable Disease 160

Control of Non-Communicable Disease 161

D Data Interpretation: Lab Tests 96

Data Interpretation: Slides 111

Data Interpretation: ECG 123

Data Interpretation: Radiology 129

Data Interpretation: Self Assessment Exercise 136

195

Diabetes Mellitus: Approach to patient with DM 12

- Counseling newly diagnosed DM 13

- Diabetes Investigations 99

Dermatology (see Data interpretation: slides) 111

Depression 31

Diarrhea: Approach to patient with diarrhea 83

Disastermanagement 162

Dizziness – Vertigo History 34

- Deferential diagnosis of vertigo 34

Dyspepsia 92

- Management of dyspepsia 93

E Ear, Nose & Troat 120

Epilepsy Counseling 51

Epidemiology 160

Evidence Based Medicine 164

F Febrile Convulsion Counseling 53

Field Survey 162

G Gastroenteritis: Approach to patient with gastroenteritis 57

Glaucoma 49

Glasgow Scale 190, 192

Glucose Tolerance Test 99

H Headache: Approach to patient with headache 85

- Headache alarming symptoms 86

- Headache deferential diagnosis 86

Hepatitis B Chronic Carrier Counseling 62

- Hepatitis investigation 100

Hormone Replacement Therapy (see menopause) 61

Hypertension: Approach to patient with hypertension 15

- History 15

- Examination 16

- Poor Compliance 18

I Impotence history 36

Infertility Female History 37

Infestations (see data interpretation: lab tests) 109

Insomnia Counseling (sleep hygiene) 64

INTERNET Resources 196

Investigations of epidemics 162

Irritable Powel Syndrome: Approach to patient with IBS 94

J Jaundice Syndromes (see data interpretation: lab tests) 100

Joint Examination 42

K Knee Examination 46

M Macrocytic anemia investigation 97

Management Cycle 158

Menopause counseling 61

Mental Status Examination 48

MI Counseling (Post MI) 54

196

N Nasal Bleeding: History 41

O Obesity Counseling 58

- Body Mass Index 59

Ophthalmology (see data interpretation: slides) 121

Optic Nerve Examination 50

Oral Exam 148

Otitis media: Approach to patient with OM 91

P Palpitation History 27

Planning Health Education Program 159

Periodic Health Examination 164

Pruritis History 29

R Red Eye Examination 49

Rheumatoid Arthritis 21

S Saudi Board Examination 1

Screening: Cholesterol 184

Screening: Colorectal Cancer 95

Screening: DM 99

Shoulder Examination 44

Short Stature 188

Simulated Clinic Exam 70

Statistics 168

Surgery 122

Surveillance 163

Smoking Counseling 60

Sore Throat: Approach to patient with sore throat 89

Studying Advice 194,195

STD History 40

T TB 187

Time Management 197

Teamwork 182

Toxpolasma management 103

Tremor History 28

Thyroid Function Tests 104

Traveler Diarrhea 68

Tetenus Prophylaxis 193

U Urinary Tract Infection: Approach to patient with UTI 88

Urine Analysis and MSU 105

V Vaccination 166

- Missed opportunity 166

Vaccinology General Roles 165

Vaginal Discharge History 38

- Deferential diagnosis and treatment 39

Vertigo (see dizziness) 34

W Weaning Counseling 56

Wrist Examination (Carpal Tunnel Syndrome) 42

X X-Ray (see data interpretation: radiology) 129

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