Approach to A Patient Presenting With Unconciousness

A patient with unconsciousness is usually brought o the emergency department and is categorized as having a GCS of less than 8.
There may be many causes that can lead to unconsciousness. A list of these are given below:

Causes;

1. Trauma:
   
- Head injury:

• Diffuse axonal injury.
• Extradural hemorrhage. 
• Subdural hemorrhage. 

2. Metabolic causes: 

• Hypothermia
• Hypoglycemia
• Hyperglycemia
• Hypernatremia
• Diabetic ketoacidosis

3. Organ failure: 

• Cardiac/circulatory failure
• Respiratory failure
• Liver failure leading to encephalopathy.
• Renal failure (uremic coma)
• Hypothyroidism

4. Vascular causes: 

• Stroke.
• Subarachnoid hemorrhage. 

5. Infections:

• Meningitis
• Encephalitis
• Cerebral malaria.

6. Toxins or Drug Induced: 

• Alcohol
• Overdose of opiates tricyclics, benzodiazepines
• Carbon monooxide poisoining

7. Neurologic Causes: 

• Brain tumor
• Brain abscess
• Epilepsy

Clinical History: The history of an unconscious patient is usually obtained from the ambulance crew, relatives, friends or witnesses. other sources of information are previous hospital notes and records kept by general practitioners and tablets or prescriptions found at the patient's premises.

Chronic Renal Disease and Hypertension.

A 45-year-old woman with type 1 diabetes mellitus is reviewed in the diabetes clinic. Three months ago her blood tests were as followed:
K+ 4.5 mmol/l , Creatinine 116 μmol/l , eGFR 47 ml/min

At the time she was started on lisinopril to treat both the hypertension and act as a renoprotective agent. Lisinopril had been titrated up to treatment dose. Her current bloods are as follows:
K+ 4.9 mmol/l , Creatinine 123 μmol/l ,  eGFR 44 ml/min

Of the following options, what is the most appropriate course of action?
A. Stop lisinopril and arrange investigations to exclude renal artery stenosis
B. Switch to a angiotensin 2 receptor blocker
C. Switch to a different ACE inhibitor
D. No action
E. Reduce dose of lisinopril

Answer:

Estimated GFR or eGFR For Staging Chronic Renal Disease.

A 62-year-old man with chronic kidney disease secondary to diabetes mellitus is reviewed. When assessing his estimated glomerular filtration rate (eGFR), which one of the following variables is not required by the Modification of Diet in Renal Disease (MDRD) equation?
A. Age
B. Serum creatinine
C. Ethnicity
D. Gender
E. Serum urea

Answer:

Initial Therapy for a 67-year-old woman with Newly Diagnosed Parkinson's disease?

What should be initial therapy for a 67-year-old woman with newly diagnosed Parkinson's disease?
A. Levodopa/carbidopa combination
B. Dopamine agonist
C. Levodopa/carbidopa plus a COMT inhibitor
D. MAO-B inhibitor
E. Any of the above choices

Answer:  

NICE Guidelines for the Management of Dyspepsia.

A 35-year-old man who is usually fit and well presents to his GP with a 2 month history of indigestion. His weight is stable and there is no history of dysphagia. Examination of the abdomen is unremarkable. Of the following options, what is the most suitable initial management?
A. Urea breath testing and non-urgent referral for endoscopy
B. H pylori eradication therapy and full-dose proton pump inhibitor for three months
C. Full-dose Proton pump inhibitor and immediate referral for endoscopy
D. Three month course of a standard-dose proton pump inhibitor
E. One month course of a full-dose proton pump inhibitor

Answer:

Regarding Management Of Congenital Inguinal Hernias

The mother of a 2-month-old boy comes to surgery as she has noticed a soft lump in his right groin area. There is no antenatal or postnatal history of note. He is breast feeding well and is opening his bowels regularly. On examination you note a 1 cm swelling in the right inguinal region which is reducible and disappears on laying him flat. Scrotal examination is normal. What is the most appropriate action?
A. Refer to paediatric surgery
B. Refer to orthotics for fitting of a Pavlik harness
C. Reassure mother + ask her to return if not resolved by 6 months
D. Reassure mother + ask her to return if not resolved by 12 months
E. Reassure mother + ask her to return if not resolved by 2 years

Answer:

Case Scenarios Of Patients presenting With Hematuria And Their Diagnosis .

A. Transitional cell carcinoma of the bladder
B. Renal stones
C. Chlamydia
D. IgA nephropathy
E. Urinary tract infection
F. Renal cell carcinoma
G. Polycystic kidney disease
H. Goodpasture's syndrome
I. Urethral syndrome
J. Renal vein thrombosis

For each one of the scenarios given below  please select the most likely diagnosis from the list of choices given above:

1. A 14-year-old boy develops visible haematuria following an upper respiratory tract infection.

Answer: IgA nephropathy which is also called Berger's disease.

2. A 60-year-old man presents with visible haematuria for the past three weeks. He has an ache in the left loin but examination is unremarkable other than a left varicocele. He also notes to feeling intermittently hot and sweaty.

Answer: Renal cell carcinoma.

Features of renal cell carcinoma include:

• classical triad: haematuria, loin pain, abdominal mass
• pyrexia of unknown origin
• left varicocele (due to occlusion of left testicular vein)
• endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
• 25% have metastases at presentation

3. A 21-year-old female complains of dysuria for the past week, despite just completing a three day course of trimethoprim. Urine dipstick is positive for blood + and leucocytes +. A MSSU shows no organism.

Answer: Chlamydia infection

Features of Chlamydia include: 

•  asymptomatic in around 70% of women and 50% of men
• women: cervicitis (discharge, bleeding), dysuria
• men: urethral discharge, dysuria

Brief Discussion On Hematuria 

A 42-year-old carpenter presents with wrist pain and grip weakness

A 42-year-old carpenter presents with wrist pain and grip weakness. On exam, he is found to have pain over the radial aspect of the wrist that is aggravated by flexing the thumb and applying ulnar flexion. The most likely diagnosis is
A) Carpal tunnel syndrome
B) Scaphoid fracture
C) de Quervain’s tenosynovitis
D) Boxer’s fracture
E) Hamate fracture


Answer and Discussion

Predictors For Preterm Labor.

Which of the following tests has been shown to be a good predictor of preterm birth in women presenting with symptomatic preterm uterine contractions, and thus help guide the pharmacologic management of preterm labor patients?

A) Screening for genitourinary infections
B) Measurement of salivary estriol
C) Cervical length measurement
D) Fetal fibronectin screening
E) Both C and D


Answer and Discussion

Irritable Bowel Syndrome: Management

A 28-year-old woman is diagnosed with constipation predominant irritable bowel syndrome. She occasionally experiences spasms of pain in the left iliac fossa.
Which one of the following is LEAST likely to help her symptoms?
A. Mebeverine
B. Ispaghula
C. Methylcellulose
D. Sterculia
E. Lactulose

Answer:

Colorectal Cancer: Referral Guidelines

A 62-year-old man presents with insomnia and lethargy. He has no other systemic symptoms of note. Routine clinical examination reveals a palpable mass in the right lower quadrant of the abdomen, which doesn't move with respiration and is non-pulsatile.
What is the most appropriate management?

A. Blood screen including LFTs, U&Es
B. Urgent referral to local urological service
C. Ultrasound abdomen
D. Urgent referral to local colorectal service
E. Routine referral to general surgical clinic.

Answer:

Prescribing Drugs in Patients With Renal Failure

A 54-year-old man with stage 4 chronic kidney disease presents for review. Which one of the following drugs is it most important to avoid?

A. Erythromycin
B. Diazepam
C. Rifampicin
D. Tetracycline
E. Warfarin

Answer :

Cause Of Hyponatremia In a Patient With Head Injury

A 21-year-old man was admitted to the intensive care unit after a road traffic accident during which he suffered a severe head injury. He required ventilation.
Investigations are shown.below:

Sodium 128 mmol/l
Potassium 3.6 mmol/l
Creatinine 81 mmol/l
Urea 4 mmol/l
Thyroxine 30 nmol/l
TSH 2 mu/l
Serum cortisol 1000 nmol/l
(NR 170–700 nmol/l)

What is the cause of the hyponatraemia?
a. Hypopituitarism.
b. Addison’s disease.
c. Syndrome of inappropriate ADH secretion.
d. Hypothyroidism.
e. Cushing’s syndrome.

Answer:

Symptoms suggestive of Wernicke's encephalopathy

A 58 year old man is brought to the emergency department in a confused state. He is unsteady on his feet. This man has a long history of alcohol abuse.
Which of the following findings would most strongly support the diagnosis of Wernicke's encephalopathy?

A. Drowsiness, jaundice and metabolic flap
B. Fluctuating conscious level with focal neurologic signs.
C. Nystagmus amd ataxia of gait.
D. Nystagmus and intention tremor
E. Tachycardia and tremulousness.

Answer And Discussion:

Best Treatment To Improve Coronary Perfusion In A Patient Presenting With Acute Chest Pain

A 49-year-old male presented to the Accident and Emergency Department with a one-hour history of severe central chest pain. He smoked 30 cigarettes per day.
Physical examination was normal.
The 12-lead ECG revealed ST segment elevation in leads V1–V4. There were no contraindications to thrombolysis.

What is the best treatment to improve coronary perfusion?
a. IV Streptokinase.
b. IV Tenectoplase.
c. IV Alteplase.
d. Half-dose tenectoplase and half-dose abciximab.
e. Primary coronary angioplasty.

Answer And Discussion:

Approach To A Case Of Infertility.

A 32 year old female presented with the concern of infertility. She got married at the age of 26 but despite trying has not conceived.
1. What relevant points on history should be further explored? enlist 8 points.
2. What are the common causes of infertility in a couple? name any 4
3. List at least 4 investigations that should be advised in this scenario, write in order of importance.

( Question from Family medicine MCPS paper October 19th 2016)

Solution:

Regarding Overdose With Antidepressants....

1. A 20-year-old female presents to the ED with an overdose. She has a history of depression, and there were empty bottles found at her bedside. The bottles had contained clonazepam and nortriptyline. The patient is unconscious with diminished breathing and is unable to protect her own airway.
The BEST next step is to:
A) Intubate the patient.
B) Begin gastric lavage and administer charcoal.
C) Administer flumazenil, a benzodiazepine antagonist,
to awaken her and improve her respirations.
D) Administer bicarbonate.
E) Any of the above.

Answer and Discussion

Regarding Anthrax ?

1. Which of the following properly describes the isolation requirements of a patient with pulmonary anthrax?
A) No isolation necessary. The patient may be in the same room with an uninfected patient.
B) Respiratory isolation only.
C) Respiratory and contact isolation.
D) Negative pressure room (such as with tuberculosis) + contact isolation.

Answer And Discussion

Symptoms Specific For Depression

A 45-year-old professional male who recently suffered an uncomplicated anterior wall myocardial infarction (MI) thinks he is depressed. He is tired all the time, has poor sleep, a poor appetite, and
he has been irritable. He has also been tearful and blames himself for his MI.
You know that some of this patient’s symptoms could be secondary to his medical illness.

Which one of the following symptoms, if present, is the most specific for depression?
A) Sleep problems.
B) Appetite difficulties.
C) Psychomotor agitation.
D) Low energy.
E) Excessive preoccupation with death.

Answer And Discussion

Most Common Factor Responsible For Infertility

What is the most common factor responsible for a couple's infertility?

A. Ovulatory factor
B. Male factor
C. Tubal and peritoneal factor
D. Cervical factor
E. Uterine factor

 Answer :

Regarding a Child With History Of Anaphylaxis

For a child with a history of anaphylaxis, which of the following preventive measures would be inappropriate:

A. Allergen desensitization with insect venom for those sensitive to stinging insects
B. Avoidance measures
C. Patient education on the use of epinephrine
D. Pre treatment with diphenhydramine before administration of antibiotics causing anaphylaxis
E. Education of close family members concerning treatment of anaphylaxis

Answer : 

A young Man Presents With Acute Abdominal Pain

A 20 year old young male presents to your clinic with 12 hour history of severe right lower abdominal pain. It has started earlier around the umbilicus and is associated with nausea and low grade fever. On examination he has a temperature of 100 F and has tenderness in right illiac fossa with rebound tenderness.
1. What is the provisional diagnosis?
2. Enlist 4 investigations you would order?
3. Outline your management plan?
 
( Question from MCPS Family Medicine October 19th 2016 paper)

Solution: 

1. What is the provisional diagnosis?

Answer: Acute Appendicitis.

2. Enlist 4 investigations you would order?

A 12 Year Old Boy With Pain In His Legs At Night

A 12-year-old obese boy presents to your office complaining of bilateral leg pain that occurs only at night. His mother denies any pain during the day and reports he has not had a limp. The most likely diagnosis is
A) Slipped capital femoral epiphysis
B) Legg–Calve–Perthes disease
C) Osgood–Schlatter’s disease
D) Patellofemoral syndrome
E) “Growing pains”

Answer and Discussion

Regarding Acute Sinusitis In Children

In treating acute sinusitis in children, which of the following sinuses is unlikely to be infected in a 6-year-old?
A) Frontal
B) Maxillary
C) Ethmoidal
D) Sphenoidal

Answer and Discussion

Examining For Ascites

Ethical Principles In Counselling A Patient With A Positive HIV Screening Result.

A 35 year old male, businessman by profession presents to your clinic with history of fatigue and weight loss for last 3-4 months. He has come to you to discuss his HIV screening report which shows positive result. He does not want this to be discussed to anyone, not even his wife.
Answer the following questions:
1. How would you counsel the patient keeping in mind the ethical principles?
2. Enlist 4 tests you would like to do in this patient?
3. Give your opinion regarding breach of confidentiality in this case. Justify your answer?

( Question from MCPS Family Medicine October 19th 2016 paper)

Solution:

Regarding Cervical Cancer And Its Screening.

A 25 year old recently married woman presents to your clinic wanting information.
1. What are the screening recommendations for cervical cancer and how often should this be done?
2. What is the most appropriate method recommended to prevent cervical cancer?
3. What are the risk factors for cervical cancer and what life style modifications would you suggest?

(Question From MCPS Family Medicine Paper on October 19th 2016)

Solution:

1. What are the screening recommendations for cervical cancer and how often should this be done?

Answer:

Approach to a Case Of 3 Year Old Boy With Malnutrition

A 3 year old boy is brought by his mother as she feels he is not gaining weight. His height is on the 25th centile and weight is below 5th centile for age. There is also history of passing worms in stool.
Answer the following questions.
1. Enlist 6 relevant questions you would like to ask in history?
2. Enlist 2 relevant investigations you would order?
3. Enlist 3 nutritional points you would like to emphasize?
4. Enlist 4 points in your pharmacological management plan.?

(Question From MCPS Family Medicine paper October 19th 2016.)

Solution:

 1. Enlist 6 relevant questions you would like to ask in history?

Answer:

Cardiac Lesion In Infant With Congenital Rubella

Which of the following cardiac lesions is likely to be found in an infant with congenital rubella?
A) Patent ductus arteriosus (PDA).
B) Tetralogy of Fallot.
C) Transposition of great vessels.
D) Coarctation of aorta.
E) Bicuspid aortic valve.

Answer And Discussion

Contraindication For Circumcision

Routine circumcision is absolutely or relatively contraindicated in all of the following situations
EXCEPT:
A) Congenital phimosis.
B) Micropenis.
C) Hypospadias.
D) Ambiguous genitalia.
E) Religious beliefs of the parents that circumcision is wrong.

Answer And Discussion

Common Causes Of Cough

The three most common causes of chronic cough (cough lasting longer than 8 weeks) are:
A) Postnasal drip, asthma, GERD.
B) GERD, COPD, congenital lung disease.
C) Lung cancer, postnasal drip, COPD.
D) Obstructive sleep apnea, respiratory infections, asthma.

Answer And Discussion

A 53 Year Old Man with Complains of Night time Cough For 6 Weeks

A 53-year-old male is accompanied by his wife to your office and complains of a cough for 6 weeks. It is worse at night and any time he lies down. He denies sputum production, shortness of breath, chest pain, and wheezing. He takes an antacid once or twice per day to settle his stomach and notes very bad heartburn. He smoked three packs of cigarettes per day until 1 year ago, when he quit “cold turkey.” He takes only hydrochlorothiazide for hypertension and a daily aspirin. He has no cardiac disorders. His wife reports that he snores at night, and she adds, “He’s always hacking and clearing his throat—all night.” The review of systems is negative. In order to sleep better, he has recently started having a shot of whiskey before going to bed.

What is the most likely cause for the cough?
A) Gastroesophageal reflux.
B) Lung cancer.
C) Antihypertensive medication.
D) Alcohol abuse.
E) Congestive heart failure (CHF).

Answer And Discussion

A 7 Year Old Boy With Autism Has Trouble Falling Asleep.

A 7 year old boy , a known case of autism is brought to his pediatrician with trouble falling asleep. The pediatrician checks his clinical record which shows normal growth and no significant past medial or surgical histories. On further questioning mother says that the child has been under the care of multiple caregivers as she herself is busy with her tough job.It is very likely that the caregivers have been putting the child to bed with no consistent timing and routine.

Q 1. What is your Diagnosis?

Regarding Normal Sleep Biology

Which of the following statements about normal sleep biology is FALSE?

A. Parasomnias include sleep walking, sleep talking and night terrors.

B. There are no significant age related changes in sleep duration and sleep patterns between infancy, early childhood, young adulthood and old age.

C. Sleep can be segregated into 5 stages although the REM stage is so distinctive that sleep is often separated in to REM and non-REM sleep.

D. Duration of sleep and walking is one of the most prevalent health disorders in persons in the US and is a major public health concern accounting, for example, for many traffic accidents.


The correct answer is:

Examination Of The Upper Limbs Motor Function

Examination Of The Motor System Of The Lower Limbs

A 69 Year Old Man Presents With Weakness In His Left Arm

A 69 year old man comes to your clinic with presenting complain of weakness in his left arm. His vitals are:
Temp: 98.6 F
BP: 160/100 mmHg
HR: 80/min
RR: 20/min

Q 1. List the points you would like to ask in clinical history? 

Answer: In this ask ask about:

A Case OF Tetanus

A 26-year-old male presented to the Accident and Emergency Department with a stiff jaw and being unable to open his mouth. Three days previously he was immunized with tetanus toxin after lacerating his finger at work.  On examination, he had evidence of ‘lock jaw’. His injured finger was swollen, painful and exuding pus.

What is the immediate management?
a. Debridement and cleansing of the wound.
b. Injection of tetanus antitoxin into the wound.
c. Oral penicillin V.
d. Intramuscular human tetanus immunoglobulin.
e. Intravenous pancuronium.

Answer:

A Case Of Prosthetic Valve Endocarditis

A 62-year-old male presented with fever and breathlessness four weeks after a prosthetic aortic valve
replacement for aortic stenosis. On examination he appeared pale and had a temperature of 38°C (100.4°F). Auscultation of the heart revealed a prosthetic second heart sound and a long early diastolic murmur. Auscultation of the lungs revealed inspiratory crackles at both lung bases.
Initial investigations are shown.

Hb 11 g/dl
WCC 15 109/l
Platelets 400 109/l
ESR 70 mm/h
Sodium 140 mmol/l
Potassium 4.2 mmol/l
Urea 8 mmol/l
Creatinine 130 mol/l
12-lead ECG Left bundle branch block (old)
Chest X-ray Cardiomegaly and pulmonary oedema

Q 1. Which two of the following investigations will provide the most diagnostic information?
a. C-reactive protein.
b. Renal ultrasound.
c. ASO titres.
d. Serial blood cultures.
e. Transthoracic echocardiography.
f. Urinalysis for blood.
g. Complement fixation tests for Coxiella burnetii.
h. Transoesophageal echocardiography.

Answer:

A Case Of Nocturnal Enuresis

A 5-year-old male presents to your clinic with his mother with a complaint of enuresis. Evidently, this
child has never been completely continent at night, wetting his bed several times per week. This has become somewhat of a problem for him now that his friends are having sleepover birthday parties. Plus, his mother confides that she’s tired of paying for pull-ups and cleaning sheets. His incontinence is mono symptomatic (meaning no overactive bladder symptoms or daytime wetting).
Because he has had no period of nocturnal dryness, this patient has primary enuresis.

Q 1. Which of the following is likely to be part of this child’s history?
A) A family history of enuresis.
B) A stressful event in the family such as the birth of a new child or parental divorce.
C) Increased fluid intake over the past 2 months.
D) History of urinary tract infections.

Answer And Discussion

A 2 year Old Child With Intermittent Crying Episodes And Lethargy

A 2-year-old male presents to your office with his father complaining that the patient has had intermittent crying followed by episodes of profound lethargy during which he is difficult to arouse. The father relates that the patient will sometimes clutch at his abdomen and roll into the fetal position during episodes. These episodes have been going on for about 4 hours. He has had no fever, no vomiting, and no diarrhea. Nobody else at home has been sick. He is developmentally normal and has no significant past medical history.
His exam reveals that he is afebrile and lethargic but can be aroused. His abdominal exam is benign. The rest of the exam is unremarkable. Given his presentation, your clinical suspicion is for:

A) Meningitis.
B) Renal colic.
C) Intussusception.
D) Gastric outlet obstruction.
E) Appendicitis.

Answer and Discussion:

Common Side Effect Of Immunization In A 2 Month Old Baby

A 2 month old baby was brought for routine immunization .What is a common side effect that this baby might have after her immunizations.

A) Fever to 104◦ F.
B) Autism.
C) Diabetes.
D) Erythema at the site of immunization.
E) Symptomatic shedding of virus in her stool.

Answer And Discussion

A 35 Year Old Man Presents With Back Pain

A 35 Year old man comes to your clinic with back pain. He says he was not able to bend to tie his shoe laces because of the sharp pain in his back. It started a day ago . The pain does not radiate and he denies any pain, numbness or weakness in his legs. His vitals are within normal limits.

Q 1. Obtain a focused history of this patient ?

Answer:

1. Since the main complain is back pain the details about pain should be asked:

• Site of pain
• Intensity of pain
• Quality of pain
• Onset of symptoms
• Radiation of Pain
• Aggravating and relieving factors.
• Previous episode of similar pain.

2. History of any trauma

3.  Ask about any medicines the patient might be taking.(prescription and Over the counter)

4. History of any allergies, hospitalization, surgery , major illness.

5. Review of systems must include any urinary symptoms like pain on urination or blood in urine.

6. Any sensory loss or motor weakness in the legs . 

Q 2. List the main points you would like to perform during examination? 

Answer:

Medical Condition Associated With Mental Retardation

Which of the following conditions is commonly seen in patients with mental retardation?

A) Hyperthyroidism
B) Hyperparathyroidism
C) Diabetes mellitus
D) Osteoporosis
E) Pernicious anemia

Answer and Discussion

Extra Caloric Requirement During Pregnancy

During pregnancy, it is important to counsel pregnant patients to add an additional _________ calories to their dietary intake for normal activity.
A) 150
B) 300
C) 500
D) 1,000
E) 1,500

Answer and Discussion

Asymptomatic Bacteriuria in A Pregnant Lady

A 21-year-old woman who is 12 weeks pregnant with her first child presents to your office. A urinalysis shows evidence of bacteriuria. She is completely asymptomatic. Appropriate management at this time includes which one of the following?

A) No treatment at this time; repeat urinalysis at her next visit.
B) Reassure the patient that antibiotic administration is not necessary unless she should develops symptoms.
C) No antibiotic treatment; ask the patient to drink more fluids and cranberry juice daily.
D) Discontinue urinalysis at OB visits because of the high rate of false positives.
E) Treat the patient with a 7-day course of amoxicillin.

Answer and Discussion

Regarding Dysmenorrhea

Which of the following is considered first-line therapy for primary dysmenorrhea?
A) Nonsteroidal anti-inflammatory drugs (NSAIDs)
B) Selective serotonin reuptake inhibitors (SSRIs)
C) Antiestrogens
D) Acupuncture
E) Tricyclic antidepressants

Answer and Discussion

Treatment of Breast milk jaundice

The current recommendation for the treatment of breast milk jaundice (NOT breastfeeding failure
jaundice) is:
A) Continue to breastfeed.
B) Stop breastfeeding and change to a cow’s milk formula.
C) Stop breastfeeding and change to soy milk formula.
D) Stop breastfeeding and treat with rehydration solution (e.g., Pedialyte).

Answer And Discussion

A 48 Year Old Patient With Breathlessness And Ankle Swelling

You are seeing a 48 year old patient in your clinic who has a 3 month history of progressive exertional dyspnoea, fatigue and peripheral edema. He has been generally fit and without prior medical history. He mentions his father died in his forties due to 'large heart'. He is not taking any medications and you start furosemide 40 mg once daily.
Regarding the case answer the following questions:

Q 1. What further questions you should ask in history? 

Answer: Ask about:
• Chest pain: if present, does this sound like ischemic cardiac pain or like pleurisy?
• Cough/sputum: has it been present and has there been haemoptysis?
• Wheeze: note that this is not synonymous with airway disease. It may occur in pulmonary oedema when it is known as ‘cardiac asthma’.
• Recurrent asthma/bronchitis or any other respiratory problem.
• Smoking, which is obviously a substantial risk factor for both chronic airway disease and ischaemic heart disease.
• Alcohol intake, which is a risk factor for cardiomyopathy. Ask: ‘How much alcohol do you drink now? Have you ever been a heavy drinker in the past?’
• Previous BP measurements: untreated hypertension can lead to left ventricular failure.
• Previous cardiac surgery might be suggestive of impaired left ventricular function or constrictive pericarditis

Q 2 . List The Differential Diagnosis for a patient with breathlessness and ankle swelling? 

Answer: Differential Diagnosis

A 33 Year Old Man With Complaints Of Irritability, Difficulty Sleeping, Inability to Concentrate And Excess Worry

A 33 year old man comes to your clinic complaining of irritability, difficulty sleeping, inability to concentrate and excessive worry. These symptoms have been present over the past 8 months. The most appropriate diagnosis is : 

A. Major depression disorder with anxiety.

B, Anxiety disorder with depression

C. Generalized anxiety disorder

D. Mood disorder not otherwise specified

E. Obsessive compulsive personality disorder.

Answer And Discussion: 

The correct answer is 

Causes Of Jaundice

Jaundice is yellow discoloration of the tissues niticed especially in the skin and sclera, due to accumulation of bilirubin. For jaundice to be clinically apparent the circulating bilirubin levels should exceed 35 micro mol/l

Causes: The causes of jaundice may be divided into:

• Prehapatic = due to hemolysis, 
• Hepatic = due to intrinsic liver disease.
• Posthepatic = due to either intrahepatic cholestasis or post hepatic biliary obstruction. 

1. Pre-Hepatic Causes:

• Congenital Defects: 

                      - Gilbert's disease.

                      - Crigler Najjar syndrome

• Hemolysis: 

           Congenital Red cell defects:

                       - Hereditary spherocytosis

                       - Sickle cell disease

                       - G6PD deficiency

                       - Thalassemia

            Acquired:

                      - Malaria

                      - Incompatible blood transfusion

                      - Autoimmune

                      - Hemolytic disease of newborn

                      - Absorbing large Hematoma

                      - Hypersplenism

2. Hepatic Causes: 

• Acute hepatocellular disease: 

Evaluation Of the Patient with Delirium

The appropriate evaluation of the patient with delirium includes which of the following?
A) Evaluation of metabolic causes such as electrolytes and glucose.
B) Evaluation for infection such as UTI and pneumonia.
C) Evaluation of a patient’s medications.
D) Evaluation of oxygen saturation.
E) All of the above.

Discussion
The correct answer is

Gastroesophageal Reflux Disease

A 35 year old man presents in your clinic complaining of substernal chest pain and a metallic taste in mouth. He has been having this pain for the past few months and usually starts when he take heavy oily meals. You suspect GERD (gastroesophageal reflux disease).
Answer the following questions.

Q 1. What are the alarming signs and when should one perform endoscopy in a patient with suspected GERD?

Answer: The following symptoms should be considered serious and an endoscopy should be performed:

• Weight loss
• Anemia
• Blood in stool
• Dysphagia