CCTD 2
Station 1
Case scenario summary: + Demographics Yaser is a 65-year-old diabetic and hypertensive ethiopian man works as accountant; minimal movement in work, married.
Chief of complaint: Severe Chest Pain He presented with severe chest pain after lifting up box
HPI Sudden Diffused heavy chest pain with no radiation associated with palpitation no cough, dizziness, nausea, vomitting - the symptom usually came for 45 minutes then subsided in recent episode chest pain persisted until the ER - at rest the pain subsided on lifting of heavy objects the pain exacerbates severity of 6
Past HX i want to ask you personal questions, would help me alot in diagnosis, are you okay with that? known case of HTN First time having chest pain with family hx of DM, MI - previously close relative died from MI
Currently taking medications of nsaids to manage the pain with no known allergen no previous transfusions or surgeries
Yaser works in office, smokes for 10 years - 2 packs a day, drinks alcohol twice or once week, no use of recreational drug use, no previous travel hx
Systemic Review: no headache, no blurred vision no nasal discharge no sore trhoat usual chest pain no constipation diarrhea no abdominal or blood in stool pass medium no blood in urine no skin rashes, eczema good sleep pattern no stress not to cold hot
Guide Case
Student instruction:*
- Obtain an accurate, focused medical history.
- Critically analyze clinical data obtained through history.
- Formulate and prioritize a differential diagnosis using reasoning skills
- Suggest a workup plan
- please take a focused history from this patient.
Presentation of chest pain: Chest wall: skin: Herpes zoster bones: Costochondirits - when breathing pain - Sharp, constant - acute lung: heart:
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Acute pain due ACD: angina (come & go // exertion) + MI (At rest)
- protective factor estrogen in females
- II III AVF corresponding leads to inferior wall (specific not widespread)
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Pericarditis: Acute not severe as angina - mostly viral pericarditis no radiation relieved by leaning forward - supine is worse -
- St Elevation - widespread (rarely could be localized due viral)
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Fever
esophagus:
Aorta:
- Aortic Dissection: acutely very sharp pain, uncontrolled BP
Chief of Complaint: Severe Chest Pain
HPI S: Site - Retrosternal O: Sudden or gradual | timing C: Stab | Dull | Pricking R: radiation A: angina - palpitation, SOB, Sweating, Dizziness, Syncop, Neusea T: started month ago? do you get it every day? E: alleviated by rest, on elevating on exertion S: Severity - scale of 1 to 10
Past Hx
- Comorbidities any kidney problem?
- Family Hx - anyone in family suffers from …
Systemic Review
Reference: 1. Talley NJ. Clinical Examination: A Systematic Guide to Physical Diagnosis. 8th ed. New York: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2018. Page: 88, 59-63
2. Kumar P, Clark M. Clinical Medicine. 10th ed. Philadelphia, PA: Elsevier; 2021. 1020, 1028-1029.
3. Lytvyn, Y. et al. (2022) Toronto notes 2022: Comprehensive medical reference and a review for the Medical Council of Canada Qualifying Exam (MCCQE). Toronto, Ontario, Canada: Toronto Notes for Medical Students, Inc. Page : C4-7 Cardiology
Station 2
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Introduce(cardiologist), purpose (consultation/advice)
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take demographic data, past hx
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ask if he knows his condition then explain if not with simple language
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then give advice (depending on risk factor; diet smoking alcohol obesity exercise married sexual activity (Sildenafil) travel) to decrease further attacks
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if he had attack again what he should do,
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what are associated symptom,
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compliance with medication
khalaf, 57y, sudanese teacher, married (doesnt know about heart attack) cardiac ischemic issue perticipated by risk factors, genetics from occlusion of…
DM HTN CL - smokes 2 packs a day for 20 years he tried to stop but failed, doesnt drink, or use any recreational drug, no recent travel
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we will give medications to reduce mortality,
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controlling DM, HTN (BP), CL and use reliever GTN when symptoms appear, come to ER when…
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avoid risk factors such as bad diet (processed food, low fiber), lack of exercise, smoking; try to go to cessation smoking center
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Try avoid driving in upcoming 2w & 6wk small large veichle respectively,
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6w with no sexual activity
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Avoid traveling
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do you have any questions?
Station 2 A Communication and counselling stations. Dr Sami Scene: cardiology ward
Case scenario 1 A 52-year-old gentleman teacher with a history of angina. He has come in with severe chest pain, unrelieved by GTN. The ambulance crew gave them pain relief and did an ECG. The ECG looks like an acute STEMI.
ILOs of the station:
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Communicate effectively with patients and their families.
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Demonstrate the ability to deal with patients in difficult circumstances.
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Communicate medical information appropriately, using verbal and writing skills (e.g. patient records, referrals, medical reports).
Candidate instruction: Please explain to him what you think has happened and what will happen now.
YOU DO NOT HAVE TO TAKE A HISTORY. THE DIAGNOSIS IS MI.
N.B : Learning objective: D_ealing with frightened patients. Watch how the_
doctors on the wards and in the clinics cope with anxious patients and reflect on what you
think works well. The doctor’s bedside manner is an important part of the treatment.
Station 2 B Communication and counselling stations. Dr Sami Scene: cardiology ward
Case scenario 2 A 52-year-old man has recently been discharged from the hospital following treatment for an ST elevation MI and has come in to see you now for the first time after discharge.
ILOs of the station:
- Communicate effectively with patients and their families.
- Demonstrate the ability to deal with patients in difficult circumstances.
- Communicate medical information appropriately, using verbal and writing skills (e.g. patient records, referrals, medical reports).
Candidate instruction: Please talk to the patient, answering any questions and addressing any concerns. Give appropriate lifestyle advice for a patient post-MI.
References 1. Philip Jevon_ Manoj Samaranayake_ Steve Odogwu - Medical Student Survival Skills_ History Taking and Communication Skills-Wiley-Blackwell (2019). 239. 2. Philip Jevon_ Manoj Samaranayake_ Steve Odogwu - Medical Student Survival Skills_ History Taking and Communication Skills-Wiley-Blackwell (2019). 243.
Station 3
My name is dr… Dempgraphic, SOCRATES
History: Clinical case scenario. Dr. Farouq
Station title: Right-sided weakness
Fatima A 34-year-old woman teacher married with two kids, on wheel chair presents with a history of sudden onset of right-sided weakness, first time participated at night after work was going to fall but husband held her
6m hx of progressive fatigue & blurring vision with pain on left eyes which subsided by it self few days later; optical neuritis; MS? (eutoph phenomina?)
electric back when head goes down warrd…CC symptoms increase on hot shower,
Exclusion no vomiting, nausea, urinary/stool incontinence, headache, loss of vision, trauma, hearing, speech, loss of consciousness, sensory, no loss of memory, dysphagia, no neck stiffness, no confusion, no photo/phonophobia, menstrual, no palpitation, no other neurological symptom, no arterial fibrillation, headache, SLE, no previous misscariage (APA), vegetation rheumatic fever, no fever
Past Hx No HTN, No Diabetes No family hx of same symptom, one of her cousin on wheel chair doesnt know why.
previously did appendectomy Takes oral contraceptive (increase stroke), multivitamins
CNS ⇒ Heart
Examination
- CNV normal
- hyper reflexia, +VE babinski
- Motor loss on right side
- loss of position sense, vibration
- overshooting;
- disbalance
(Cerebellar + post column + optic nerve + cortex involvement)
investigations
- CT exclusion infarction, hemorrhage (first line)
- MRI Plain without contrast: to R/O stroke/ hemorrhage (gold standard)
- High protien, normal glucose, oligoclonal bands
Treatment
- High dose Steroids - 1g for 5 days - improved magically on acute but will come back
- use disease modifying drugs (monoclonal antibodies ((nitroglixumab ??; infection spread))) try to supress immunity
methotrexate interferon gamma
((Hemiplegic migraine??? Conversion disorder???)) hemplegia + Severe headache - hx of delivery 2 days ago cortical/venous sinus thrombosis (risk of postpartum + OCP) - DVT PE SLE - thrombosises
(hemeperesis moves, hemeplegia cant move) first loss of vibration & Position sense
Rheumatoid arthiritis (Methotrexate)
ILOs of the station: Obtain an accurate focused medical history. Critically analyze clinical data obtained through history.
- Formulate and prioritize a differential diagnosis using reasoning skills
- Suggest a workup plan
Student instruction**:** please take a focused history from this patient.
Case scenario summary: A 34-year-old female patient presented with Rt hemiplegia and was found to have MS.
Reference: 1. Talley NJ. Clinical Examination: A Systematic Guide to Physical Diagnosis. 8th ed. New York: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2018. Page: 489-499
2. Kumar P, Clark M. Clinical Medicine. 10th ed. Philadelphia, PA: Elsevier; 2021.836-845
3. Lytvyn, Y. et al. (2022) Toronto notes 2022: Comprehensive medical reference and a review for the Medical Council of Canada Qualifying Exam (MCCQE). Toronto, Ontario, Canada: Toronto Notes for Medical Students, Inc. Page : N51-55 Neurology
4. https://youtu.be/0hhcxaeOCYs
Station 4
A Procedural Skills stations
Mr. Robinson
Station title: ECG recording
A 40-year-old woman presented with chest pain.
.
ILOs of the station:
· Perform an ECG with proper counselling before the procedure.
· Outline the indications of the procedure.
Student instruction: please perform an ECG .
Case Summary:
Examination: ECG recording
Reference:
1. Jevon P, Ruchi Joshi. Medical student survival skills. Procedural skills. Hoboken, Nj: Wiley-Blackwell; 2020. Page 41.