wooohooooo!

71 malay male, retire teacher (16 years)

PCx
generalized abdo pain

sudden onset epigastric region radiating to back
started April
aggravated by eating --> induces vomitting to stop pain
last for 12 hours

other Sx review - unremarkable (no change in bowel habits)

1st went to clinic --> pain killers --> didnt do much --> 1 month still have condition

went to GH 3 days ago and was admitted

Ix
FBC
ECG
OGDS (pending)
stool sample

Ass Sx
19 kg lost with los appetite (6 month)

Ex
cachexic, mild palor, not jaundice
no stigmata of liver disease

no palpable mass, no abdo swelling

Task

1) defined anemia, common causes (devide into medical and surgical) and risk factors for developing anemia saree
(physiology of blood production and destruction, its just the same thing with causes, classify it in a systematic way)

2) clinical manifestation (sign n symptoms) maze

3) diagnosis (investigation - finding out causes of anemia) yazid

4) indication and complication of blood transfusion chris

5) describe Duke and TNM staging for bowel cancer and compare both of them christine

6) screening, prevention and prognostic factors of CA bowel alvin

1. physiology of normal gait or walking maz

2. describe patterns of gait abnormality- videos and stuff yazid

3. consequences of gait abnormalities saree

4. examination of gait disorders chris

5. investigation for gait disorders. christine

6. principles of management of gait disorders alvin

TASKS

1. What brain structures and body functions are important in consciousness chris

2. assessment of severity of delirium christine

3. precipitating causes of delirium maz

4. ICD 10 Diagnostic Criteria for delirium - DSM IV - Saree

5. management of delirium - APA practice guideline for management of delirium 2004 - alvin

6. investigation for delirium yazid

Mr Milton Fong
67 yr old Retired accountant
10 yr hx of type II diabetes. claim to be well controlled.
gradual onset of decreased sensitivity of feet over last 3 yrs and numbness.
also has unpleasant burning sensation in feet and toes - keeps him wake at night.
difficulty walking on uneven ground - especially in dark.
no family hx of similar symptoms.
Normal CN examination - but mild to moderate retinopathy.
- UL = normal tone, power, reflexes, sensation and coordination.
- Symmetrical decreased sensitivity - pin prick up to midshin level with diminished proprioception and vibration.
Absent ankle tendon reflexes.
Power relatively normal.

poor to moderate values of diabetic control.
microalbuminuria,
serum protein = normal.
syphillis, Hep B, C, and HIV = negative.
CSF protein non elevated.
nerve conduction studies = LL low amplitude or absent sensory responses compare to UL which is normal. EMG mildly lon duration high amplitude polyphasic motor unit potentials in distal but not proximal LL muscles.


TASKS:

1. Pathophysiology of Peripheral Neuropathy yazid

2. Clinical features of peripheral neuropathy vs myopathy - features of history maz

3. Diabetic foot care + how to manage pain and maintenence of function of neuropathy saree

4. investigations to diagnose peripheral neuropathy - nerve conduction studies! and others if there are. alvin

5. common causes of peripheral neuropathy & how it causes the peripheral neuropathy if there is an explanation how to classify them. chris

6. examination - Clinical features of peripheral neuropathy vs myopathy christine

5.

1.discuss the epidemiology, economic impact, role of health promotion and prevention of stroke yazid

2. define stroke - aetiology/causes and major risk factor for stroke as well as the pathophysiology of stroke christine

3. anatomy of the brain and spinal cord - bloody supply in spinal canal and ventricle essential alvin

4. diagnosis of stroke - what are the key features in the history, examination (nervous system) investigations for stroke - what do you do first etc etc. saree

5. describe the drugs used in stroke prevention treatment. mechanism of the drugs pls. maz

6. management plan for stroke patient including role of allied health professionals and other medical specialty - physiotherapy etc. basically the HOLISTIC CARE lol chris

1. GCS – IN DETAIL!!!!!!!!! + pharmacology of patients who are comatose – what drugs come into play – sedation etc yazid
2. full neurological examination on a comatose patient – DEMOOOOO!! alvin
3. management of a comatose patient – algorithm of managing a coma patient and then how you investigate maz
4. causes of coma – CLASSIFY chris
5. definition of coma & brain death and assessment of brain death saree
6. issues behind a brain dead patient – who decides, the psychosocial stuff christine

1) anatomy of the rectum and anal canal (nerve blood) christine

2) negotiation of consent for PR and proctoscopy (explaining procedure to patient) - alvin

3) causes of painful perianal condition --> describe - anal fissure, perianal abscess, anal fistula, thrombos pile - sareeta

4) diagnosis of painful perianal condtion (Hx, Ex, Ix) - yazid

5) diagnosis of rectal bleeding - maze

6) management of painful perianal condition - chris

1. Coagulation cascade -everything!!including antithrombin etc, where is the vWF produced chris
2. History + examination for bleeding disorder- explain all the signs etc saree
3. Investigations- what to do when the patient comes in with bleeding disorder, explain all the stuff in the case alvin
4. epi, types of bleeding disorders (genetics)- common in Aust, Msia- how to differentiate maze + christine
5. types of bleeding disorders-
6. Management -algorithm for bleeding disorder, step-by-step!, peri-op management- what do u assess before going for surgery yazid

1. anatomy of thyroid gland - including embryology and gross anatomy and histology, blood supply and stuff yazid

2. physiology of the thyroid gland -TSH everything alvin

3. classification of goiter - diffused, multinodular etc and describe the common causes of goiter saree

4. diagnosis of goiter - history, examination and investigation christine

5. management of goiter - especially multinodular goiter, thyrotoxicosis/hyperthyroid and CA thyroid, solitary thyroid nodule/thyroiditis (hashimotos,autoimmune) - maz

6. complications of thyroid surgery chris

1. principles of management
a) medical christine
b) surgical chris
2. How obesity can occur? from there discuss the various causes based on the pathophysiology of obesity yazid
3. complications of obesity maz
4. look up the various diets and how they work. what local people used (pills) - their complications and side effects. saree
5. psychosocial issues surrounding obesity - barriers people put up. etc etc etc etc alvin

1. describe anatomy of kidney, ureter, bladder,prostate, urethra (saree)
2. physiology of urine formation (yazid)
3. Diagnosis of common urinary tract symptoms - (hx, Ex, appropriate Ix) (alvin)
4. List types of pathology which affect prostate and pathophysiological changes following BPH (maze)
5. aetiology , pathology, clinical features and diagnosis of BPH and CA prostate (christine)
6. treatment of BPH +CA prostate (chris)

* primary lung metastasize to lumbar..

terminal CA

1) disclosure of information to patients. who has the right? patient, family? explain in legal issues and ethical issues. (chris)

2) use of translator. in terms of information transfer? (the difference between official and family members.) (chrisitine)

3) palliative cancer treatment? --> chemotherapy, radiotherapy (guidelines) (saree)

4) breaking bad news (death)? methods (maz)

5) accepting death (difference between culture in accepting death.) (yazid)

6) isu surrounding doctors in coping with terminal patients (alvin)

45 year old lady, presented with lump in the right breast for six weeks duration.

HOPC
notice the lump on the right breast six weeks ago. For the past 2 weeks, there was obviously increase in size of lump. However there is no pain. There is similar lump in her eldest sister.

On examinationm there is no skin changes, no sign of inflammation and no nipple retraction. The lump is 3 X4 cm hard, irregular and mobile. No skin involvement.
Axilla no lymph nodes palpable. Left breast normal.

Menstruation hx.
5 X30 days cycle. S/t menorrhagia.
Drug
OCP consumption for the past 30 years

Provisional Dx
Ca breast stage 1 (T2N0M0)

DDX
Firbocystice disease
Phylloyde tumour
Fat necrosis
Ductal papilloma.


TAsk
BREAST CA

1. anatomy-->gross (quadrants, location) blood supply, lymph drainage, nerve
physiology (christine)

2. discuss psychological, ethical, legal isu such autonomy, trust and privacy. (sareeta)

3. screening of breast cancer, rule of screening (maze)

4. dDx lumps in the breast + explanation (clinical symptom, Ex) (yazid)

5. investigation of breast lump (chris)

6. managament of common breast lump (detail on the CA breast, outline others) (alvin)

Tasks:
1 . describe anatomy of liver and biliary tree yazeeeeee
- blood supply, nerve supply and lymphatic drainage
- microscopic anatomy and macroscopic anatomy (segments and ligaments of liver)

2. metabolism of bile – christine
- production, secretion and circulation with DIAGRAM

3. aetiology, types of gall stones and stuff – saree

4. describe the difference between the pre hepatic, hepatic and post hepatic causes of jaundice – maz
- clinical and biochemical differences
5. describe the pathophysiology of biliary obstruction
- any obstruction in the extrahepatic biliary tree, what is the pathophysiology

6. describe the complication of gall stones and role of MRCP/ERCP and management of gall stones - big baby alvin

1.Pain physiology- fibres, pathways, DEFINE PAIN
- big fibres - Chris
- smaller ones Yazid

2. Mazeee! I change the question a bit, to make it clear.
pharmacological treatment of acute pain + side effects, complications (BASIC STUFF!)+ how to treat complications + overdose
- local Maz (cover simple analgesics, stronger analgesics (tramadol, ketamine and oxycodone), local anaesthetics) discuss on thier phramacodnamics, mode of action dan potential side effects. Yang complication and overdose tak payah. Also include means of analgesics introduction (IM, IV, oral ke)
Ok?
I'll cover opioids and everythign bout it.. Gile banyak and PCA
- systemic- patient-controlled analgesics (PCA)- Alvin

3. Pain assessment + complication of acute pain - severity- adult + children- how to differentiate Saree

4. Weaning off analgesia? - how do you do it-guidelines- Christine

1. Review anatomy of GI track - esophagus, stomach, duodenum, small and large intestine - focus on blood supply only yazeee
2. pathophysiology of hemorrhagic shock saree
3. define causes of upper and lower GI bleed - how do you differentiate between them. clinical maz
4. diagnosis of GI bleed (upper and lower) - history, examination chris
5. management of GI bleed (upper and lower) christine
6. risk factors for acute upper GI bleed & role of H pylori in peptic ulcer disease.alvin

Tasks:
1. Aetiology of acute + chronic pancreatitis, risk factors YAZID
2. Pathophysiology- how does alcohol cause pancreatitis CHRISTINE
3. Clinical presentation of acute + chronic pancreatitis ALVIN
- how do you define an alcoholic?how many standard drinks?
- classifications (LATEST!)
4. Investigations for acute+ chronic SAREE
- how to differentiate btwn acute + chronic= lab results etc
- ERCP!
-explain complications, indications, SE
5. Management- medical + surgical- CHRIS
6. Anatomy + physiology of pancreas Maz

1. blood supply of the lower limbs and lungs Alvin
2. risk factor for DVT and PE yazid
3. clinical presentation of DVT and PE – history and examination christine
4. focused history and examination of the cardiorespiratory system in relation to DVT and PE chris
5. diagnosis of DVT and PE - investigations. Maz
6. management of DVT and PE saree

1) pathophysiology of Inflammatory BD (saree)

2) difference in crohn's and UC (chris)
a) clinical presentation (Hx, Ex)
b) diff in Ix?
c) diagnosis critetia


3) etiology, risk factors, epidemiology (yazid)
a) gross pathology --> describe difference

4) investigation (maze)
a) expaining the results in case + extras Ix
b) screening

5) management (christine)

6) complications + associated disease(alvin)

1. Outline the anatomy of the GI tract, Renal, Pancreas and Hepatobiliary
- stomach, duodenum, small gut and large gut. yazeee
2. type of abdominal pain and pathophysiology of pain pathway from abdominal viscera.
- outline the nerve supply of the abdominal viscera.stomach, liver, duodenum, pancreas and gall bladder. chris
3. physiology of the gut - motility of the small and large gut saree
4. describe clinico - pathological feature of the differential diagnosis of acute and chronic abdominal pain. christine
- whats the difference in acute and chronic abdo pain by feature and by pathology
5. imaging technique and indication for their use - abdominal x ray, chest x ray, CT scan, ultrasound, MRI, small bowel series and HIDA scan. maz
6. outline the management plan of chronic abdominal pain and define the acute abdomen and describe the indication for surgery in the acute abdomen. alvin

1. Clinical presentation of colon cancer. History, examination & diagnosis based on history and examination. maz
i. Various presentations
ii. All the criterias – tnm, dukes whatever
2. Causes, risk factors, epi – aetiology of colorectal cancer. Look up the inheritance etc. christine
i. Answer his question about what he can do to not get another cancer.
3. Management – surgical. Various types of surgeries. Colostomy/colectomy etc etc Palliative saree
i. How its done. Why its done
4. Management – medical. Chemo yazid
i. How its done, how much, what’s used
5. investigations for colorectal cancer alvin
i. explain the procedures and how to do them briefly. Don’t be technical people.
ii. why do you do sigmoidoscopy or colonoscopy? do the instruments differ?
6. Anatomy of the lower GI and correlations with CA. chris
i. Why it happens there?
ii. Blood supply – metastasis
iii. Lymphatics – metastasis

1. ANATOMY OF THE INGUINAL CANAL, DEFENCE MECHANISM TO PREVENT DEVELOPMENT OF HERNIA - ALVIN
2. REVIEW THE COMMON CAUSES OF LUMP IN THE GROIN & AETIOLOGY - CHRISTINE
3. CLINICAL PRESENTATION OF INGUINAL HERNIA – DIRECT, INDIRECT & FEMORAL - SAREE
4. DIAGNOSIS & MANAGEMENT OF INGUINAL HERNIAS - CHRIS
5. REVIEW THE COMMON CAUSES OF LUMP IN SCROTUM & TESTIS - YAZID
6. DIAGNOSIS & MANAGEMENT OF SCROTAL & TESTICULAR SWELLING - MAZ

1. risk factors for PVD – diabetes, hypertension, others. How do they contribute to PVD chris
2. pathophysiology of pain – why have to hang out of bed. Acute (when walking) and chronic (even at rest why?) alvin
3. history, examination and diagnosis (appropriate tests) of PVD. Common sites of arterial occlusion yazid
4. investigation maz
i. (angiography and why angiogram contraindicated in diabetics)
ii. How to assess severity and how to determine further management
5. management of PVD – pharmaco and non pharmaco. Medical and surgical christine
6. pre, peri post operative management of diabetic patient. saree

1. psychological assurance +preparation for operation saree
2. pre-operative assessment of patient – what factors do you assesss? Chris
3. why is CCF or unstable angina is considered a “red flag” in the peri-operative period? How different is perioperative AMI from an ordinary AMI? alvin
4. describe the COMMON post operative complications yazid
a. according to systems.
5. diagnosis of post operative complications Christine
a. according to system
6. management outline of post operative complications. COMMON not all maz
a. according to system

1. Aetiology, Risk Factors, of Gout -Maze
2. History, Examination & clinical presentation of Gout Chrisine
3. Pathophysiology of Gout Alvin
4. investigations for GOUT. Why to do FBE? Chris
5. Management of Gout. pharmaco & non pharmaco. how to avoid further attacks. Yazid
6. overview and management of septic arthritis – ddx of gout. -Saree
Socso – on what basis can he make claims? What are the legal issues when u have an injury at work

1. Define osteoporosis and describe calcium homeostasis & role of vitamin D and PTH - yazid
2. Risk factors for development of osteoporosis discuss the impact of menopause & aging on bone and mineral metabolism – chris
3. Describe the aetiology and clinical presentation of osteoporosis. Saree
4. Diagnosis of osteoporosis – history, examination and APPROPRIATE investigation, not all ahhh! – Christine
5. OUTLINE the management for osteoporosis - maz
6. Complications of osteoporosis and the management of complication – Alvin

1. Guidelines of Managing of a MVA victim? First line A&E management of a trauma patient. Eg: vital signs, Alvin
2. Investigations for trauma patients. Physiology of SHOCK. In detail chris
- ECG
- X rays
- ABG
- Interpretation of findings
3. Types of injuries in MVA. BRIEF management. No need detail. maz
- Lung injuries in relation to MVA
- GI injuries – intra-ab
- Open fractures & Crush injury
4. Types of injuries in MVA. BRIEF management. No need detail christine
- Head injuries - various intra-cranial bleeds, fractures, GCS
- Cervical spine – differences in how they occur.
5. Important A&E procedures – indication & contradindication. Show pictures of equipments. yazid
- Chest drains – physiology of pneumothorax
- Tracheostomy
- Cricothyroidstomy?
- Cannulation
- Peritoneal tap
6. Important A&E procedures – indication & contradindication. Show pictures of equipments.
- Insertion of central line
- intubation
- Wound cleaning. Types of wounds
- Urinary catheterization
- Oxygen therapy – explain all the saturation stuff.

1. Anatomy of the Lower Limb – microscopic & gross anatomy + blood supply, and nerves yazid
2. Aetiology and Classification Types of Fractures christine
3. Diagnosis of Fractures – alvin
a. various clinical presentations
b. history
c. examination
d. investigation
4. Physiology of Bone Healing & Complications of Fractures. chris
5. Principles of management of Fractures saree
6. Principles (outline) of Management of Complications of Fractures maz
a. Immediate complications  local and general
b. Early complications  local and general
c. Late complications  local and general

1. Differences between OA + rheumatoid A – differences in clinical features, history etc , first symptoms/signs saree
2. Aetiology – Causes & Risk Factors of OA. Joints commonly affected, grading system ,maz
3. Pathophysiology – what happens at the joint and how it causes pain and discomfort etc. focus on the knee? - yazid
4. investigation –fbe – exclusion criterias etc. x rays (show examples!), 4 cardinal signs, - Alvin:
how to assess severity. Share with the class. Be nice
5. management – occupational therapy, glucosamine, pharmacological, non pharmaco. – chris
6. complications and prognosis – why is there back and neck pain?? Thickening on fingers etc. – Christine

Diarrhoea PBL patient 10

1. Aetiology of diarrhoea, and immunocompromised patients( funny organisms), common pathogens maze

2. Types of diarrhoea (acute, chronic, secretory etc), presentation and pathogenesis saree

a. Differentiate infective Gastroenteritis vs Inflammatory bowel diseases saree

3. Life threatening signs and symptoms of severe diarrhoea, admit or not admit, from HX and physical EX(PR) how to differentiate infectious, inflammation and malignancy alvin tay

4. Investigations yazid

5. General Management (hydration, electrolyte balancing and specific Tx) christine

6. Nosocomial diarrhoea and pathogens and specific MX chris

Task:
1. HIV – Pathogenesis. Course of Disease – saree
2. Complications of HIV – opportunistic infections, and EVERYTHING ELSE (focus on main stuff – not every disease that shows up coz of immunosuppresion!  yazid
3. Management of HIV – retrovirals and HAART chris
4. Investigations to confirm HIV maze
5. Psychosocial aspects – lifestyle modification, counseling, family planning, relationships etc etc Christine
6. DDx – TB, STD, dengue, meningitis, lymphoma, Infectious mononucleosis, alvin

TASK

Types of complications. Must cover pathogenesis, investigation, Management, clinical presentation

-Retinopathy – Soft exudates, cotton wool, blot and dot haemorrhages – Saree

- Neuropathy- Christine

-Nephropathy- Yazid

-Infection + skin +Vascular disease (macro vascular)-- Christopher


-Acute complication of hyperglycaemia in DM seizures? Neurological deficits? Other symptoms? Epilepsy partialis-continuem,???
Hyperglycaemic hyperosmolar syndrome??
DKA?? Diabetic ketoacidosis ---- Maz

-Management- long term DM, blood sugar control ideal target, Drugs and therapies include usage as well (mechanism of action) Look for NEW DRUGS! Incretine … etc..
Insulin- diff types and their usage.
Non-phramacological examination.---- Alvin

TASKS

1. Epidemiology Malaysia, Risk Factors maze
2. Types (primary, secondary, extrapulmonary TBs) and Clinical Presentation saree
3. Pathogenesis of TB yazid
4. Management of TB Alvin
a. Effects of default treatment.
5. Investigation of TB + Associated investigations (HIV etc) chris
a. X ray findings as well
b. Mantoux test
c. Best method of diagnosis
6. Complications of TB and associated diseases Christine

Task

1. Risk factors (and Statistic of IE in malayisa in any?) - alvin

§ Valvular defect

§ Rheumatic heart disease

§ IVDU

2. Clinical presentation (saree)

§ DUKE criteria

3. Mechanism of entry (pathogenesis) (Christine)

§ Organism involves (causes)

4. Investigation (yazid)

§ How sample taken (method)

§ Timing between three culture

§ Site

§ Why different method

5. Management of IE (maze)

§ Treatment type (organism)

§ Treatment length

§ Prophylaxis for underlying heart disease (valvular defect)

6. Complication of IE (chris)

§ extracardiac

PCx

Fever – relieved by paracetamol (initially)

Shiver

Malaise

Nonproductive cough

Headache

Muscle ache

Risk

Sexually active with boyfriends (on OCP)

Smoking

Travel history

Medical Student

Task

1. Algorithm of fever and dDx (yazid)
1. Further Hx of patient (other important question for patient)
2. Investigation (if any?)
2. Epi of infectious disease in SEA (saree)
1. Typhoid, Hep A + B, leptospirosis
3. what advice would you give to doctor? (Alvin)
1. Who else can give advice?
2. What diagnosis is most likely?
3. dDx?
4. Does she need to be admitted to hospital?
5. Other Ix?
4. How to diagnose malaria in lab? (aka Ix) (maze)
1. Why was 1^st blood film reported –ve for parasite (pathogenesis of malaia)
5. Management of malaria (chris)
1. Why was pregnancy test ordered? (can malaria cause spontaneous abortion or drug related)
2. Side effects of quinine and how should patient be monitored?
3. Does patient required additional treatment? (where would you find this information?)
4. At what point could Mx of ms Pang be improved? (vaccination?)
6. infectious disease (Christine)
1. sexually transmitted
2. medical student

PNEUMONIA case 17 patient PBL

1) Aetiology and classifications of pneumonia

how is it classified ,

comparison of hospital vs community vs etc, typical and atypical and

CXR classification of various types of pneumonia SAREE

2) diagnostic criteria of pneumonia: clinical features and +ve findings in clinical exam CHRISTINE

3) Rrf of pneumonia. meliodosis (common is SEA) caused by WHAT BUG?? Relationship of what organisms assoc with what environ, or what type of patients ALVIN

4) Investigations: sputum, CXR, blood gases MAZE

5) management: pharmacological and assess how severity of patient is( tx inpatient or outpatient), YAZID

6) complications ( what cx more prone in what patients, pneumonia in immunocompromised patient, in GORD patient?? Dunno, go check it out) CHRIS

1. Clinical Presentations of Meningitis - Differentials for Neck stiffness, light sensitivity, general rash- maz
2. Investigations - Results that differentiate between each type of meningitis (viral or bacterial)
eg: CSF appearance, Glucose etc etc - alvin
3. Pathophysiology of Meningitis - Various Causes Viral & Bacterial, Route of Infection into Meninges, --- include meningococcal etc - chris
4.Management of Meningitis - saree
5. Production of CSF, Anatomy of Meninges, ventricles, Choroid Plexus and CSF outflow tracts. - yazid
6. Part I: Epidemiology of Meningitis
Part II: Complications and prognosis of Meningitis - christine

1. Lymphoma –Staging (after diagnosis how do you stage - explain), Classification, Diagnosing criteria General Stuff Mazeee
2. Types (Hodgkins, Non Hodgkins, Burkitts, others too!) – histology and various other distinguishing factors Yazeee
3. Clinical Presentation (A&B Sypmtoms) – Sareetaa
4. Treatment – general management for lymphoma. Regime changes according to drugs so don’t bother. Christine
5. Complications of Chemo, biochemical and obstructive complications of lymphoma and
6. Prognosis of Lymphoma Chris
Investigations – morphology and surface markers Alvin

Dyslipidemia

1. types of dislipidemia, aetiology, causes and risk factors of dyslipidemia saree
2. lipid metabolism and transport – biochemistry yazis
3. management of dyslipidemia – for simple dyslipidemia chris
4. clinical presentation / signs & symptoms christine
5. investigation for dyslipidemia and investigations for those that can cause secondary dyslipidemia such as diabetes etc maz
6. pathophysiology of dyslipidemia – primary, secondary and familial dyslipidemia alvin

1. common causes- splenomegaly- how to define mild, massive, lymphadenopathy
1. oil palmà splenomegaly??- chris
2. Pathophysio of both- alvin
3. lymphatic drainage- ANATOMY!!- regional, generalized lymphadenopathy + causes- yazid
4. DDx- regional, generalized lymphadenopathy, -3 MOST common causes+other assoc symptoms (infection)- saree
5. EBV infection- natural hx + long term effects on tumorigenesis+- christine
6. basic Ix- maze

1. Aetiology of Parkinson’s disease + Epidemiology (chris)
2. Clinical Presentation of Parkinson’s disease (Early + Late features) (saree)
3. Pathophysiology (alvin)
4. Extrapyramidal pathway (Basal ganglia etc.) (chrissie)
5. Management à daily living (maz)
6. Pharmacodynamics of drugs (Drugs lose efficacy?) + Surgical intervention (yazid)

Tasks
1) Causes of exacerbation of liver failure (chronic) + what decompensates it, how??-drugs (COMMON), infection etc Saree
2) Pathophysiology of liver cirrhosis esp in alcoholism + Other Causes of liver cirrhosis+ how Chris
3) Clinical presentation of liver cirrhosis/failure- signs+symptoms
a. Staging/assessing the severity of liver failure Maz
4) Investigations- liver enzymes, explain results, other Ix-u/sound etc + why?? Yazid
5) Complications of liver cirrhosis- coagulopathy, CA, portal HPT (what compl. Does it cause), splenomegalytypes, ascitesspontaneous bact peritonitis, Patho of everything Alvin
6) Mx + Mx of complications Christine

Tasks:

1. Epilepsy/ Seizures – aetiology , epi,what is status epilepticus? Management saree
2. types of epilepsy – clinical presentation, distinguishing factor and diagnostic criteria – yazid
3. pathophysiology and risk factors and causes (amphetamine is ONE of them) alvin
4. investigations – those mentioned in the case and others Why sleep deprived EEG. – chris
5. management of epilepsy – pharmaco and non pharmaco maz
6. complications and pruognosis of epilepsy and psychosocial Christine

Migraine

Pathogenesis and causes ( chris)

Clinical presentation and Diagnostic criteria (sareetaa)

Risk factors and aggravating factors ( food and stress) and long term effects of analgesics (maze)

Management of migraine,chronic headaches( yazid)

investigations for migraine and chronic headaches, clinical presentation of different types of chronic headaches, as well as distinguishing factors of headaches (alvin)

Patient education and psychosocial aspects (stine)

sorry for the late post guys.my fault!christine

Tasks:

1. Differences in clinical features of Hypercapnia vs Hypoxia type 1 & 2 - yazid
2. investigations for COPD – how to assess severity - Christine
3. management of COPD – oxygen therapy in COPD patient, types, how much and why …can kill them if too much oxygen. Explore other management too. Long term and pharmacological – rationale for using them – Alvin
4. role of non invasive ventilation in COPD. Role of positive pressure ventilation in COPD patients – chris
5. Pathophysiology of COPD – blue bloaters pink puffers. Effects of smoking - saree
6. difference between asthma and COPD – clinical features and how to differentiate otherwise - maz

Nephotic Syndrome

-A clinical complex characterized by increased basement membrane permeability due to injury to the capillary walls of the glomeruli

-Characterized by

1. Massive proteinuria >3.5g/day
2. Generalized edema from decreased plasma colloid oncotic pressure
3. Hypoalbunimea secondary to proteinurea
4. Hyperlipidemia and hypercholesterolemia due to increased hepatic lipoprotein synthesis

Nephritic syndrome

-A clinical complex, usually of acute onset, characterized by inflammatory rupture of the glomerular capillaries with resultant bleeding into the urinary space

Characterized by:

1. Oliguria (<400ml)
2. Azotemia (abnormal levels of nitrogen-containing compounds, such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood) 
3. Hypertension 
4. Hematuria with red cell casts
5. Mild proteinuria and edema

1. Causes of CCF-maz
2. signs + symptoms-explanation-saree
3. pathophysio- afterload, preload, hormonal changes that occur, BNP-yazid
4. Ix of CCF- echo, ECG etc- alvin
5. Management- mx of acute pulm oedema in ED - christine
6. Mx- chronic CCF- include all diff drugs used in HF- chris

Read about Ix for young patient with HTN?

1. Different between nephritic and nephrotic syndrome? (chris)
2. Primary cause + pathophysiology glomerulonephritis (christine)
3. 2^nd cause + pathophysiology glomerulonephritis (saree)

· Post strept infection (rheumatic fever)

· DM (due increase filtration à protein deposition)

· Lymphoma + leukemia

4. Investigation of glomerulonephritis? (Alvin)
1. Ix to further Dx – classify nephritis
2. When is biopsy done? (indication)

i. Ix before biopsy

ii. Procedure

iii. Contraindication

iv. Precaution

3. Urinalysis

i. How Dx nephritis?

4. Ix to rule out 2^nd cause

5. Management (maze)
6. Brief systemic vasculitis (yazid)
1. Types (large, medium, small)
2. manifestion

Lai is a 42 year old Chinese lady who works as a factory worker (quality check) in Singapore. She was referred to HSA a week ago from Johor Specialist on a 2 month history of swelling in her legs, face and abdomen.

Presenting complaint

Lai presented to the clinic with a sudden onset of swelling in her legs and mild fever on 1^st February while she was on a road trip to Penang.

HOPC

Progression: migratory swelling from legs to trunk and face over a period of 2 weeks. In addition, her weight increased from 62kg to 71kg.

Aggravating or alleviating factors: none mentioned by the patient

Associated symptoms:

• Loss of appetite not associated weight loss but weight gain, started with the onset of oedema. She only takes one meal a day instead of 3 meals per day.
• No change in urinary habits( no oliguria, anuria or change in frequency).
• Frothy urine one week after onset of oedema.
• Disturbed sleep at night, unable to sleep throughout the night, she wakes up around early morning and goes back to sleep near morning. She is not woken up by SOB or need to go to the toilet.
• General fatigue

Time line

1) went to GP for oedema of legs (1 feb)

2) blood test showing SLE positive results

3) admitted to JS by her GP

4) JS performed a kidney biopsy on her 12/2/08

5) After the biopsy, she complained of haematuria, dysuria, feeling of swelling and mild sharp pain in her kidneys that went away after 2 days.

6) Admitted to H SA on 28/ 3

Rheumatology??

Neurology??

SLE

No other symptoms of SLE (hair loss, photosensitivity, rash, oral ulcers, pain, arthritis, bleeding tendency)

Blurring vision?

Numbess? + weakness?

* important –ve findings should be include in HOPC

Cardiovascular systems review:

Exertional dyspnoea on walking 100m( from one end of the PP1 ward to the other) since hospitalization in HSA.

Leg swelling on both legs (bilateral oedema until mid tibia)

No orthopnoea or PND.

No claudication

No angina, or sweating

No syncope

Respiratory Review

Mild non productive cough ( started 2 weeks ago), through out the day

No hemoptosis

No wheeze

No facial pain

No pleuritic pain

Mild intermittent 1 day fever concurrent with onset of leg oedema

GI

Loss of appetite

No other GI symptoms

Past medical Hx

• No history of atopy (allergy rhinitis, conjunctiva, asthma, migraine)
  high BP (5 years ago)

– on regular checkup every 3month on antihypertensive medication

– ask about investigation of HTN (maybe 2^nd cause)

§ possibility of involvement of renal during onset

• Stop recently, not staying in Singapore
• Borderline cholesterol
• Borderline uric acid
• No past hospitalization, or trauma.
  

Drugs/allergy/CAM

· Traditional Chinese meds – 2 pills at Penang, stopped taking the pill because it had no effect on her oedema

· Herbal remedies for general well-being

o last dose was ½ year ago

· On OCP since her visit to the obstetrics and gynecology regarding her menstruation. Been taking the Pill for more than 5 years. She cannot remember when she started on it.

· -antihypertensive

· -prednisolone

Allergies:

• No drug allergy
• Allergic to mangoes, rambutan and durian. Feels hot and suffers from a sore throat after consuming the fruits.

Last Menstrual period

Lastmonth

Regular since on OCP

Irregular since menarche (age 14)

Once per 3 month or every few months

Went to OnG – prescribe OCP to regulate her menses.

Family Hx

Mother (70) – hypertension, on antihypertensive

Father (age 75 ) – skin cancer on face 2 years ago, got removed surgically,

Siblings: 2 /12 – no known illness, no history of atopy

Social/occupation

Does not smoke

Passive smoking at workplace (during lunch break)

Doesn’t drink

12hour shift – 7am – 7pm

QC – not exposed to chemicals

Nature of work: involves her standing at the production line and checking the microchips for correct assembly

dDx

1. Chronic renal failure 2^nd to hypertension/nephritis
2. nephrotic syndrome 2^nd to glomerulonephritis
3. CCF x
4. chronic liver failure x

Examination

General Inspection:

Alert, comfortable, hydrated, not in respiratory distressed

Vital signs

Pulse: 112 bpm, regular rhythm, strong in volume

RR: 12 breaths/min

T: 37⁰C

BP: 160/110

No elevated JVP

Hands

- Capillary refill normal

- Wasting of Thenar and hypothenar eminence of both hands

- proximal muscle wasting, no weakness

- no flapping tremor

Neurological Examination?

* peripheral neuropathy

Face

- No signs of anemic, central cyanosis, jaundice

- signs of hirsutism

-puffy face

-no malar or discoid rash

-no oral ulcers

-no paraorbital oedema

Chest

- Heart

o Apex beat not displaced

o Audible S1 and S2

- Lungs

o Symmetrical chest expansion

o Dullness on percussion, reduce vocal resonance, reduce breathing sounds at lower L lung

- Abdomen

o Distended

o No signs of tenderness or guarding

o No palpable mass

o +ve shifting dullness test

o Normal bowel sound

- Leg

o Pitting edema up until mid tibial

radial-radial delay?

Radial-femoral delay?

Signs of systemic vasculitis?

*Fundoscopy (microcirculation)

Examine 2^nd cause of HTN

Emily, 27, manager

PCx
Visual Sx L eye (blurring), colour vision less intense than normal
Mild pain on movement

PHx
UTI?
Urinary urgency
Incontinence (10 days) – 15 years ago

Tendency to drag left leg
Frequent trips + new fall

Social
Nonsmoker
Drink few glass (weekends)
Marijuana (during teenager)
OCP

Ex
Blurring of L optic disc margin
Disc pallor
afferent papillary defect (L)
deep tendon reflex (brisk) at L lower limb
plantar reflex (extensor) à upper motor neuron lesion?

MRI scan
Brian
T2 hyperintensity of anterior L optic nerve
Small T2 hyperintense lesion in corpus collosum + periventricular white matter
Small in T1 image

Thorax
Non-specific abnormality at T4 left side

CSF
Oligoclonalprotein bands (-ve in serum)

TASK
Multiple Sclerosis
a. Clinical presentation (saree)
i. Patho
b. Epidemiology (more common where? Who?) + Psychosocial (Chris)
i. Patient’s reaction
d. Crititeria for Dx (Alvin)
i. Communicating skill
e. Investigation (yazid)
i. MRI
ii. Oligoclonalproten bands
f. Management + Palliative care
(Christine)
g. Complication + Prognosis + Progression (Maze)

Skin cancers

1. Aetiology, incidence in Malaysia + Aus, Classification (Sareee)

2. Basal cell carcinoma - Clinical manifestation and management??

3. Squamous cell carcinoma- Clinical manifestation and management (Yazid)

4. Melanoma - Clinical manifestation and management ??

5. Skin biopsies- Types..Maz

6. Describe lesions-- Alvin


Really sry.. didnt record the task.. Plz fill in those question marks.

- An exaggerated ↑ in blood sugar following a meal.
- people who don’t have diabetes, pancreas secretes some insulin all the time. It ↑ its output as blood glucose ↑ following meals.
- people with Type 2 diabetes, the pancreas can be slow about secreting insulin in response to a mealà to postprandial hyperglycemia
- an independent risk factor for the development of macrovascular complications.
- normalizing post-prandial blood glucose is more difficult than normalizing fasting glucose.
- poses a challenge to people with diabetes striving to maintain near-normal blood sugar levels.
- Multiple injection regimens and insulin pumps provide flexibility in handling the challenge.
- A person can take regular insulin ½ to 1 hour before eating so that the insulin peak and glucose rise coincide.

tests used for diagnosis:

1) fasting plasma glucose test (FPG)

o measures your blood glucose after you have gone at least 8 hours without eating.

o used to detect diabetes or pre-diabetes.

o the preferred test for diagnosing diabetes due to convenience

o most reliable when done in the morning

Plasma Glucose Result (mg/dL)	Diagnosis
110 and below	Normal
110 to 125	Pre-diabetes (impaired fasting glucose) -more likely to develop type 2 diabetes)
126 and above	Diabetes*

Table 1. Fasting Plasma Glucose Test

*Confirmed by repeating the test on a different day.

2) oral glucose tolerance test (OGTT)

o measures your blood glucose after you have gone at least 8 hours without eating and after you drink a glucose-containing beverage. (75 grams of glucose dissolved in water; 100 grams for pregnant wome)

o blood will be taken before drinking glucose-containing solution, and again every 30 to 60 minutes after drinking the solution. The test takes up to 3 hours.

o can be used to diagnose diabetes or pre-diabetes, gestational diabetes.

2-Hour Plasma Glucose Result (mg/dL)	Diagnosis
139 and below	Normal
140 to 199	Pre-diabetes (impaired glucose tolerance)
200 and above	Diabetes*

Table 2. Oral Glucose Tolerance Test

o For diagnosis of gestational diabetes, blood glucose levels are checked 4x during the test.

o If blood glucose levels are above normal at least twice during the test, you have gestational diabetes.

When	Plasma Glucose Result (mg/dL)
Fasting	105 or higher
At 1 hour	190 or higher
At 2 hours	165 or higher
At 3 hours	145 or higher

Table 3. Gestational Diabetes: Above-Normal
Results for the Oral Glucose Tolerance Test

3) random plasma glucose test (RPG)

o doctor checks your blood glucose without regard to when you ate your last meal.

o random blood glucose level of 200 mg/dL or more + presence of the following symptoms, can mean that you have diabetes:

· increased urination

· increased thirst

· unexplained weight loss

· Other symptoms include fatigue, blurred vision, increased hunger, and sores that do not heal

o This test, along with an assessment of symptoms, is used to diagnose diabetes but not pre-diabetes.

o Positive test results should be confirmed by repeating the fasting plasma glucose test or the oral glucose tolerance test on a different day.