0:00 welcome you all for the video series on purs to secure a distinction in medicine La case so as you know medicine loan case is one of the most important components in your clinical examination and to secure a good grade in medicine to secure a distinction in medicine you need to perform very well in your clinical examination so in this series of video what I'm going to do is I'm going to discuss common loan cases common medicine loan cases and to show the common questions that the examiner would ask from the student and what are the ideal answers the examiners would expect so here with us we have Dr kavishka one of the recently passed out medical graduat from perad and he's going to do the role playing of a
0:46 medical student so he's going to present me a summary of a lawn case and I will be asking questions in the same way that we ask from the final nbbs exam and at the end of his answer I'm going to give him a feedback [Music] okay now can you present the summary of the hisan examination that you have taken from the patient my patient is Mr Sira a 50-year-old manual laborer from Pia who is a diabetic and a hypertensive for The Last 5 Years with a poor Disease Control he presented with the ischemic type chest pain for 2 hours duration to the etu he's a current smoker with 20
1:33 pack years and a heavy ethanol consumer his father passed away with a sudden cardiac event at the age of 60 years on examination he is obese with the BMI of 30 he's not pale he has sesma and acantosis Sans his pul is 80 per minute is regular and all peripheral pulses were present his blood pressure is is 160 by 100 mm Mercury he has a stocking type sensory loss in the lobal limbs okay good so in this patient Mr Sir what are the problems that you have identified he has chest pain diabetes mtis hypertension also he's a smoker and
2:20 a heavy alcohol consumer he's obese and he has financial problems well making a problem list is something that one should master because having a good problem list at the end of your summary is very important to organize your thoughts as well as to streamline the discussion and importantly when you present a problem list as kavishka did it should not only be a list of symptoms or list of diseases but you should put some weight on your problems and you have to pick common areas and make a sensible problem say for instance Mr s what I would expect from from an ideal student would be something like this so Mr cida has multiple medical problems so
3:07 he has accute problems and chronic problems as well as he has financial and social problems as well his acute medical problem is he has ischemic type chest pain in the presence of multiple atherosclerotic cardiovascular risk factors in addition he has many chronic medical problems he has Type 2 diabetes thitis with poor control on maximum oral hypoglycemic medications with macro and microvascular complications he has poorly controlled hypertension on three anti-hypertensive medications with poor control and having many undesirable dietary and lifestyle factors he is obese and he has features of metabolic syndrome he's a heavy
3:52 ethanol consumer with features of dependency and he is a heavy smoker with 30 paas and in addition in Mr C The Main Financial problem main social problem he has is he has lot of work with the current acute medical problem and he is the sole bread winner of a family with four school going children so your problem list should be something like that where you give overall idea and for the examiner it is very easy to take one problem and discuss in detail right so if you are the doctor in the ET when Mr CA comes with chest pain how would you manage him initially you should take a history to see whether it is an esic pain and then you should
4:39 examine the patient and then take an ECG you should give oxygen and Pain Relief to the patient aspine Cog and at setting should be given to the patient if ECG changes are there if there is a Ste elevation myard inunction you you should arrange PCI right so this answer is not bad but there are many aspects that we can improve the answer right so first thing is that when you ask such a question that how would you manage this patient the student what we expect from the student is to tell what he will be doing so you should not use the word that you should do this thing you should do that thing so because the examiners are not the people who are going to manage this patient so you you have to be very
5:25 confident and tell okay I will investigate this patient I will do this thing I will do that thing right and the next thing is when you ask about a question about the patient whom have already taken the history and examined you don't have to go back to the history and examination you can tell from your history and examination what you have gathered you have a patient with a two hour history of skinic type chest pain so what we expect is for you to present what you would do to this patient so the ideal answer would be when Mr CA comes with tets on the chest P to the E I will immediately attend to him I will give him a bed I will connect him to a multi Monitor and arrange an urgent 12 D and
6:11 he's in severe pain so I will relieve His Pain by giving intravenous morphine sufate 7.5 mg as is 75 Kg of weight and along with that I will administer 10 mg of I metalite and then I will give him 300 mg of as screen to be chewed and Sol out and 300 mg of Cl and I will start him on atting 80 mg and then I will look at the ECG and depending on the ECG findings my rest of the management will differ and usually here we examiners would direct you so examiner might tell you that okay the ECG shows St elevations in lead 2 3 and avf or else sometimes we would give you an ECG and we expect you to go
6:58 through the ECG and interpret it so when you are given that task or when you are told about these are the changes always make a diagnosis tell Mr czen has an acute inferior s elevation myocardial infection and then he's in which is not a PCI capable Center so you would talk with candy which is the PCI capable Center and it is a place where we can trans the patient well within 2 hours and you will tell that you will Li with the candy card Lo unit and if they are happy to accommodate the patient you will immediately transer the patient for a primary percutaneous coronary intervention okay right so assume candy catlab is currently undertaking two primary PCI so unfortunately they can't
7:43 accommodate our patient within next couple of hours so if that is the case what would you do then I will tralize the patient does your patient have any contraindications for thrombolysis no sir so what are the Contra indications for thrombolysis in this patient uh previous intal humor inra cranial neoplasms recent stroke uncontrolled hypertension and any bleeding tendency okay right now what prolic agents are available in paral Al place place and stto okay and how would you tralize this patient you should give 35 mg of T
8:32 Ballers so in this answer when I asked that when the PCI is not available for this patient you will go for a thrombolysis but the student needed lot of prompting I had to ask several questions to get the answer but an ideal student would tell okay Mr Sira is a candidate for primary PCI but unfortunately we can't trans the patient within 2 hours because PCI Center is not available at the moment so in that case I will consider troying the patient then I will go back to the patient and look for any contraindications for trombolisis I will ask about any history of intracranial bleeding any history of intracranial neoplasm any stroke of Unknown Origin or any recent stroke within last any recent schic stroke
9:19 within last 6 months Etc so if the patient does not have any contraindication for thrombolysis I will consider throling him so ideally once the ECG diagnosis is made the thrombolytic balls need to be given within 10 minutes we have stus we have alas and we have tinas so if he qualifies for thrombolysis I will explain him the risks and benefits of thrombolysis and get the consent from the patient and then I will thrombol so if I'm troying him with dapas the dose will depend on his body weight and his age and I will administer 30 mg of enoxaparin intravenously just before thrombolysis and then I will administer the thrombotic ballus which will be followed
10:06 by one Mig per kg subcutaneous Inox which will be continued twice a day until the patient has been discharged and during the thrombotic period I will closely monitor the patient so asum know we have thrombol the patient so how would you know that your thrombolysis is successful so if the thrombolysis is successful the S elevations should come down okay that's right tation should come down but the ideal answer should be something like this well the success of thrombolysis will depend on clinical and ECG criteria so I will talk to my patient Mr cila and see whether his chest pain has improved whether he's feeling better and at the same time I will arrange another 12 dcg where I will
10:52 look for more than 50% reduction in SD elevations okay right so Mr czen had an acute coronal event what risk factors have you identified in his gen examination that can account for his myocar infection yes sir as the RIS factors I identified that he's a diabetic he has uncontrolled hypertension is a current smoker and a alcohol consumer yes the answer is correct the student has identified the patient has diabetes hypertension smoking and he's ethanol consumer but an ideal answer would be more organized than is so one can present yes Mr S I have identified modifiable and non-modifiable risk factors for his
11:39 acute Coral event so his non-modifiable risk factors include his old age his male sex and having a first degree relative with a sudden cardiac death and in addition he has many modifiable respect factors such as he's a poorly controlled diabetic poorly controlled hypotensive and he's a current acuse smoker he has harmful use of ethanol consumption with features of dependency and he has features of metabolic syndrome okay now assume you receive the patient to your ward after thrombolysis now he's in the ward HD and as a house officer how would you assess this patient when he comes to the boat I will check his blood pressure pulsate and the lung bases also I will do the basic
12:26 investigations I will continue as spring and at our study also I will continue the answer is correct but as examiners we expect a very broad approach to this question a house officer is expected to cover several areas in the assessment during his V down of a postm patient so the first thing is he has to assess whether there is clinical Improvement after thrombolysis so he can talk to the patient and see whether the patient has any chest pain any shortness of breath and then he can examine in the patient looking for any complications after Mi maybe picardia maybe Taki Aras or hypotension and then we can repeat the e g to confirm the resolution of s
13:11 elevations and then secondly the chice is supposed to assess the complications of the treatment so he has received a thrombolytic ballis and he's on in oxin he's on aspirin so looking into facts like whether the patient is bleeding whether the patient has developed any GE the symptoms or whether the patient has any uh complications like hypotension it's important and then in the history he has identified that he has many risk factors the patient has diabetes patient has hypertension so we have to see whether the patient RIS factors are being well controlled during the admission so if it's you will check a random blood sugar and if it is very high you might start insul him for this patient during the acute period and he's
13:58 hypertensive so you need to control the blood pressure so you might start his routine antihypertensive medications and here usually the beta block is not a first line antihypertension but now we have a compelling indication to use a beta block as because of his enzy so you might optimize or you might change his anti-hypertensives and then he's a heavy ethanol consumer who consumes ethanol in a daily basis so as a house officer You Should Be watchful whether he develops any features of alcohol withdraw so if that is the case you might have to treat prophylactically to prevent him going into withdrawal and then you have to address the aspect of his diet so he need he should not be consuming heavy diet and he should be on a light diet for the
14:44 first couple of days and then the mobility now immediately after acute MI which was tralized he can be walk into the toilet so he should be advised to sort of have some bed bre in first day and just walk around the bed within next couple of days but not to exert himself to a high degree right so you are the house officer the same day night the nurse calls you and tells um doctor Mr Sir blood pressure is low it is 70x 50 so you rush to the patient and patient tells you I'm feeling bit dizzy but no chest pain so how would you approach this patient sir I will immediately attend to the patient I will manage him in hdu I realizes his Airway breathing and
15:31 circulation then as he has had the inferior Mi I suspect him to have a right ventricular infection therefore I will give him a normal sine bers right so to start with whenever you are asked about a medical emergency in the medicine loan case as a blanket answer don't tell about the estd because sdu is not therapeutic and the other thing is I have told told you that Mr Sir is telling you that he's feeling bit dizy but he doesn't have chest pain so when he's talking to you that means that his air and breathing is all right therefore whenever you asked about a medical emergency don't tell that I will attend to his arv breathing circulation unless
16:18 it is medically relevant and I agree with kavishka right ptical infection is a common complication in inferior Mi patients and the treatment is a fluid ballus but at the final mbbs at a house officer level we expect a broader approach than this so an ideal student would answer Hy potention in a postm patient is a medical emergency so I will immediately attend to the patient and there are many possibilities so one thing could be right pentle infection yes because in FMI that is common and in addition to that it could be due to a reinfection could be in the same vascular territory or in a different vascular territory or it could be due to a Tei arthia or bre arthia and sometimes
17:04 after a myocardial infection you can have acute Val incompetencies and also now this patient has received tinas and he's on Inox he's on anti so he can have a big bleed at any time so he may be high potential because of a torrential GI bleed and also as you know uh for these patients we have start lot of medications to improve the prosis we start them on a Inhibitors we start them on beta blockers so this hypotension may be secondary to one of these anti-hypertensive medications or sometimes we start many drugs on a patient and he may be developing an allergic reaction that may be the reason why the blood pressure is low and also he's a vasculopath he's a heavy smoker
17:51 he has lot of atherosclerotic risk factors so he can have atherosclerotic disease in the big vessels in in the arms so there can be a discrepancy in the blood pressure readings in both arms so this should be the differential diagnosis and keeping that differential diagnosis in the mind you will approach to the patient and you will take a history so in the history you will ask whether the patient has any chest pain any shortness of breath any bleeding manifestations any palpitations and at the same time you will do a targeted examination where you will look at check the PSE you reconfirm the blood pressure and see whether the patient is really hypotensive and you check the blood pressure in both arms and you can go for radio radial delay as well and then you
18:39 will examine the L bases and look at the JDP because in RV infection we expect hypotension with clear lungs and raised jenus pressure so in this patient the most likely scenario would be ar infection therefore I would expect the patient to have clear lungs press jvp and low blood pressure so the treatment in that case would be to give fluids to increase the preload I will start a normal sine balls and I will monitor the blood pressure and usually in RV infection patient might need 1 to 2 L of fluids to get the blood pressure up and very rarely even with aggressive fluid resusitation if the blood pressure is not picking up then I can consume the SAT him okay good so in this patient uh the
19:27 fasting BL sugar is you have done a fasting blood sugar which is 180 and you have done hba1c it is 10.5% so what do you think uh and what would you do for this patient blood sugar value of 180 is high then the blood sugar control is not satisfactory therefore I will start patient on in okay so I agree with that answer is blood sugar is high so we need to control it with hypogly but an idea student would differentiate these to blood sugar eings so his fasting blood sugar can be high because it is done immediately after a myard infection so I stress reactions can give rise to high blood sugars but in this particular patient having hb1c of more than
20:14 10.5% reflects that is overall glycemic control had been very poor so in this patient I would start hon insulin to control the blood sugar in the acute period but then once the patient is stable and eating and drinking I will talk to the patient and at the same time I will go through his past medical records to see what medications was she was he on and how was the glycemic control so depending on that I will decide whether to start him on oral hypogly Mi or to put him on insulin so if the patient is ke to be started on oral agents I will start him on metformine as the first line treatment and then I will add second line and third line medications so as as he had
20:59 acute coronary event in ideal setting second line of duck would be to stting on sglt2 inhibitor something like EMP glyos because it is shown that it controls the blood sugar as well as it improves the cardiovascular mortality and morbidity but unfortunately osin is not freely available in government sector and it is very costly in private sector so if the patient cannot afford it I will consider other second line medications such as Sile uas and I will crossly monitor his sugars and if the glycemic control is poor with maximum oral hypoglycemic I would consider starting him on insulin okay so now we have managed the patient very well and you are planning to discharge Mr czen so what medications
21:47 will he take home ASP at a inhibitor or ARB and the beta well that answer is correct so you may mention that he need to be on aspine clopp Statin a beta blocker and AC emitter but an ideal answer would be I will start the patient on Dual anti treatment including aspirin and and also I will start him on a high intensity static for secondary prophylaxis and then I will start him on maximum tolerable dose of a inhibitor and a maximum tolerable dose of beta blocker to improve his prognosis and in addition I will give him sublingual gtn okay now we have given sublingual
22:34 gtn to this patient so as a house officer how would you advise the patient about using sublingual gtn I will ask the patient to keep a gtn tablet subing if he develops in chest pain and I will advise him that he may repeat it up to three times and if the chest pain is not improving he should come to a hospital well this is a very common question that we ask in the exam how to advise the patient about gtn so the ideal answer would be I mean you need to introduce what is gtn to the patient otherwise he would not know so you will sit with the patient and take the gtn tablets and explain it so the bottle which is the plastic brown bottle is the bottle that contains your gtn tablets so whenever
23:21 you get a chest pain at home take one tablet of these and keep it under the top and importantly when you taking this tablet either be seated or lie on the bed the reason is it can dilate your vessels and your blood pressure can precipitously drop therefore you can have a collapse so you take first tablet and see whether your chest pain improves and if it doesn't you can wait for 5 minutes and you can take the second gtn tablet sublingual and even with the second tablet if your pain is not getting away you need to come to the hospital so you need to call an ambulance or for call a family member to bring you to the hospital but on your way you can take the third sublingual tablet and the other important thing is
24:08 sometimes you might not need gtn for a month but just because of that you can't keep the same plastic bottle for the next months you need to bring that to the hospital when you come to the clinic and get a refill because usually by a month period of time jtn can get decomposed and expired and the other another important thing is if the patient is on any tablet something like sanil for erectile dysfunction and taking gtn at the same time would cause dangerous hypotension so he should avoid taking gtn if he's taking any uh medications like vram or medically SE genic okay so that brings to the end of
24:54 today's medicine lawn case about acute con syndrome and I will discuss similar common medicine Dawn cases in upcoming videos so if you're interested in going through these videos please subscribe the channel okay then I will see you guys in the next video good luck [Applause] [Music]
