_fm1Short and OSCE Cases in Internal Medicine Clinical Exams for PACES, MRCPI, Arab Board and Similar Exams
_fm3Short and OSCE Cases in Internal Medicine Clinical Exams for PACES, MRCPI, Arab Board and Similar Exams
SECOND EDITION
Wanis H Ibrahim MB ChB FRCP (Edin) FRCP (Glasg) FRCPI FCCP F (Pulm)
Senior Consultant Physician, Department of Medicine, Hamad General Hospital,
Doha, Qatar
Professor of Clinical Medicine, College of Medicine, Qatar University and Weill-Cornell Medicine, Qatar
Core Faculty, Residency Training Program, Department of Medicine, Hamad General Hospital, Doha, Qatar
Certified International Clinical Examiner for Various National and International Clinical Examinations Winner of 17 “Best Teacher” Awards
Foreword
Rayaz A Malik
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Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.
9781787791244
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_fm5Foreword
“Forewarned, forearmed; to be prepared is half the victory”
—Miguel de Cervantes
Medicine is both an art and a science. Scientific knowledge creates the foundation and the art of deduction and application enables the discerning clinician to arrive at the correct diagnosis and therefore appropriate management.
Nowhere is the practice of medicine challenged as acutely as it is in the postgraduate examinations in internal medicine. The candidate is expected to undertake a thorough and systematic physical examination, identify the pertinent physical signs, create a sensible differential diagnosis, apply clinical knowledge, and present their findings in a clear, structured, and professional manner. However, when the pass rate is below 50% for the PACES examination, preparation is the key. In the words of my old mentor Professor JD Ward (ex-vice president of the Royal College of Physicians), ‘preparation and daily practice is key to success in the MRCP’.
I believe Professor Wanis H Ibrahim has created a comprehensive book from the “examiner's perspective” and incorporated a unique conversational style, which recreates the conditions encountered in the examination. The material covered is comprehensive and up-to-date and builds on a wealth of experience, which guides you through what to expect during the examination and how to examine proficiently and present your findings professionally and competently.
Rayaz A Malik
Professor of Medicine and Consultant Endocrinologist,
Weill Cornell Medicine-Qatar, Doha/Qatar
_fm7Preface to the 2nd edition
I am glad that the 1st edition of this book was very well-received and was a resounding success. The book has gained wide popularity among international candidates (particularly those preparing for their MRCP, PACES, MRCPI, and Arab Board clinical examinations) over less than four years from its publication. Feedback from internal medicine residents and medical students indicated that the book was extremely helpful during their preparation for clinical examinations. I was pleasantly surprised and extremely delighted to receive positive feedback not only from candidates but also from experienced clinician colleagues and seasoned examiners. I am ever grateful for their comments and suggestions for improvement in future editions of this book. The main driver of the book was a desire to provide a resource to busy clinicians during their clinical examination preparation, which is both concise and easy to assimilate but, at the same time, comprehensive and does not omit any vital component of the examination. A consistent theme from the positive feedback is the book's unique conversational style and the precise and concise information it delivers to the readers. Although this was the intention of starting this project in the first place, this positive feedback exceeded my expectations and encouraged me to improve even further the utility of the book by bringing this 2nd edition. As teaching has always been a passion for me, I always looked at how medical education can be made easy and more straightforward for a busy clinician. While acting as an examiner for many years, I realised the particular areas in which candidates struggle during examinations. This book is an effort to help candidates overcome these difficulties.
This 2nd edition keeps the same basic theme of conversational style of the book (an examiner asks a question and a candidate provides the typical answer), which recreates the conditions encountered in the real clinical examinations. However, various additions have been made based on feedback from students, residents, seasoned clinicians, and examiner colleagues.
The approach to each case in the book has been standardised into a unified format that includes the common instructions by examiners encountered in clinical examinations, the common mistakes (pitfalls) committed by candidates, and the typical style of presentation of findings. This is followed by a succinct summary of diagnosis, differential diagnosis, management, and further information usually required in clinical examinations. Throughout the book, particular emphasis has been placed on a highly professional approach to the case, a competent and relevant examination technique, and a concise professional presentation. This is followed by the questions that are commonly asked by the examiners on each case along with their standard answers, encompassing all aspects of the case. A paragraph containing the essential rules/clues for each case has been added and updated to help candidates understand common practical facts about that case.
The list of cases has been expanded to include cases recently encountered by candidates in international clinical examinations.
The list of questions (number and type of questions asked by examiners) on each case, as well as typical answers expected by examiners, have been expanded and updated as well.
All the sections have been thoroughly reviewed and updated based on new information and advancements in the medical field since the publication of the 1st edition.
A ‘how to examine’ paragraph precedes each case in this book, which emphasises and explains the most competent and professional manner of examination for that case._fm8
The section on ‘examiner instructions’ that guides the candidate through the most common instructions encountered for each case has been updated to include commonly encountered instructions in clinical examinations. This helps to take away the element of surprise and alleviate the candidate's anxiety during the stressful examination. The candidates can also use these instructions during their mock examination drills before the examination.
A section on ‘the typical presentation of the findings’ expected from candidates for each case has also been added and again can be thoroughly practised by the candidates during their mock examination drills before the examination.
To improve the candidate's visual learning experience, and supplements the other aspects of the book, the number of photos and illustrations has been expanded in this edition to include about 150 photographs.
Finally, many candidates continue to enquire about the best way to prepare for clinical examinations. In the 2nd edition, a section entitled ‘how to prepare for and pass your clinical examinations’ has been added to explain important practical tips that help candidates to plan and prepare for their clinical examinations.
I sincerely hope that this book will continue to remain a great resource for all the future candidates going through their undergraduate and postgraduate clinical examinations. I will continue to look forward to any suggestions or comments from all the candidates, fellow examiners, and colleagues for any future improvements.
This book could not have been possible without continued support from my loving family. I also would like to express my sincere gratitude to all candidates and colleagues for their invaluable and encouraging comments and suggestions during the writing of this book.
To all the future candidates, I wish you a happy and enjoyable learning and the best of luck in your examinations.
Wanis H Ibrahim
_fm9Preface to the 1st edition
Clinical examinations are considered in many countries as an integral part of the assessment of a doctor's clinical competence. To candidates, they represent a major hurdle during their training. There are significant anxiety and stress associated with the preparation of these examinations that peak on the day of the examination. Internationally, there is a significant variation in the way these examinations are conducted. Two types of postgraduate clinical short case examinations are currently conducted at national and international levels. In the traditional unstandardised examination, a candidate is typically assessed by two examiners on all short cases. The more standardised and structured form of examination requires two examiners (who mark independently) at each station. The former examinations have a considerable number of disadvantages including inconsistency in marking and judgement between examiners (hawk versus dove), gender, personality, and ethnic biases. Furthermore, many national and some international boards appoint clinical examiners without prior training, which results in further variability and inconsistency in marking. Despite being considered as more objective and fair, the recent standardised types of clinical examinations have the disadvantages of cost and preparation. Nevertheless, the key factor for passing clinical examinations remains the candidate's preparation. Going for a clinical examination is like going to a battle. Irrespective of clinical experience, preparation and practice are the keys to passing clinical examinations. You can hear about cardiology fellows who fail cardiac cases, gastroenterology fellows who fail abdominal cases, or neurology fellows who fail neurology cases in clinical examinations because they have not prepared well. Preparation for such examinations requires, in addition to the attainment of broad medical knowledge, acquisition of the required clinical skills of physical examination and mastering the art and discipline of presenting findings and case discussion in a clear systematic manner. Several crucial steps can help candidates to prepare for their short/OSCE cases. While many candidates feel confident in their clinical skills and techniques, the stress in the ‘real examination’ will expose significant skill and knowledge gaps. It is essential, therefore, that a day-by-day short case practice should become second nature to all candidates preparing for their clinical examinations. The best way of attaining this is by frequent bedside assessment and teaching of a motivated group of candidates by a registrar or a consultant (preferably who has been through the examination hurdle). Examination-oriented consultant supervision and comments during the ward round and mock examinations are also helpful. Revision courses may help to familiarise candidates with the common examination cases and examination methods, but alone are never sufficient to pass clinical examinations. Parallel to mastering proper examination skills is a good grasp of medical knowledge related to the common examination cases. Reading medical textbooks without considering commonly encountered cases in clinical examinations is virtually guaranteed with failure. The examiners are assessing knowledge and clinical acumen and the latter cannot be derived from the textbooks. Candidates should also focus on reading books that are dedicated to helping candidates to pass their clinical examinations. These books familiarise candidates with the most common cases encountered in examinations. Nevertheless, many candidates believe that currently there are not enough books that meet this purpose. Hence, many of these books are becoming large medical textbooks that are detailed and extremely wordy, but lack focus and include detailed theoretical information that is useful in written rather than clinical examinations. The examiners are looking for common sense clinical answers, not the latest theories on the molecular basis of disease. As an international clinical examiner, _fm10a primary organiser, and host examiner for different clinical board examinations, I endorse the view that candidates need concise information to help them systematically examine cases, quickly identify the abnormality, and derive the correct diagnosis. In this book, I have put a tremendous effort into including all possible questions that my examiner colleagues have asked or may ask in the clinical examinations. To provide the candidate with a model answer, I have provided a typical conversation between an examiner and a candidate where the examiner asks and the candidate provides the expected answer. This may also put the reader of this book in a more interactive atmosphere rather than reading a large text with the bottom line information lost in the details. Furthermore, being a previous candidate for undergraduate and postgraduate clinical examinations, I realise how a candidate's working memory is negatively affected by examination-provoked stress. Candidates, for example, can easily forget a simple list of causes of a disease as a result of such stress. Considering this, I have included some mnemonics in various pages to help recall some long lists. Each case or system in this book is preceded by ‘how to examine’ to help candidates focus on important physical signs related to that case. Common mistakes or pitfalls committed by candidates and various examiner instructions that have been observed in real examinations are also clearly addressed at the beginning of each case. Particular attention has been paid to the up-to-date management of each case, which is a mandatory question in clinical examinations. Finally, I have gathered all my experience as a clinical examiner, organiser, and educator in this book to help postgraduate doctors feel confident when proceeding to their clinical examinations.
This book is intended for candidates preparing for all postgraduate clinical examinations using the short case/OSCE format such as MRCP (UK and Ireland), PACES, Arab Board, Arabian Gulf Boards, FCPS (Pakistan), MD (India), FARCP (Australia), and other national board clinical examinations. Medical students will also find this book useful.
Good Luck!
Wanis H Ibrahim
_fm11Dedication
My mother, Mubaraka Al-Darrat, for her sacrifice and constant support throughout my life.
Wanis H Ibrahim
Important note
This book is intended to provide postgraduate medical doctors and medical students with the necessary information to pass their clinical examinations. The author of this book has made every effort and care to ensure the information provided in this book is accurate. However, since medical knowledge is constantly changing, neither the author nor the publisher can assume any responsibility for any consequences arising from the use of the information contained in this book.
_fm12Acknowledgements
I am indebted to the following colleagues from Hamad Medical Corporation for their great assistance and providing some photographic materials included in this book—Dr Amjad Mahboob, Dr Gowri Karuppasamy, and Dr Elrazi Awadelkarim from Internal Medicine Section; Dr Liaquat Ali, Dr Dirik Deleu, Dr Mohammed Alhatou, Dr Ahmad Shihab, Dr Suha Makki, Dr Naveed Akhtar, Dr Faisal Ibrahim, and Dr Yasser Osman from Neurology Section; Dr Abdul-Wahab Al-Allaf, Dr Fiaz Alam, Dr Samar Al-Emadi, Dr Izzat Khanjar, Dr Abdul-Razzakh Poil, Dr Salah Mahdi, and Dr Mohammed Hamoudeh from Rheumatology Section; Dr Hamda Ali and Dr Mohsen Elidrisi from the Endocrinology Section; Dr Farouq Hamed, Dr Hawraa Omran, Dr Hisham Elsabah, Dr Kakil Rasul, and Dr Mufid Elmistiri from Oncology Section; Dr Maha Elshafei, Dr Mohammed Mousa, and Dr Fatima Almansouri from Ophthalmology Section; Dr Farook Ahmed from Nephrology Section; and Ms Mary Anne Tourette from the Department of Medicine. Special thanks go to Professor Rayaz Malik, Dr Mushtaq Ahmed, Dr Tasleem Raza, Dr Salah Elbadri, Dr Ahmed Al-Mohammed, and Dr Dhabia Al-Mohanadi and my brother Dr Gamal Ibrahim for their invaluable suggestions and continuous support during the preparation of this book.
_fm14List of abbreviations
6MWT:
Six-minute walking test
ABG:
Arterial blood gas
ACCP:
Anti-citrullinated protein antibody
ACE:
Angiotensin-converting enzyme
ACTH:
Adrenocorticotropic hormone
AD:
Autosomal dominant
AF:
Atrial fibrillation
AFB:
Acid-fast bacilli
AIDS:
Acquired immunodeficiency syndrome
ALK:
Anaplastic lymphoma kinase
ALP:
Alkaline phosphatase
ALT:
Alanine aminotransferase
AMA:
Anti-mitochondrial antibodies
ANA:
Anti-nuclear antibodies
ANCA:
Anti-neutrophil cytoplasmic antibody
anti-dsDNA:
Anti-double stranded DNA antibody
anti-VEGF:
Anti-vascular endothelial growth factor
APKD:
Adult polycystic kidney disease
AR:
Aortic regurgitation
AR:
Autosomal recessive
ARB:
Angiotensin II Receptor Blocker
ARNI:
Angiotensin receptor neprilysin inhibitor
ARP:
Argyll Robertson pupils
AS:
Aortic stenosis
ASD:
Atrial septal defect
ASMA:
Anti-smooth muscle antibody
AST:
Aspartate aminotransferase
AVM:
Arteriovenous malformations
BAL:
Bronchoalveolar lavage
BIPAP:
Bi-level positive airway pressure
BNP:
B-type natriuretic peptide (brain natriuretic peptide)
BP:
Blood pressure
CABG:
Coronary artery bypass graft
CAD:
Coronary artery disease
CAT:
COPD assessment test
CBC:
Complete blood count
CBD:
Common bile duct
CF:
Cystic fibrosis
CFTR:
Transmembrane conductance regulator gene
CHF:
Congestive heart failure
CIDP:
Chronic inflammatory polyneuropathy
CLD:
Chronic liver disease
CML:
Chronic myeloid leukaemia
CMT:
Charcot-Marie-Tooth
CMV:
Cytomegalovirus
CNS:
Central nervous system
COPD:
Chronic obstructive pulmonary disease
CPK:
Creatine phosphokinase
CRA:
Central retinal artery
CRP:
C-reactive protein
CRT:
Cardiac resynchronisation therapy
CRVO:
Central retinal vein occlusion
CSF:
Cerebrospinal fluid
CT scan:
Computed tomography scan
CTEPH:
Chronic thromboembolic pulmonary hypertension
CTPA:
Computed tomography pulmonary angiography
DIC:
Disseminated intravascular coagulation
DIP:
Distal interphalangeal joint
DLCO:
Diffusing capacity for carbon monoxide
DNAR:
Do not attempt resuscitation
DVT:
Deep vein thrombosis
EBV:
Epstein–Barr virus
ECG:
Electrocardiogram
EDS:
Ehlers–Danlos syndrome
EGFR:
Epidermal growth factor receptor
EMG:
ENA:
Extractable nuclear antigen antibodies
ERCP:
Endoscopic retrograde cholangiopancreatography
ESR:
Erythrocyte sedimentation rate
ESRD:
End-stage renal disease
ET:
Essential thrombocythemia
FeNO:
Fractional exhaled nitric oxide
FEV1:
Forced expiratory volume in the first second
FSGS:
Focal segmental glomerulosclerosis
FSH:
Facioscapulohumeral muscular dystrophy
FSH:
Follicle-stimulating hormone
FTA-ABS:
Fluorescent treponemal antibody absorption test
FVC:
Forced vital capacity
G6PD:
Glucose-6-phosphate dehydrogenase
GBS:
Guillain–Barré syndrome
GD:
Gaucher's disease
GERD:
Gastroesophageal reflux disease
GFR:
Glomerular filtration rate
GH:
Growth hormone
GHRH:
Growth hormone-releasing hormone
GOLD:
Global initiative for chronic obstructive lung disease
HACEK:
Haemophilus parainfluenzae and aphrophilus, Actinobacillus, Cardiobacterium, Eikenella and Kingella
HBA1C:
Glycosylated haemoglobin
HBV:
Hepatitis B virus
HCM:
Hypertrophic cardiomyopathy
HCV:
Hepatitis C virus
HD:
Huntington's disease
HFpEF:
Heart failure with a preserved ejection fraction
HfrEF:
Heart failure with a reduced ejection fraction
HHT:
Hereditary haemorrhagic telangiectasia
HIV:
Human immunodeficiency virus
HPOA:
Hypertrophic pulmonary osteoarthropathy
HRCT:
High-resolution CT scan
HSP:
Henoch–Schönlein purpura
HTN:
Hypertension
HVPG:
Hepatic venous pressure gradient
ICD:
Implantable cardioverter defibrillators
ICS:
Inhaled corticosteroid
IE:
Infective endocarditis
IGF-I:
Insulin-like growth factor 1
ILD:
Interstitial lung disease
INO:
Internuclear ophthalmoplaegia
INR:
International normalised ratio
IPF:
Idiopathic pulmonary fibrosis
JAK2:
Janus kinase 2
JVP:
Jugular venous pressure
LABA:
Long-acting beta-agonists
LAMA:
Long-acting muscarinic antagonist
LBBB:
Left bundle branch block
LDH:
Lactate dehydrogenase
LGMD:
Limb-girdle muscular dystrophy
LH:
Luteinising hormone
LKM:
Liver kidney microsomal antibody
LMN:
Lower motor neuron
LTOT:
Long-term oxygen therapy
LVAD:
Left ventricular assist device
LVEF:
Left ventricular ejection fraction
LVESD:
Left ventricular end-systolic dimension
MCP:
Metacarpophalangeal joint
MCT:
Methacholine challenge test
MD:
Myotonic dystrophy
MELD:
Model for end-stage liver disease
MIE:
Meconium ileus equivalent
MLF:
Medial longitudinal fasciculus
MND:
Motor neuron disease
MR:
MRA:
Magnetic resonance angiography/mineralocorticoid receptor antagonist
MRCP:
Magnetic resonance cholangiopancreatography
MRI:
Magnetic resonance imaging
MS:
Mitral stenosis/multiple sclerosis
NAFLD:
Non-alcoholic fatty liver
NEP:
Neprilysin inhibitor
NMO:
Neuromyelitis optica
NPDR:
Non-proliferative diabetic retinopathy
NSAID:
Non-steroidal anti-inflammatory drugs
NT-proBNP:
N-terminal (NT)-pro hormone BNP
NYHA:
New York Heart Association
OGD:
Oesophagogastroduodenoscopy
PAP:
Pulmonary artery pressure
PBC:
Primary biliary cirrhosis
PD:
Peritoneal dialysis
PDR:
Proliferative diabetic retinopathy
PEF:
Peak expiratory flow
PEG:
Percutaneous endoscopic gastrostomy
PET scan:
Positron emission tomography scan
PHT:
Pulmonary hypertension
PMF:
Primary myelofibrosis
PTH:
Parathyroid hormone
PV:
Polycythemia vera
QP/QS:
Pulmonary blood flow/ systemic blood flow
RA:
Rheumatoid arthritis
RF:
Rheumatoid factor
RFT:
Renal function test
RHD:
Rheumatic heart disease
RP:
Retinitis pigmentosa
S1:
First heart sound
SAAG:
Serum-ascites albumin gradient
SAM:
Systolic anterior motion movement
SBP:
Spontaneous bacterial peritonitis
SLE:
Systemic lupus erythematosus
SPECT:
Single-photon emission computed tomography
SVC:
Superior vena cava
TAVR:
Transcatheter aortic valve replacement
TB:
Tuberculosis
TEE:
Transesophageal echocardiography
TFT:
Thyroid function test
TIPS:
Transjugular intrahepatic portosystemic shunt
TTE:
Transthoracic echocardiography
UIP:
Usual interstitial pneumonia
UTI:
Urinary tract infection
VAT:
Video-assisted thoracoscopy
VDRL:
Venereal disease research laboratory test
VSD:
Ventricular septal defect