As 4y student medicine sub all case presentation or clinical case list form all system and approch

Reading File

Here is a complete, organized clinical case presentation list for a 4th-year medical student, covering all major systems with the standard approach for each:

Clinical Case Presentations - 4th Year Medicine

All Systems + Approach

HOW TO PRESENT ANY CASE (Universal Framework)

1. Patient ID - Age, sex, occupation, referral source 2. Chief Complaint (CC) - In patient's own words, with duration 3. History of Present Illness (HPI) - OLDCARTS: Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Timing, Severity 4. Review of Systems (ROS) 5. Past Medical/Surgical History (PMH/PSH) 6. Medications + Allergies 7. Family History (FH) 8. Social History (SH) - smoking, alcohol, drugs, occupation, travel 9. Physical Examination (PE) - Vitals → General → System-specific 10. Investigations - Labs, imaging, ECG, etc. 11. Summary - "In summary, this is a [age] [sex] with [key findings] consistent with..." 12. Differential Diagnosis (DDx) - Most likely first, then alternatives 13. Working Diagnosis 14. Management Plan - Investigations to confirm + Treatment

SYSTEM 1: CARDIOVASCULAR

#	Case	Key Approach
1	Acute STEMI	ECG (ST elevation), troponin, immediate PCI vs thrombolysis. Killip class.
2	NSTEMI/Unstable Angina	ECG (ST depression/T-wave changes), troponin, GRACE/TIMI score, anticoagulation.
3	Stable Angina	Exertional chest pain, relieved by rest/GTN, exercise stress test, coronary angiography.
4	Acute Left Ventricular Failure	Orthopnoea, PND, bilateral basal crepitations, S3 gallop, CXR (bat-wing shadowing).
5	Chronic Heart Failure	NYHA class, echo (EF), BNP, diuretics, ACEi, beta-blocker.
6	Atrial Fibrillation	Irregularly irregular pulse, ECG, CHA2DS2-VASc, anticoagulation, rate/rhythm control.
7	Infective Endocarditis	Duke criteria (major: blood cultures, echo; minor: fever, predisposition, Janeway, Osler).
8	Hypertensive Emergency	BP >180/120 + end-organ damage, fundoscopy (papilloedema), IV labetalol/hydralazine.
9	Aortic Stenosis	Ejection systolic murmur (radiates to neck), narrow pulse pressure, echo gradient.
10	DVT/PE	Wells score, D-dimer, CTPA, anticoagulation.

SYSTEM 2: RESPIRATORY

#	Case	Key Approach
1	Community-Acquired Pneumonia	CURB-65 score, CXR consolidation, blood cultures, antibiotics.
2	COPD Exacerbation	Smoking history, spirometry (FEV1/FVC <0.7), ABG, bronchodilators, steroids.
3	Bronchial Asthma	Wheeze, diurnal variation, PEFR, SABA, stepwise management (BTS/GINA).
4	Pulmonary Tuberculosis	Cough >3 weeks, night sweats, weight loss, AFB sputum smear, Mantoux, CXR (upper lobe).
5	Pleural Effusion	Stony dull percussion, absent breath sounds, Light's criteria (transudate vs exudate).
6	Pneumothorax	Sudden pleuritic pain + dyspnoea, absent breath sounds, CXR (lung edge), chest drain.
7	Lung Cancer	Haemoptysis, weight loss, clubbing, CXR/CT mass, bronchoscopy + biopsy, staging.
8	Sarcoidosis	Bilateral hilar lymphadenopathy, erythema nodosum, raised ACE, non-caseating granulomas.
9	Pulmonary Fibrosis (IPF)	Dry cough, fine inspiratory crackles, clubbing, HRCT honeycombing.
10	Obstructive Sleep Apnoea	Snoring, daytime somnolence, Epworth scale, overnight oximetry, CPAP.

SYSTEM 3: GASTROENTEROLOGY / HEPATOLOGY

#	Case	Key Approach
1	Upper GI Bleed	Haematemesis/melaena, Rockford/Blatchford score, urgent OGD, PPI, Helicobacter pylori.
2	Lower GI Bleed	Bright red PR bleeding, colonoscopy, diverticulosis vs colorectal cancer vs IBD.
3	Peptic Ulcer Disease	Epigastric pain, H. pylori CLO test, OGD, triple therapy.
4	Acute Appendicitis	RIF pain, Alvarado score, USS/CT abdomen, emergency appendicectomy.
5	Acute Pancreatitis	Epigastric pain radiating to back, raised amylase/lipase, Ranson's criteria, Imrie score.
6	Liver Cirrhosis	Jaundice, ascites, spider naevi, Child-Pugh/MELD score, varices, SBP risk.
7	Viral Hepatitis	HBsAg, anti-HCV, LFTs, liver biopsy, antivirals.
8	Cholecystitis/Choledocholithiasis	RUQ pain (Murphy's sign), USS biliary, ERCP, cholecystectomy.
9	Inflammatory Bowel Disease	Crohn's vs UC (granulomas, skip lesions, smoking, fistulae vs continuous, bloody diarrhoea).
10	Colorectal Cancer	Change in bowel habit, anaemia, colonoscopy + biopsy, staging CT, CEA.

SYSTEM 4: NEUROLOGY

#	Case	Key Approach
1	Ischaemic Stroke	FAST, NIHSS score, NCCT (exclude haemorrhage), thrombolysis within 4.5 hrs, DAPT.
2	Haemorrhagic Stroke	Sudden severe headache ("thunderclap"), NCCT, BP control, neurosurgical review.
3	Subarachnoid Haemorrhage	Worst headache of life, NCCT, LP (xanthochromia), Hunt & Hess grade, nimodipine.
4	Epilepsy/Status Epilepticus	Seizure classification, EEG, MRI brain, anticonvulsants, management protocol.
5	Meningitis/Encephalitis	Neck stiffness, Kernig/Brudzinski, LP (CSF analysis), IV antibiotics (do not delay).
6	Multiple Sclerosis	Relapsing-remitting, optic neuritis, Lhermitte's sign, MRI (periventricular plaques), McDonald criteria.
7	Parkinson's Disease	Tremor (pill-rolling), rigidity, bradykinesia, postural instability, levodopa.
8	Guillain-Barré Syndrome	Ascending paralysis post-infection, areflexia, CSF (albuminocytological dissociation), IVIG/plasmapheresis.
9	Myasthenia Gravis	Fatigable weakness, ptosis, diplopia, anti-AChR antibodies, Tensilon test, pyridostigmine.
10	Raised ICP/Brain Tumour	Headache (morning, worse on bending), papilloedema, CT/MRI, dexamethasone, neurosurgery.

SYSTEM 5: ENDOCRINOLOGY

#	Case	Key Approach
1	Diabetic Ketoacidosis (DKA)	Type 1 DM, Kussmaul breathing, ketonuria, HbA1c, DKA protocol (fluids, insulin, K+).
2	Hyperosmolar Hyperglycaemic State	Type 2 DM, no ketosis, very high glucose, gradual fluid replacement, heparin.
3	Hypoglycaemia	Sweating, tremor, confusion, BM <3.5, IV dextrose/IM glucagon.
4	Hypothyroidism	Bradycardia, weight gain, cold intolerance, raised TSH, low T4, levothyroxine.
5	Hyperthyroidism/Thyrotoxicosis	Weight loss, tremor, exophthalmos (Graves), low TSH, high T4, carbimazole/propylthiouracil.
6	Thyroid Storm	Medical emergency: hyperpyrexia, tachycardia, IV propylthiouracil + Lugol's iodine + propranolol + dexamethasone.
7	Addison's Disease	Hyperpigmentation, hypotension, hyponatraemia, hyperkalaemia, short Synacthen test, hydrocortisone.
8	Cushing's Syndrome	Central obesity, striae, buffalo hump, 24-hr urinary cortisol, dexamethasone suppression test.
9	Acromegaly	Large hands/feet, coarse facies, IGF-1, oral GTT (GH not suppressed), MRI pituitary.
10	Phaeochromocytoma	Paroxysmal hypertension, headache, sweating, 24-hr urine metanephrines, CT abdomen.

SYSTEM 6: RENAL / UROLOGY

#	Case	Key Approach
1	Acute Kidney Injury (AKI)	KDIGO staging (creatinine/urine output), pre-renal/renal/post-renal, urine Na+, fractional excretion of Na.
2	Chronic Kidney Disease (CKD)	eGFR staging, proteinuria (ACR), USS kidneys (small bilateral), anaemia of CKD.
3	Nephrotic Syndrome	Proteinuria >3.5g/24h, hypoalbuminaemia, oedema, hyperlipidaemia, renal biopsy.
4	Nephritic Syndrome	Haematuria, hypertension, oliguria, raised creatinine, ANCA/anti-GBM/complement.
5	Renal Calculi	Severe loin-to-groin pain, haematuria, USS/KUB/CT KUB, hydration, alpha-blocker, urological intervention.
6	UTI/Pyelonephritis	Dysuria, frequency, costovertebral tenderness, MSU culture, antibiotics.
7	Hyperkalaemia	Peaked T-waves (ECG), causes (AKI, ACEi, Addison's), IV calcium gluconate, insulin/dextrose.
8	Hyponatraemia	Severity/symptoms, SIADH vs hypovolaemic vs hypervolaemic, fluid restriction vs NaCl.
9	Renovascular Hypertension	Young woman + flank bruit + renal artery stenosis, renal USS Doppler, MRA.
10	Prostate Cancer/BPH	LUTS, PSA, DRE, TRUS biopsy, Gleason score, TNM staging.

SYSTEM 7: HAEMATOLOGY

#	Case	Key Approach
1	Iron Deficiency Anaemia	Microcytic hypochromic, low ferritin, low serum iron, high TIBC, endoscopy to find cause.
2	Macrocytic Anaemia (B12/Folate)	Peripheral smear (hypersegmented neutrophils), pernicious anaemia (anti-IF antibodies), Schilling test.
3	Haemolytic Anaemia	Jaundice + anaemia + splenomegaly, raised bilirubin/LDH, low haptoglobin, Coombs test.
4	Sickle Cell Disease	Vaso-occlusive crisis, acute chest syndrome, stroke, Hb electrophoresis, hydroxyurea.
5	Thalassaemia	Mediterranean/Asian origin, target cells, Hb electrophoresis, regular transfusions.
6	Acute Leukaemia (AML/ALL)	Pancytopenia, blast crisis, bone marrow biopsy, cytogenetics, induction chemotherapy.
7	CML/CLL	Philadelphia chromosome (BCR-ABL), imatinib for CML; Rai staging for CLL.
8	Lymphoma (Hodgkin/Non-Hodgkin)	Lymphadenopathy + B symptoms, LN biopsy (Reed-Sternberg cells for HL), Ann Arbor staging.
9	Multiple Myeloma	CRAB (Calcium, Renal, Anaemia, Bone pain), serum protein electrophoresis, Bence Jones protein, bone marrow biopsy.
10	DIC	Bleeding + clotting, prolonged PT/APTT, low fibrinogen, raised D-dimer, FFP/cryoprecipitate.

SYSTEM 8: RHEUMATOLOGY / MUSCULOSKELETAL

#	Case	Key Approach
1	Rheumatoid Arthritis	Symmetrical small joint arthritis, morning stiffness, RF, anti-CCP, DAS28, DMARDs.
2	SLE	Multi-system, butterfly rash, ANA, anti-dsDNA, complement, ACR criteria, hydroxychloroquine.
3	Gout	Acute monoarthritis (1st MTP), hyperuricaemia, synovial fluid (negatively birefringent crystals), colchicine, allopurinol.
4	Ankylosing Spondylitis	Young male, inflammatory back pain, bamboo spine, HLA-B27, NSAIDs, anti-TNF.
5	Reactive Arthritis	Post-infection (urethritis/diarrhoea), Reiter's triad (can't see, can't pee, can't climb a tree).
6	Septic Arthritis	Hot swollen joint, fever, synovial fluid WBC >50,000, IV antibiotics, joint washout - orthopaedic emergency.
7	Osteoarthritis	Elderly, weight-bearing joints, Heberden/Bouchard nodes, X-ray (LOSS - Loss of joint space, Osteophytes, Subchondral sclerosis, Subchondral cysts).
8	Polymyalgia Rheumatica	>50 years, shoulder/pelvic girdle pain, raised ESR/CRP, prednisolone (dramatic response).
9	Giant Cell Arteritis	Temporal headache, jaw claudication, visual loss, temporal artery biopsy, high-dose steroids.
10	Systemic Sclerosis	CREST syndrome, Raynaud's, anti-centromere/anti-Scl-70.

SYSTEM 9: INFECTIOUS DISEASES

#	Case	Key Approach
1	Sepsis/Septic Shock	qSOFA/SOFA score, Sepsis 6 bundle (within 1 hour), blood cultures before antibiotics.
2	Malaria	Travel history, fever cycles, thick & thin blood film, RDT, artemisinin combination therapy.
3	HIV/AIDS	CD4 count, viral load, opportunistic infections, ART, cotrimoxazole prophylaxis.
4	Typhoid	Relative bradycardia, rose spots, Widal test (low specificity), blood culture (gold standard), ciprofloxacin.
5	Meningococcal Meningitis	Non-blanching petechial/purpuric rash, LP, IV benzylpenicillin immediately.
6	Infective Diarrhoea	Stool culture/microscopy, ORS, antibiotics only if indicated (cholera, dysentery).
7	Urinary TB	Sterile pyuria, AFB urine culture, RIPE therapy (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol).
8	COVID-19/Pneumonia	Hypoxia, CT chest (ground-glass), SpO2 monitoring, dexamethasone, anticoagulation.
9	Dengue Fever	Thrombocytopenia, dengue NS1 antigen, IgM/IgG serology, platelet monitoring.
10	Leptospirosis	Weil's disease (jaundice + renal failure + haemorrhage), serology, IV penicillin.

SYSTEM 10: DERMATOLOGY (Common in Medicine)

#	Case	Key Approach
1	Cellulitis	Ery, warm, tender skin; swab, IV antibiotics (flucloxacillin), mark border progression.
2	Herpes Zoster (Shingles)	Dermatomal vesicular rash, post-herpetic neuralgia, acyclovir within 72 hrs.
3	Stevens-Johnson Syndrome	Drug reaction, mucocutaneous blistering, stop offending drug, supportive, dermatology.
4	Psoriasis	Silvery plaques, extensor surfaces, Koebner, nail pits, associated arthritis.
5	Eczema/Atopic Dermatitis	Flexural distribution, IgE-mediated, emollients, topical steroids, triggers.

SYSTEM 11: PSYCHIATRY (Brief Medicine Cases)

#	Case	Key Approach
1	Delirium	Acute confusion - differentiate from dementia; examine for infection/metabolic cause; MMSE/AMT, treat cause.
2	Alcohol Withdrawal	CIWA score, tremors, seizures, DTs, chlordiazepoxide regime, thiamine (Pabrinex).
3	Drug Overdose/Poisoning	Paracetamol (NAC), salicylate (alkalinise urine), opioids (naloxone), Toxbase guidance.
4	Suicide Risk Assessment	Ideation, intent, plan, means, protective factors - urgent psychiatry referral.

SYSTEM 12: OBSTETRICS & GYNAECOLOGY (for finals)

#	Case	Key Approach
1	Ectopic Pregnancy	Amenorrhoea + pain + bleeding, b-hCG, transvaginal USS, surgical emergency.
2	Pre-eclampsia/Eclampsia	BP >140/90 + proteinuria after 20 wks, magnesium sulphate (seizures), delivery is definitive treatment.
3	Antepartum Haemorrhage	Placenta praevia vs placental abruption (USS, do NOT PV if praevia suspected).
4	Postpartum Haemorrhage	>500 mL blood loss, HAEMOSTASIS mnemonic, IV oxytocin.
5	Ovarian Cyst/Torsion	Sudden pelvic pain, USS, laparoscopy (torsion = surgical emergency).

QUICK APPROACH MNEMONICS

Mnemonic	Use
OLDCARTS	History of any symptom
SOCRATES	Pain history
AEIOU TIPS	Causes of altered consciousness
MUDPILES	Causes of high anion gap metabolic acidosis
CURB-65	Pneumonia severity
Wells Score	DVT/PE probability
CHADS2 / CHA2DS2-VASc	AF stroke risk
ABCDE	Emergency approach (any sick patient)
SBAR	Handover communication
4Hs & 4Ts	Cardiac arrest reversible causes

CASE PRESENTATION TEMPLATE (Quick Version)

"This is [Mr./Ms. X], a [age]-year-old [occupation], who presented with a [duration] history of [chief complaint]. The pain/symptom is [OLDCARTS]. Relevant positives: [...]. Relevant negatives: [...]. Background: [PMH, medications, allergies, SH, FH].

On examination: Vital signs showed [...]. General inspection [...]. System examination: [relevant findings].

Key investigations: [ECG, bloods, imaging findings].

In summary, this is a [age] [sex] with [1-2 line summary]. My differential is [most likely] due to [reason], with [2nd] and [3rd] as alternatives.

My management plan: [immediate stabilisation (ABCDE if needed)] + [investigations to confirm] + [definitive treatment] + [monitoring/follow-up]."

This covers all major systems tested in 4th-year clinical medicine. Focus on the top 3 cases per system for exams (usually the most common presentations), and always structure your presentation using the universal framework above. Good luck with your sub-internship!

All these case above all system give case presentation template include sign symtom lab and treatment

Finding Sources

Here is the complete clinical case presentation template for every case, all systems, with symptoms, signs, labs, and treatment:

COMPLETE CLINICAL CASE PRESENTATION TEMPLATES

4th Year Medical Student - All Systems

Format for each case: Patient Intro → Symptoms (History) → Signs (Examination) → Investigations/Labs → Treatment/Management

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SYSTEM 1: CARDIOVASCULAR

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CASE 1.1 — ACUTE STEMI

PRESENTATION INTRO: "Mr. X, 58-year-old male smoker, presenting with 2-hour history of severe central crushing chest pain."

Symptoms (History)

Severe central/retrosternal chest pain - crushing, heavy, pressure-like
Radiation to left arm, jaw, or back
Diaphoresis (sweating), nausea, vomiting
Dyspnoea, palpitations
Sense of impending doom
Risk factors: HTN, DM, dyslipidaemia, smoking, family history, obesity
No relief with GTN (distinguishes from angina)

Signs (Examination)

Tachycardia, hypotension (if cardiogenic shock)
Pallor, cold clammy peripheries
S4 gallop may be present
Signs of LVF: bilateral basal crepitations, raised JVP
Inferior MI (RV involvement): hypotension, raised JVP, clear lungs
Pericardial friction rub (if pericarditis develops)
Killip Classification:
- I: No heart failure
- II: Mild HF (S3, basal crepitations)
- III: Pulmonary oedema
- IV: Cardiogenic shock

Investigations/Labs

Test	Finding
ECG	ST elevation ≥1mm in ≥2 contiguous limb leads or ≥2mm in chest leads; new LBBB
Troponin I/T	Raised (rises 3-6 hrs, peaks 12-24 hrs)
CK-MB	Elevated
FBC	Leucocytosis (stress response)
U&E	Baseline renal function
Lipids	Fasting lipid profile
CXR	Pulmonary oedema if LVF
Echo	Wall motion abnormality, EF assessment
Coronary angiogram	Culprit vessel identification

ECG territories:

Inferior MI: II, III, aVF (RCA)
Anterior MI: V1-V4 (LAD)
Lateral MI: I, aVL, V5-V6 (LCx)
Posterior MI: tall R in V1-V2, ST depression V1-V3

Treatment

Immediate (MONA + antiplatelet):

Morphine 2.5-5mg IV (pain)
Oxygen only if SpO2 <94%
Nitrates (GTN sublingual - avoid if systolic <90)
Aspirin 300mg loading + Clopidogrel/Ticagrelor (DAPT)
Anticoagulation: Heparin/Fondaparinux/Enoxaparin

Reperfusion (within 12 hours):

Primary PCI (preferred, within 90 minutes of first medical contact)
Thrombolysis if PCI not available within 120 min: Streptokinase/Alteplase/Tenecteplase

Secondary Prevention (ABCDE):

Aspirin + Atorvastatin (high intensity)
Beta-blocker (bisoprolol/metoprolol)
Captopril/ACE inhibitor
Diet + Diabetes management
Exercise cardiac rehabilitation

CASE 1.2 — NSTEMI / UNSTABLE ANGINA

PRESENTATION INTRO: "Mr. X, 65-year-old male, presenting with 30-minute chest pain at rest, not fully relieved by GTN."

Symptoms

Chest pain at rest OR chest pain with minimal exertion
Recent change in previously stable angina pattern
Diaphoresis, dyspnoea
Unstable angina: troponin negative
NSTEMI: troponin positive

Signs

May be unremarkable
Signs of haemodynamic compromise if severe
New murmur (papillary muscle ischaemia - mitral regurgitation)

Investigations

Test	Finding
ECG	ST depression, T-wave inversion, or normal
Troponin	Elevated in NSTEMI; negative in UA (serial at 0 and 3 hrs)
GRACE Score	Risk stratification (in-hospital mortality)
TIMI Score	Risk stratification
Echo	Assess LV function
Coronary angiogram	For moderate-high risk

Treatment

Antiplatelet: Aspirin 300mg + Ticagrelor or Clopidogrel
Anticoagulation: Fondaparinux (preferred) or Enoxaparin
Anti-ischaemic: GTN, beta-blocker, Ca-channel blocker
Statin: High intensity atorvastatin
Invasive strategy (angiography): within 24 hrs for high risk; 72 hrs for intermediate risk
Long-term: DAPT x12 months, ACEi, statin, beta-blocker

CASE 1.3 — ACUTE LEFT VENTRICULAR FAILURE (Pulmonary Oedema)

PRESENTATION INTRO: "Mrs. X, 72-year-old female with known IHD, presenting with sudden-onset severe breathlessness at rest."

Symptoms

Severe dyspnoea at rest (acute onset)
Orthopnoea (cannot lie flat)
Paroxysmal nocturnal dyspnoea (PND)
Pink frothy sputum
Anxiety, sense of suffocation

Signs

Tachycardia, tachypnoea
Low BP or normal
SpO2 low
Diaphoresis, cold clammy skin
Respiratory: bilateral basal fine crepitations ± wheeze ("cardiac asthma")
Cardiovascular: displaced apex beat, S3 gallop, elevated JVP
Pitting oedema (peripheral)

Investigations

Test	Finding
CXR	Bat-wing shadowing, upper lobe venous diversion, Kerley B lines, cardiomegaly, pleural effusion (ABCDE: Alveolar oedema, Bat-wing, Cardiomegaly, Dilatation of upper lobe veins, Effusion)
BNP/NT-proBNP	Markedly elevated
Troponin	Elevated if underlying ACS
ECG	Causative arrhythmia, ischaemia
Echo	Reduced EF (<40% = HFrEF), diastolic dysfunction
ABG	Hypoxia ± hypercapnia
U&E/Creatinine	Before diuretics

Treatment

Acute:

Position: sit up, legs down (reduce preload)
O2: high-flow, CPAP/BiPAP if not responding
Furosemide IV: 40-80mg (diuresis and venodilation)
GTN IV infusion (if systolic >90 - reduces preload)
Morphine 2-5mg IV (anxiolysis, venodilation - use with caution)
Treat underlying cause (AF, MI, HTN crisis)

Chronic HF management (HFrEF):

ACEi/ARB (ramipril/valsartan) - reduces mortality
Beta-blocker (bisoprolol/carvedilol) - reduces mortality
Spironolactone/Eplerenone - if EF <35%
SGLT2 inhibitor (dapagliflozin/empagliflozin) - new standard of care
Furosemide for symptoms
CRT/ICD if EF <35% + LBBB or at risk of VT/VF

CASE 1.4 — ATRIAL FIBRILLATION (AF)

PRESENTATION INTRO: "Mr. X, 68-year-old male with hypertension, presenting with palpitations and breathlessness for 12 hours."

Symptoms

Palpitations (fast, irregular)
Dyspnoea, reduced exercise tolerance
Dizziness, presyncope
Chest discomfort
May be asymptomatic (incidental finding)

Signs

Irregularly irregular pulse (pathognomonic)
Pulse deficit (apical rate > radial rate)
Variable S1 intensity
Signs of underlying cause: thyrotoxicosis, HF, valve disease
Signs of haemodynamic compromise

Investigations

Test	Finding
ECG	Absent P waves, irregularly irregular QRS, fibrillatory baseline
TFTs	Exclude thyrotoxicosis
FBC, U&E	Baseline
Echo	Structural heart disease, LA size, LV function, thrombus
Holter monitor	For paroxysmal AF
CHA2DS2-VASc score	Stroke risk (Congestive HF, Hypertension, Age≥75×2, DM, Stroke×2, Vascular disease, Age 65-74, Sex female)
HAS-BLED	Bleeding risk

Treatment

Rate control (first-line for most):

Beta-blocker (bisoprolol) or Rate-limiting CCB (diltiazem/verapamil)
Digoxin (in HF or sedentary patients)

Rhythm control:

DC cardioversion (if AF <48 hrs or adequately anticoagulated for ≥3 weeks)
Flecainide, amiodarone, sotalol (pharmacological cardioversion)
Catheter ablation (recurrent symptomatic AF)

Anticoagulation (if CHA2DS2-VASc ≥2 male, ≥3 female):

DOAC preferred: Apixaban, Rivaroxaban, Dabigatran
Warfarin (if mechanical valve/renal impairment)
Never anticoagulate if CHA2DS2-VASc = 0 (male)

CASE 1.5 — INFECTIVE ENDOCARDITIS (IE)

PRESENTATION INTRO: "Mr. X, 35-year-old IVDU, presenting with 3-week history of fever, malaise, and a new heart murmur."

Symptoms

Fever, rigors, night sweats
Malaise, fatigue, weight loss
Joint pains, myalgia
Dyspnoea (if valvular damage)
Symptoms of emboli: stroke, haematuria, flank pain

Signs

Classical peripheral stigmata:

Osler's nodes - painful nodules on finger pads (immune complex)
Janeway lesions - non-tender palmar/plantar haemorrhagic macules (embolic)
Splinter haemorrhages - linear nail haemorrhages
Roth spots - oval retinal haemorrhages with pale centre
Clubbing (chronic)
Splenomegaly
New or changing heart murmur
Petechiae (conjunctival, mucosal)
Signs of HF if valvular destruction

Investigations - Duke Criteria

Major criteria (2 = definite IE):

Criterion	Test
Positive blood cultures	2 separate cultures: Strep. viridans, Staph. aureus, HACEK
Echocardiographic evidence	Vegetation, abscess, new dehiscence of prosthetic valve, new regurgitation

Minor criteria:

Criterion	Details
Predisposing condition	Valve disease, IVDU
Fever >38°C
Vascular phenomena	Emboli, Janeway lesions
Immunological phenomena	Osler's nodes, Roth spots, positive RF

Lab findings:

FBC: anaemia, leucocytosis, raised ESR/CRP
Blood cultures: ×3 sets (aerobic + anaerobic) before antibiotics
Echo (TOE > TTE)
Urine: haematuria (embolic/immune glomerulonephritis)
Renal function: if embolic nephropathy

Treatment

Antibiotics (IV, 4-6 weeks):
- Native valve - Strep: Amoxicillin + Gentamicin (synergy)
- Staph aureus: Flucloxacillin (or Vancomycin if MRSA)
- Prosthetic valve: Vancomycin + Rifampicin + Gentamicin
Surgery indications: severe HF, uncontrolled infection, large vegetation with recurrent emboli, abscess

CASE 1.6 — PULMONARY EMBOLISM (PE)

PRESENTATION INTRO: "Ms. X, 42-year-old female on OCP, presenting with sudden dyspnoea and right-sided pleuritic chest pain 1 week after long-haul flight."

Symptoms

Sudden dyspnoea (most common symptom)
Pleuritic chest pain
Haemoptysis (pulmonary infarction)
Syncope (massive PE)
Leg swelling/pain (DVT in 70%)

Signs

Tachycardia, tachypnoea (most common signs)
Hypoxia (SpO2 low)
Hypotension (massive PE - obstructive shock)
Calf tenderness/swelling (DVT)
Raised JVP, RV heave (acute cor pulmonale)
Pleural rub

Investigations

Test	Finding
Wells Score	≥5 = high probability
D-dimer	Sensitive but not specific; if low probability + D-dimer negative = PE excluded
CTPA	Gold standard - filling defect in pulmonary arteries
ECG	Sinus tachycardia (most common); S1Q3T3 (right heart strain); new RBBB
CXR	Often normal; Hampton's hump (wedge infarct), Westermark's sign (oligaemia)
ABG	Hypoxia, hypocapnia (hyperventilation), raised A-a gradient
Echo	RV dilatation/strain (massive PE)
Troponin/BNP	Raised in submassive/massive PE (poor prognosis)
Compression USS	Confirm DVT

Treatment

Massive PE (haemodynamically unstable):

Systemic thrombolysis: Alteplase 100mg over 2 hrs
Surgical embolectomy or catheter-directed thrombolysis if contraindications

Non-massive PE:

Anticoagulation:
- DOAC preferred: Rivaroxaban (15mg BD x21 days then 20mg OD) or Apixaban (10mg BD x7 days then 5mg BD)
- LMWH bridge to warfarin (if DOAC contraindicated)
Duration: 3 months if provoked; 6 months if unprovoked; lifelong if recurrent

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SYSTEM 2: RESPIRATORY

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CASE 2.1 — COMMUNITY-ACQUIRED PNEUMONIA (CAP)

PRESENTATION INTRO: "Mr. X, 55-year-old male, presenting with 3-day history of productive cough, fever, and right-sided pleuritic chest pain."

Symptoms

Productive cough (purulent/rusty sputum - Strep. pneumoniae)
Fever, rigors
Pleuritic chest pain (lateral/localised)
Dyspnoea
Malaise, reduced appetite, myalgia

Signs

Fever (>38°C), tachycardia, tachypnoea
Low SpO2
Consolidation signs:
- Dull percussion note
- Increased vocal resonance / bronchial breath sounds
- Aegophony ("e" sounds like "a")
- Coarse crackles
Signs of pleural effusion if parapneumonic

Investigations

Test	Finding
CXR	Lobar/segmental consolidation; blunted costophrenic angle if effusion
FBC	Neutrophilia (bacterial); lymphocytosis (viral/atypical)
CRP/ESR	Elevated
Sputum MC&S	Causative organism + sensitivities
Blood cultures	×2 sets (positive in bacteraemia)
Urine Legionella/Pneumococcal antigen	If severe/hospitalised
ABG	If SpO2 <94%
CURB-65 Score	Severity assessment

CURB-65 (1 point each):

Confusion (AMT ≤8)
Urea >7 mmol/L
Respiratory rate ≥30
BP <90 systolic or ≤60 diastolic
Age ≥65

Score 0-1: Home treatment | 2: Consider admission | 3-5: Severe, ICU consider

Treatment

CURB-65 0-1 (mild - outpatient):

Amoxicillin 500mg TDS x5 days (add doxycycline if atypical suspected)

CURB-65 2 (moderate - inpatient):

IV Amoxicillin + Clarithromycin (dual therapy)

CURB-65 3-5 (severe - ICU consider):

IV Co-amoxiclav + IV Clarithromycin
Or IV Piperacillin/tazobactam if risk of Gram negatives
O2, IV fluids, physiotherapy
Treat complications: empyema (drain), septic shock (vasopressors)

CASE 2.2 — COPD EXACERBATION

PRESENTATION INTRO: "Mr. X, 67-year-old heavy smoker (50 pack-years), presenting with worsening dyspnoea, increased sputum, and wheeze over 3 days."

Symptoms

Increased dyspnoea (worse than baseline)
Increased sputum volume and/or change in colour (yellow/green)
Wheeze
Reduced exercise tolerance
Ask: trigger (viral URTI, cold weather, non-compliance with inhalers)
MRC Dyspnoea Scale (baseline severity)

Signs

Tachypnoea, tachycardia
Use of accessory muscles
Pursed-lip breathing
Barrel chest (hyperinflated), increased AP diameter
Percussion: bilateral hyperresonance
Auscultation: prolonged expiratory phase, widespread wheeze, coarse crackles
Cyanosis (central - severe)
Cor pulmonale signs: raised JVP, peripheral oedema, right parasternal heave (advanced)

Investigations

Test	Finding
ABG	Type 2 respiratory failure: low PaO2, raised PaCO2, compensated respiratory acidosis
CXR	Hyperinflation (>6 anterior ribs), flat diaphragm; consolidation if pneumonia trigger
FBC	Polycythaemia (secondary), leucocytosis if infection
Sputum MC&S	H. influenzae, S. pneumoniae, M. catarrhalis
ECG	P-pulmonale, right heart strain
Spirometry (baseline)	FEV1/FVC <0.7 post-bronchodilator (GOLD staging)
BNP	Exclude HF

GOLD Staging (post-BD FEV1 % predicted):

GOLD 1: ≥80% (mild)
GOLD 2: 50-79% (moderate)
GOLD 3: 30-49% (severe)
GOLD 4: <30% (very severe)

Treatment

Acute exacerbation:

Controlled O2: target SpO2 88-92% (hypercapnic drive - do NOT over-oxygenate)
Bronchodilators: Salbutamol nebuliser + Ipratropium nebuliser (Q4-6h)
Prednisolone: 30-40mg PO OD x5 days (reduce inflammation)
Antibiotics (if purulent sputum or consolidation): Amoxicillin / Doxycycline / Clarithromycin
NIV (BiPAP): if pH 7.25-7.35 + PaCO2 raised despite above
Intubation: if deteriorating on NIV, pH <7.25

Long-term COPD management (GOLD guidelines):

SABA (Salbutamol) PRN - all patients
LAMA (Tiotropium) or LABA (Salmeterol/Formoterol)
LAMA+LABA combination (Umeclidinium/Vilanterol)
Add ICS if frequent exacerbations or eosinophils >300
Smoking cessation (most effective intervention)
Pulmonary rehabilitation
LTOT: if PaO2 <7.3 kPa; use 15+ hrs/day

CASE 2.3 — BRONCHIAL ASTHMA (ACUTE SEVERE)

PRESENTATION INTRO: "Miss X, 22-year-old female with known asthma, presenting with severe wheeze and dyspnoea not responding to her Salbutamol inhaler."

Symptoms

Wheeze, dyspnoea
Chest tightness
Cough (nocturnal/early morning)
Diurnal variation (worse at night/morning)
Triggers: allergens, exercise, cold air, NSAIDs, beta-blockers, stress

Signs

Severity Assessment:

Feature	Moderate	Acute Severe	Life-threatening
SpO2	≥92%	≥92%	<92%
PEFR	50-75% best	33-50% best	<33% best
Respiratory rate	Normal	≥25/min	Silent chest
Pulse	Normal	≥110/min	Bradycardia
Speech	Normal	Sentences	Can't speak
Consciousness	Normal	Normal	Confusion/coma

Near-fatal asthma: raised PaCO2, requirement for mechanical ventilation

Investigations

Test	Finding
PEFR	Reduced (compare to personal best)
SpO2/ABG	Hypoxia; initially hypocapnia (hyperventilation); rising CO2 = life-threatening
CXR	Hyperinflation; exclude pneumothorax or pneumonia
FBC	Eosinophilia (atopy); leucocytosis (infection trigger)
U&E	Hypokalaemia (salbutamol/steroids)

Treatment

Acute severe asthma (SABA+SAMA+steroid+Mg):

O2: 40-60% to keep SpO2 ≥94%
Salbutamol nebuliser: 2.5-5mg (driven by O2, Q15-20min)
Ipratropium bromide nebuliser: 0.5mg (add to first 3 doses)
Prednisolone: 40-50mg PO (or Hydrocortisone 100mg IV if cannot swallow)
IV Magnesium sulphate: 1.2-2g IV over 20 min (if not responding or life-threatening)
IV Salbutamol/Aminophylline (if ITU - severe/refractory)
Intubation and ventilation if life-threatening

Step-up long-term management (BTS/GINA):

SABA PRN
SABA + Low-dose ICS (Beclometasone)
SABA + ICS + LABA (Salmeterol)
SABA + ICS (higher dose) + LABA + LTRA (Montelukast)
SABA + High-dose ICS + LABA + oral prednisolone ± biologics (Omalizumab for allergic asthma)

CASE 2.4 — PULMONARY TUBERCULOSIS (TB)

PRESENTATION INTRO: "Mr. X, 30-year-old male from sub-Saharan Africa, presenting with 6-week history of productive cough, haemoptysis, night sweats, and 8 kg weight loss."

Symptoms

Chronic productive cough (>3 weeks)
Haemoptysis
Constitutional: fever (afternoon low-grade), night sweats, anorexia, weight loss
Dyspnoea (if extensive disease)
Pleuritic chest pain
Ask: contact history, country of origin, HIV status, BCG vaccination, previous TB treatment

Signs

Cachexia, pallor
Low-grade fever
Respiratory: dull percussion (upper zones), coarse crackles/bronchial breathing (upper lobes)
Lymphadenopathy (cervical - "scrofula")
Signs of pleural effusion (TB pleuritis)
Extra-pulmonary TB signs: meningism, spine tenderness (Pott's disease), skin lesions (lupus vulgaris)

Investigations

Test	Finding
CXR	Upper lobe infiltrates/cavitation, hilar lymphadenopathy, calcified lesions (old TB)
Sputum AFB smear x3	Acid-fast bacilli (Ziehl-Neelsen stain) - screen
Sputum culture	Gold standard (Lowenstein-Jensen medium; 4-6 weeks); drug sensitivity
GeneXpert MTB/RIF	Rapid PCR (detects TB + rifampicin resistance)
Mantoux (TST)	≥10mm positive (≥5mm if immunocompromised/HIV)
IGRA (QuantiFERON)	Latent TB diagnosis; not affected by BCG
Bronchoscopy + BAL	If smear-negative but strong clinical suspicion
HIV test	Mandatory
LFTs, U&E	Baseline before therapy
CT chest	For complex cases

Treatment

RIPE Regimen:

Phase	Duration	Drugs
Intensive	2 months	Rifampicin + Isoniazid + Pyrazinamide + Ethambutol
Continuation	4 months	Rifampicin + Isoniazid
Total	6 months	2RIPE / 4RI

Add Pyridoxine (Vit B6) with Isoniazid (prevents peripheral neuropathy)
Multi-drug resistant TB (MDR-TB): Rifampicin + Isoniazid resistant → Bedaquiline-based regimen (18-24 months)
HIV co-infection: Start ART within 2-8 weeks of starting TB treatment
Notification: Statutory notifiable disease (public health duty)
Contact tracing for household contacts

CASE 2.5 — PLEURAL EFFUSION

PRESENTATION INTRO: "Mr. X, 60-year-old male, presenting with progressive dyspnoea and dull right-sided chest discomfort."

Symptoms

Progressive dyspnoea
Dull aching chest pain (pleuritic if associated pleuritis)
Dry cough
Symptoms of underlying cause (HF, malignancy, infection)

Signs

Tracheal/mediastinal shift away from effusion (large effusion)
Reduced chest expansion on affected side
Stony dull percussion (pathognomonic)
Absent/reduced breath sounds
Absent tactile/vocal fremitus
Aegophony at upper margin of effusion

Investigations

Test	Finding
CXR	Blunting of costophrenic angle (>200mL); meniscus sign; white-out (massive)
Pleural USS	Confirms effusion, guides aspiration
CT chest	If malignancy or complex effusion suspected
Diagnostic thoracocentesis	Essential to characterise
Fluid Protein	Exudate vs transudate
Fluid LDH	Light's criteria
Fluid Glucose	Low in infection/RA
Fluid pH	<7.2 = complicated parapneumonic (needs drain)
Fluid MC&S + AFB	Infection
Fluid cytology	Malignant cells

Light's Criteria (EXUDATE if any ONE met):

Pleural fluid protein / serum protein > 0.5
Pleural fluid LDH / serum LDH > 0.6
Pleural fluid LDH > 2/3 upper limit of normal serum LDH

Transudate causes: HF, hypoalbuminaemia (cirrhosis, nephrotic), hypothyroidism Exudate causes: Pneumonia (parapneumonic), malignancy, TB, PE, RA, SLE

Treatment

Treat underlying cause
Therapeutic thoracocentesis (symptomatic large effusion)
Chest drain (complicated parapneumonic effusion/empyema, haemothorax)
Pleurodesis (recurrent malignant effusion - Talc or Bleomycin)
Indwelling pleural catheter (chronic malignant effusion)

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SYSTEM 3: GASTROENTEROLOGY / HEPATOLOGY

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CASE 3.1 — UPPER GI BLEED

PRESENTATION INTRO: "Mr. X, 55-year-old male with history of NSAID use, presenting with haematemesis (coffee-ground vomit) and melaena."

Symptoms

Haematemesis (fresh blood = active arterial bleed; coffee-ground = slower bleed)
Melaena (black, tarry, foul-smelling stool = blood >4 hours in gut)
Epigastric pain (PUD)
Dizziness, syncope (hypovolaemia)
Risk factors: NSAIDs, aspirin, alcohol, H. pylori, cirrhosis, anticoagulants, previous GI bleed

Signs

Tachycardia, hypotension (shock if >20% blood volume lost)
Pallor, cold clammy peripheries
Reduced capillary refill
Abdominal: epigastric tenderness
Signs of chronic liver disease: spider naevi, palmar erythema, jaundice, splenomegaly, ascites, caput medusae (suggests variceal bleed)
PR exam: melaena on glove

Investigations

Test	Finding
FBC	Anaemia (Hb may be normal initially - takes 6-12 hrs for dilutional drop)
U&E	Raised urea disproportionate to creatinine (digested blood = protein load)
Coagulation (PT/INR)	Prolonged if liver disease or on warfarin
LFTs	Liver disease?
Group & Save / X-match	Transfusion preparation
Blatchford Score	Pre-endoscopy risk score
Urgent OGD	Diagnostic and therapeutic (within 24 hrs; within 12 hrs if haemodynamically unstable)

Treatment

Immediate resuscitation (ABCDE):

Large-bore IV access x2, IV fluids (NS/Hartmann's)
Blood transfusion: target Hb 70-80 g/L (restrictive strategy - unless haemodynamically unstable or IHD)
FFP/platelets if coagulopathy
Sengstaken-Blakemore tube (variceal bleed temporising measure while awaiting OGD/TIPSS)

Endoscopic treatment:

Adrenaline injection + clips/thermal coagulation (non-variceal)
Band ligation (oesophageal varices)
Glue injection (gastric varices)

Medical:

IV PPI (Pantoprazole/Omeprazole) - reduces rebleeding
Terlipressin/Octreotide - variceal bleed (reduces portal pressure)
IV antibiotics (Ceftriaxone) - variceal bleed (prevents SBP)
H. pylori eradication if positive: Triple therapy (Amoxicillin + Clarithromycin + PPI x7-14 days)

CASE 3.2 — ACUTE PANCREATITIS

PRESENTATION INTRO: "Mr. X, 45-year-old male, heavy drinker, presenting with severe epigastric pain radiating to the back, vomiting, and inability to eat."

Symptoms

Severe constant epigastric pain radiating to the back
Pain relieved by leaning forward (reduces stretch on pancreas)
Nausea, vomiting (vomiting does not relieve pain - distinguishes from peptic cause)
Anorexia
Causes (GET SMASHED): Gallstones, Ethanol, Trauma, Steroids, Mumps/Malignancy, Autoimmune, Scorpion sting, Hypercalcaemia/Hypertriglyceridaemia, ERCP/Emboli, Drugs

Signs

Fever (inflammatory/infective)
Tachycardia, hypotension (fluid sequestration/haemorrhagic)
Abdominal tenderness and guarding (epigastric)
Abdominal distension, reduced bowel sounds (ileus)
Grey-Turner's sign - bruising in flanks (retroperitoneal haemorrhage)
Cullen's sign - bruising around umbilicus (retroperitoneal haemorrhage)
Jaundice (if gallstone-obstructed CBD)

Investigations

Test	Finding
Serum amylase	>3× upper limit = significant (may be normal if >24-48 hrs)
Serum lipase	More sensitive and specific; remains elevated longer
FBC	Leucocytosis
CRP	>150 at 48 hrs = severe disease
U&E	Raised creatinine (AKI), raised urea
LFTs	Elevated ALP/bilirubin (gallstone aetiology)
Glucose	Hyperglycaemia
Calcium	Hypocalcaemia (saponification) - poor prognosis
Triglycerides	If no gallstone or alcohol cause
USS abdomen	Gallstones; CBD dilatation
CT abdomen (at 48-72 hrs)	Assess necrosis, complications (not immediately unless diagnostic doubt)
CXR	Left pleural effusion, ARDS

Severity Scoring:

Ranson's Criteria (5 at admission + 6 at 48 hrs)
Glasgow/Imrie Score (at 48 hrs - score ≥3 = severe): PaO2 <8kPa, Age >55, WCC >15, Calcium <2 mmol/L, Urea >16 mmol/L, LDH >600, Albumin <32, Sugar >10
APACHE II score
CT Severity Index (Balthazar score)

Treatment

Nothing by mouth (bowel rest) initially; early enteral nutrition (NG/NJ) preferably within 24-48 hrs
Aggressive IV fluids (Lactated Ringer's preferred - 250-500 mL/hr initially)
Analgesia: Morphine/Pethidine IV; regular paracetamol
Monitor: Urine output (catheter), fluid balance, daily bloods, ABG
Treat cause: ERCP + sphincterotomy (gallstone pancreatitis with biliary obstruction); cholecystectomy after recovery
Antibiotics: Only if infected necrosis confirmed (NOT routine prophylaxis)
Surgical/IR: Necrosectomy (infected pancreatic necrosis), drain pseudocyst/abscess

CASE 3.3 — LIVER CIRRHOSIS WITH COMPLICATIONS

PRESENTATION INTRO: "Mr. X, 52-year-old male with 20-year history of heavy alcohol use, presenting with increasing abdominal distension, jaundice, and confusion."

Symptoms

Abdominal distension (ascites)
Jaundice
Confusion (hepatic encephalopathy)
Haematemesis/melaena (variceal bleed)
Easy bruising, bleeding gums
Weight loss, muscle wasting
Loss of libido, menstrual irregularities

Signs

Hepatic stigmata:

Spider naevi (>5 = significant, SVC distribution)
Palmar erythema
Leuconychia (white nails - hypoalbuminaemia)
Clubbing (hepatopulmonary syndrome)
Dupuytren's contracture (alcoholic)
Parotid enlargement (alcoholic)
Gynaecomastia, testicular atrophy (oestrogen excess)
Jaundice, scleral icterus
Caput medusae (dilated periumbilical veins)
Splenomegaly (portal hypertension)
Hepatomegaly (enlarged or shrunken in late cirrhosis)
Ascites (shifting dullness, fluid thrill)
Asterixis (liver flap - hepatic encephalopathy)
Fetor hepaticus (musty breath - hepatic encephalopathy)
Peripheral oedema

Investigations

Test	Finding
LFTs	Raised bilirubin, low albumin, raised ALT/AST; AST:ALT >2:1 in alcoholic
PT/INR	Prolonged (liver synthetic function)
FBC	Pancytopenia (hypersplenism)
U&E	Hyponatraemia (dilutional), renal impairment (hepatorenal syndrome)
USS abdomen	Echogenic liver, splenomegaly, ascites, portal vein diameter
OGD	Oesophageal varices
Ascitic tap (SBP screen)	WCC >250 cells/mm³ = SBP; culture
Serum-ascites albumin gradient (SAAG)	>11 g/L = portal hypertension
AFP	Hepatocellular carcinoma surveillance
Liver biopsy	Gold standard for staging

Child-Pugh Score (A/B/C - prognosis):

Bilirubin, Albumin, PT, Ascites, Encephalopathy

MELD Score (predict 3-month mortality - transplant listing)

Treatment

Ascites:

Salt restriction (<2g/day), diuretics: Spironolactone (aldosterone antagonist) + Furosemide
Therapeutic paracentesis (>5L): replace with albumin (8g per litre removed)
TIPS (transjugular intrahepatic portosystemic shunt) - refractory ascites

Spontaneous Bacterial Peritonitis (SBP):

IV Cefotaxime or Piperacillin/tazobactam
IV Albumin (prevents hepatorenal syndrome)
Prophylaxis: Norfloxacin/Ciprofloxacin (if previous SBP or ascites protein <15)

Variceal bleed:

IV Terlipressin + antibiotics + band ligation (as per UGIB section)
TIPS (if refractory)
Beta-blocker prophylaxis (Carvedilol/Propranolol) for primary/secondary prevention

Hepatic Encephalopathy:

Lactulose (2-3 soft stools/day - reduces NH3)
Rifaximin (non-absorbable antibiotic - reduces gut bacteria)
Treat precipitants: infection, GI bleed, constipation, electrolyte imbalance, drugs

Hepatorenal Syndrome:

IV Albumin + Terlipressin
Liver transplant (definitive)

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SYSTEM 4: NEUROLOGY

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CASE 4.1 — ISCHAEMIC STROKE

PRESENTATION INTRO: "Mrs. X, 72-year-old female with AF and hypertension, presenting with sudden-onset right-sided weakness and slurred speech 2 hours ago."

Symptoms

Sudden onset (key feature)
Unilateral facial drooping
Arm/leg weakness (hemiparesis/hemiplegia)
Speech disturbance: dysphasia (dominant hemisphere) or dysarthria
Visual disturbance: homonymous hemianopia, monocular visual loss (amaurosis fugax = TIA of retinal artery)
Ataxia, vertigo, diplopia (posterior circulation)
Sensory loss, neglect
FAST: Face drooping, Arm weakness, Speech difficulty, Time to call

Signs

Neurological examination:

Facial asymmetry (lower motor neurone = ipsilateral; UMN = contralateral)
Pronator drift, weakness (UMN pattern - extensors weak in arm, flexors weak in leg)
Hyperreflexia + upgoing Babinski (acute phase may show flaccidity initially)
Sensory deficit (hemisensory loss)
Homonymous hemianopia (optic radiation involvement)
Dysphasia/aphasia (Broca's/Wernicke's)
Neglect (non-dominant parietal)

Stroke Syndromes:

TACS (Total Anterior Circulation): all 3 - motor, sensory, higher cortical dysfunction
PACS (Partial): 2 of 3
POCS (Posterior): cerebellar/brainstem signs
LACS (Lacunar): pure motor, pure sensory, sensorimotor

Investigations

Test	Finding
NCCT Head (URGENT)	Exclude haemorrhage before thrombolysis; may be normal in early ischaemia
MRI brain (DWI)	Restricted diffusion = acute ischaemia (more sensitive)
ECG	AF? (cardioembolic)
Carotid Doppler USS	Stenosis (anterior circulation)
Echocardiogram	Cardioembolic source (thrombus, PFO)
Bloods	FBC (polycythaemia), coagulation, lipids, glucose, HbA1c
NIHSS Score	Severity

Treatment

Acute (time-critical - "time is brain"):

IV Alteplase (thrombolysis): within 4.5 hrs of onset (exclude haemorrhage, absolute contraindications)
- Dose: 0.9 mg/kg (max 90 mg), 10% as bolus, rest over 60 min
Mechanical thrombectomy: within 6-24 hrs if large vessel occlusion (NIHSS ≥6)
Aspirin 300mg: if not thrombolysed (start immediately); if thrombolysed - start 24 hrs later
Admit to stroke unit (reduces mortality by 20%)

Secondary prevention:

Antiplatelet: Aspirin 75mg + Clopidogrel x21 days (dual) then single agent
Anticoagulation (if cardioembolic/AF): DOAC after 2-14 days (timing based on infarct size)
Statin: Atorvastatin 40-80mg
Antihypertensive: Amlodipine/ramipril (do NOT acutely lower BP unless >220/120 or thrombolysis)
Treat AF, DM, hyperlipidaemia, smoking
Rehabilitation: Physiotherapy, speech therapy, occupational therapy

CASE 4.2 — BACTERIAL MENINGITIS

PRESENTATION INTRO: "Mr. X, 20-year-old university student, presenting with 12-hour history of severe headache, neck stiffness, fever, and non-blanching purpuric rash."

Symptoms

Triad: Fever + Neck stiffness + Altered consciousness
Severe headache (rapid onset)
Photophobia, phonophobia
Nausea, vomiting
Non-blanching petechial/purpuric rash (meningococcal septicaemia)
Seizures
Ask: recent URTI, travel, immunisation history, contact with cases

Signs

High fever
Neck stiffness (meningismus)
Kernig's sign - pain/resistance on knee extension with hip flexed
Brudzinski's sign - involuntary hip/knee flexion on neck flexion
Non-blanching petechiae/purpura (meningococcal - press glass test)
Altered GCS
Papilloedema (raised ICP - contraindication to LP)
Focal neurological signs (cerebral abscess/infarct complication)

Investigations

Test	Finding
Lumbar puncture (LP)	Gold standard - ONLY if no signs of raised ICP, no focal neurology, no coagulopathy
CSF analysis:
- Bacterial meningitis	Cloudy; PMN leucocytosis; raised protein; very low glucose (<2.2 or <50% serum); organisms on Gram stain
- Viral meningitis	Clear; lymphocytes; normal/mildly raised protein; normal glucose
- TB meningitis	Clear/fibrinous; lymphocytes; raised protein; very low glucose; AFB
Blood cultures (x2)	Before antibiotics if no delay
FBC	Leucocytosis
CRP, ESR	Markedly elevated
Coagulation	DIC if septicaemia
CT head	Before LP if raised ICP suspected (papilloedema, focal signs, GCS <13)
PCR	Meningococcal/pneumococcal/viral PCR

Treatment

DO NOT DELAY ANTIBIOTICS

If GP/pre-hospital: IV/IM Benzylpenicillin immediately before transfer
IV Ceftriaxone 2g BD (empirical, covers Neisseria meningitidis, Strep. pneumoniae)
Add IV Amoxicillin if >50 years/immunocompromised (covers Listeria)
Dexamethasone 0.15mg/kg QDS x4 days (give 30 min before or with first antibiotic) - reduces mortality and hearing loss in bacterial meningitis
IV fluids, treat seizures (benzodiazepines)
Prophylaxis for contacts: Rifampicin/Ciprofloxacin/Ceftriaxone (meningococcal)
Notifiable disease

CASE 4.3 — EPILEPSY / STATUS EPILEPTICUS

PRESENTATION INTRO: "Mr. X, 28-year-old male, witnessed having generalised tonic-clonic seizure lasting >5 minutes, not spontaneously resolving."

Symptoms (History from witness)

Aura (simple partial onset - visual, sensory, olfactory)
Loss of consciousness, stiffening (tonic phase)
Rhythmic jerking (clonic phase)
Tongue biting, incontinence (suggestive of seizure)
Post-ictal confusion, drowsiness, headache, Todd's paresis

Signs

Decreased/fluctuating consciousness
Lateral tongue biting
Incontinence
Signs of head injury (fall)
Post-ictal focal weakness (Todd's paresis - partial onset)

Investigations

Test	Finding
EEG	Epileptiform activity (though often normal interictally)
MRI brain	Structural lesion (hippocampal sclerosis, tumour, cortical dysplasia)
FBC, U&E, Ca, Mg, Glucose	Metabolic causes
Toxicology screen	Drug-related
LP	If meningitis/encephalitis suspected
ECG	Exclude cardiac cause of syncope

Treatment

Status Epilepticus Protocol (seizure >5 min):

Time	Drug
0-5 min	Position (recovery), protect airway, O2, IV access, glucose
5-10 min	Lorazepam 4mg IV (or diazepam 10mg PR/IV if no access)
10-20 min	Repeat Lorazepam 4mg IV
20-40 min	Levetiracetam 2500mg IV OR Sodium Valproate 40mg/kg IV OR Phenytoin 20mg/kg IV
>40 min	RSI + intubation + anaesthetic agent (propofol/thiopentone)

Long-term anticonvulsants (by seizure type):

Generalised tonic-clonic: Sodium Valproate (teratogenic - use Lamotrigine in women of childbearing age) or Levetiracetam
Focal seizures: Carbamazepine or Lamotrigine
Absence: Ethosuximide or Sodium Valproate
Driving restrictions: cannot drive for 1 year after last seizure (UK)

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SYSTEM 5: ENDOCRINOLOGY

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CASE 5.1 — DIABETIC KETOACIDOSIS (DKA)

PRESENTATION INTRO: "Miss X, 19-year-old female with known Type 1 DM, presenting with 2-day history of polyuria, polydipsia, vomiting, and abdominal pain."

Symptoms

Polyuria, polydipsia, nocturia
Nausea, vomiting
Abdominal pain
Weakness, lethargy
Confusion (severe)
Symptoms of precipitant: infection (fever), missed insulin

Signs

Kussmaul breathing (deep, sighing breaths - compensatory respiratory alkalosis)
Fruity/acetone breath (ketones)
Dehydration: dry mucous membranes, reduced skin turgor, sunken eyes
Tachycardia, hypotension
Abdominal tenderness
Reduced consciousness (severe)

Investigations - DKA Diagnostic Criteria

Criterion	Value
Glucose	>11 mmol/L (or known DM)
Ketones	Blood ketones >3 mmol/L OR urine ketones 2+
Bicarbonate	<15 mmol/L (or pH <7.3)

Test	Finding
Blood ketones	>3 mmol/L
Blood glucose	>11 mmol/L
ABG	Metabolic acidosis: low pH, low HCO3, low PaCO2 (compensatory)
U&E	Hyponatraemia (pseudohypo), initially raised K+ (then drops with treatment!)
FBC	Leucocytosis (even without infection - stress response)
HbA1c	Assess control
Blood/urine cultures, CXR	Screen for precipitant infection
ECG	Tall peaked T-waves (hyperkalaemia) or flat T-waves (hypokalaemia)
Serum osmolality	Raised

Severity Classification:

Mild: pH 7.25-7.30 / HCO3 15-18 / ketones ≥3
Moderate: pH 7.00-7.24 / HCO3 10-14
Severe: pH <7.00 / HCO3 <10

Treatment - DKA Protocol (JBDS Guidelines)

1. IV Fluids (most important):

1L 0.9% NaCl over 1 hr, then 1L over 2 hrs, then 1L over 2 hrs, then 1L over 4 hrs x2
Switch to 5% dextrose when glucose <14 mmol/L (maintain glucose 6-10 mmol/L)

2. Insulin:

Fixed-rate IV insulin infusion (FRIII): 0.1 units/kg/hr
Do NOT stop long-acting insulin
Only reduce rate when ketones cleared AND glucose <14

3. Potassium replacement:

K+ 3.5-5.5: add 40 mmol/L to IV fluid bags
K+ >5.5: no K+ replacement
K+ <3.5: senior review - replace K+ first before insulin

4. Monitor:

Hourly: blood glucose + blood ketones + ECG/fluid balance
Every 2-4 hrs: U&E, pH

Resolution criteria (not glucose alone):

Blood ketones <0.6 mmol/L AND pH >7.3 AND HCO3 >18 → switch to SC insulin

Complications to watch:

Cerebral oedema (esp. in children - stop fluids, give IV mannitol)
Hypokalaemia (most dangerous complication of treatment)
Hypoglycaemia

CASE 5.2 — HYPOTHYROIDISM

PRESENTATION INTRO: "Mrs. X, 48-year-old female, presenting with 6-month history of weight gain, fatigue, cold intolerance, and constipation."

Symptoms

Weight gain despite poor appetite
Fatigue, lethargy
Cold intolerance
Constipation
Dry skin, coarse hair, hair loss
Bradycardia
Depression, poor memory, "brain fog"
Menorrhagia (women)
Hoarse voice (myxoedema)

Signs

Bradycardia (most common objective sign)
Dry, coarse skin; non-pitting periorbital oedema (myxoedema)
Coarse, thinning hair; loss of outer 1/3 eyebrow (Queen Anne's sign)
Slow-relaxing reflexes (delayed relaxation phase - classic)
Goitre (enlarged thyroid - Hashimoto's)
Hypothyroid facies: expressionless, periorbital puffiness, macroglossia
Carpal tunnel signs (thenar wasting)
Pleural/pericardial effusion (severe)

Investigations

Test	Finding
TSH	RAISED (primary hypothyroidism)
Free T4	Low
Free T3	Low (less useful)
Anti-TPO antibodies	Positive = Hashimoto's thyroiditis (most common cause)
Anti-thyroglobulin antibodies	Hashimoto's
Lipid profile	Hypercholesterolaemia
FBC	Macrocytic anaemia (associated pernicious anaemia in Hashimoto's)
CK	Raised (myopathy)
ECG	Bradycardia, low voltage, prolonged QT
USS thyroid	Structural assessment

Causes of hypothyroidism:

Primary: Hashimoto's thyroiditis (most common), post-thyroidectomy, radioiodine, drugs (amiodarone, lithium, carbimazole)
Secondary: Pituitary failure (TSH low + T4 low)
Subclinical: TSH raised, T4 normal

Treatment

Levothyroxine (T4): Start 25-50 mcg OD (elderly/IHD - start low)
Titrate by 25 mcg every 6-8 weeks based on TSH
Target TSH: 0.4-2.5 mU/L
Take on empty stomach, 30-60 min before food
Myxoedema coma (emergency): IV T3 (Liothyronine) + IV hydrocortisone (exclude adrenal insufficiency) + warming + supportive

CASE 5.3 — HYPERTHYROIDISM (GRAVES' DISEASE)

PRESENTATION INTRO: "Mrs. X, 32-year-old female, presenting with 3-month history of weight loss despite increased appetite, tremor, palpitations, and protruding eyes."

Symptoms

Weight loss despite increased appetite
Palpitations, tremor
Heat intolerance, excessive sweating
Diarrhoea
Anxiety, irritability, insomnia
Oligomenorrhoea/amenorrhoea
Muscle weakness (thyrotoxic myopathy)

Signs

Thyrotoxicosis (all causes):

Tachycardia / AF
Fine tremor (hands)
Warm, moist, smooth skin
Hyperreflexia
Goitre

Graves' disease specific (autoimmune):

Exophthalmos/proptosis (eye protrusion - Graves' ophthalmopathy)
Lid lag/lid retraction
Pretibial myxoedema (lumpy, orange-peel skin over shins)
Thyroid acropachy (clubbing)
Diffuse smooth goitre + bruit (thyroid bruit)

Investigations

Test	Finding
TSH	SUPPRESSED (<0.05)
Free T4/T3	Elevated
TSH receptor antibodies (TRAb)	Positive in Graves' disease
Anti-TPO antibodies	Often positive in Graves'
FBC	Anaemia; leucopaenia (carbimazole side effect)
LFTs	Elevated (hepatic involvement or carbimazole)
Thyroid isotope scan	Graves': diffuse uptake; toxic nodule: focal uptake; thyroiditis: reduced uptake
USS thyroid
ECG	Sinus tachycardia / AF

Treatment

Medical:

Carbimazole (first-line, blocks thyroid peroxidase): 15-40mg OD, titrate; monitor FBC (risk of agranulocytosis)
Propylthiouracil (PTU) (alternative; preferred in pregnancy 1st trimester)
Beta-blocker (Propranolol): For immediate symptom control (tremor, tachycardia, anxiety)

Definitive:

Radioiodine (I-131): Most common definitive treatment; results in hypothyroidism; contraindicated in pregnancy/breastfeeding and active severe ophthalmopathy
Thyroidectomy: Large goitre, compressive symptoms, patient preference

Thyroid Storm (emergency):

IV Propylthiouracil + Lugol's iodine (block hormone release) + IV Propranolol + Dexamethasone (blocks T4→T3 conversion) + IV fluids + antipyretics (no aspirin)

CASE 5.4 — ADDISON'S DISEASE (PRIMARY ADRENAL INSUFFICIENCY)

PRESENTATION INTRO: "Mr. X, 38-year-old male, presenting with progressive fatigue, weight loss, postural dizziness, and darkening of his skin over 3 months."

Symptoms

Fatigue, weakness (profound)
Anorexia, weight loss
Nausea, vomiting, abdominal pain
Postural dizziness (hypotension)
Salt craving
Adrenal crisis triggers: infection, surgery, trauma, intercurrent illness

Signs

Hyperpigmentation (sun-exposed areas, scars, buccal mucosa, palmar creases, pressure areas) - due to elevated ACTH/MSH
Postural hypotension
Vitiligo (associated autoimmune)
Cachexia
Reduced pubic/axillary hair (women - androgen deficiency)
Adrenal crisis: Profound hypotension, shock, confusion, collapse - EMERGENCY

Investigations

Test	Finding
Serum cortisol (9am)	Low (<100 nmol/L strongly suggests insufficiency)
ACTH level	High in primary (>200 ng/L), low in secondary
Short Synacthen Test	Gold standard: baseline cortisol + 30 min post-250mcg ACTH IM/IV; failure to rise to >500 nmol/L = insufficient
U&E	Hyponatraemia + Hyperkalaemia (aldosterone deficiency)
Glucose	Hypoglycaemia
Anti-adrenal antibodies	Autoimmune (21-hydroxylase antibodies - most common cause in developed countries)
ACTH stimulation test	Exclude secondary
CT abdomen	Adrenal calcification (TB), haemorrhage
CXR	Small heart (reduced preload)

Treatment

Adrenal crisis (emergency):

IV Hydrocortisone 100mg immediately (then 50-100mg QDS) + IV NS 1L rapidly
IV dextrose if hypoglycaemic
Treat precipitating cause

Maintenance (long-term):

Hydrocortisone 15-20mg/day (10mg morning, 5mg midday, 5mg afternoon) - mimics diurnal pattern
Fludrocortisone 0.05-0.1mg/day (mineralocorticoid replacement)
DHEA (dehydroepiandrosterone) - especially in women for wellbeing
Sick day rules: Double/triple hydrocortisone dose during illness
Medic-alert bracelet + emergency HC injection kit (patient must carry)

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SYSTEM 6: RENAL

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CASE 6.1 — ACUTE KIDNEY INJURY (AKI)

PRESENTATION INTRO: "Mr. X, 70-year-old male on ACEi for hypertension, presenting after 3 days of vomiting/diarrhoea with reduced urine output and fatigue."

Symptoms

Reduced urine output (oliguria <0.5 mL/kg/hr or anuria)
Nausea, vomiting, lethargy
Fluid retention: oedema, dyspnoea
Confusion (uraemia/electrolyte disturbance)
Symptoms of underlying cause

Signs

Signs of dehydration (pre-renal): dry mucous membranes, reduced skin turgor, hypotension, tachycardia
Signs of fluid overload: pitting oedema, raised JVP, pulmonary oedema (post-renal or intrinsic if fluid overloaded)
Bladder distension (post-renal - palpate/percuss suprapubically)
Uraemic features: Kussmaul breathing, asterixis, pericardial rub

Investigations

Test	Finding
Creatinine + eGFR	AKI staging (KDIGO)
Urea	Raised; urea:creatinine ratio >100:1 = pre-renal
U&E	Hyperkalaemia (dangerous), hyponatraemia
Urine output
ABG	Metabolic acidosis
FBC	Anaemia (CKD background; blood loss)
Urine dipstick	Blood + protein = intrinsic renal (glomerulonephritis)
Urine MC&S	UTI
Urine Na+ / FENa	<20 mEq/L or <1% = pre-renal
Renal USS	Obstruction (hydronephrosis), kidney size
Bladder scan	Post-renal (urinary retention)
Renal biopsy	Intrinsic renal disease (if no cause found)
ANA, ANCA, anti-GBM	Vasculitis/glomerulonephritis

KDIGO AKI Staging:

Stage	Serum Creatinine	Urine Output
1	×1.5-1.9 baseline or +26.5 µmol/L within 48 hrs	<0.5 mL/kg/hr for 6-12 hrs
2	×2-2.9 baseline	<0.5 mL/kg/hr for ≥12 hrs
3	×3 baseline or >353 µmol/L	<0.3 mL/kg/hr for ≥24 hrs or anuria ≥12 hrs

Causes (Pre-renal / Renal / Post-renal):

Pre-renal (60-70%): Hypovolaemia, heart failure, sepsis, drugs (ACEi + NSAID + diuretic = triple whammy)
Renal (20-30%): ATN (ischaemia, nephrotoxins), glomerulonephritis, vasculitis, interstitial nephritis
Post-renal (<10%): Prostate, stones, pelviureteric junction obstruction, bladder tumour

Treatment

Stop nephrotoxins: NSAIDs, ACEi/ARBs, metformin, gentamicin
Pre-renal: IV fluid challenge (500 mL 0.9% NaCl over 15-30 min); insert urinary catheter
Optimise cardiac output (sepsis protocol, treat HF)
Treat hyperkalaemia:
- ECG changes (peaked T, wide QRS): IV Calcium gluconate immediately
- Insulin/dextrose (20 units actrapid + 50mL 50% dextrose IV)
- Salbutamol nebuliser
- Sodium bicarbonate (if severe acidosis)
- Calcium resonium/patiromer (removes K+ from gut)
- Dialysis (if refractory)
Post-renal: Urinary catheter (retention), urology referral (structural)
Renal replacement therapy (dialysis) indications: AEIOU - Acidosis (pH <7.1), Electrolytes (K+ >6.5 refractory), Intoxication, Overload (pulmonary oedema), Uraemia (encephalopathy/pericarditis)

CASE 6.2 — NEPHROTIC SYNDROME

PRESENTATION INTRO: "Mr. X, 35-year-old male, presenting with 3-week history of bilateral leg swelling, frothy urine, and puffy eyes in the morning."

Symptoms

Oedema: periorbital (morning), leg, scrotal/labial oedema
Frothy urine (proteinuria)
Reduced urine output
Fatigue, lethargy
Pleural effusion, ascites (severe)

Signs

Bilateral pitting oedema (peripheral, sacral)
Periorbital oedema
Ascites, pleural effusion
Leuconychia (white nails - hypoalbuminaemia)
BP: hypertensive or normotensive

Investigations

Test	Finding
Urine dipstick	3+ or 4+ proteinuria
24-hr urine protein	>3.5g/24 hrs (or PCR >300 mg/mmol)
Serum albumin	<25 g/L (hypoalbuminaemia)
Lipid profile	Hyperlipidaemia (LDL high)
Urine lipids	Lipiduria (fat bodies in urine - Maltese cross pattern on microscopy)
U&E/Creatinine	Baseline renal function
FBC	Anaemia
Complement (C3, C4)	Low in secondary causes (SLE, MPGN)
ANA, anti-dsDNA	SLE
Hepatitis B/C, HIV	Secondary causes
Renal biopsy	Definitive - identifies underlying pathology

Causes by age:

Children: Minimal Change Disease (responds to steroids - commonest in children)
Young adults: FSGS, Membranous nephropathy, IgA nephropathy
Elderly: Membranous nephropathy (paraneoplastic), amyloid

Complications (HEAT):

Hypercoagulability (DVT/PE - loss of antithrombin III) - prophylactic anticoagulation if albumin <20
Edema
Atherosclerosis (hyperlipidaemia)
Thrombosis + susceptibility to infection (loss of Ig)

Treatment

Treat underlying cause (biopsy-guided)
Minimal change disease: Prednisolone 1mg/kg/day (remission in >90%)
Oedema: Fluid restriction + low-salt diet + loop diuretics (furosemide)
Lipids: Statin
Anticoagulation: DOAC/LMWH (if albumin <20 or DVT/PE risk)
ACEi/ARB: Reduce proteinuria

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SYSTEM 7: HAEMATOLOGY

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CASE 7.1 — IRON DEFICIENCY ANAEMIA (IDA)

PRESENTATION INTRO: "Mrs. X, 42-year-old female, presenting with 2-month history of increasing fatigue, shortness of breath on exertion, and heavy periods."

Symptoms

Fatigue, weakness
Dyspnoea on exertion
Palpitations
Headache, poor concentration
Pica (eating non-food items - ice = pagophagia; dirt = geophagia)
Restless legs syndrome

Signs

General anaemia signs:

Pallor (conjunctivae, palmar creases, mucous membranes)
Tachycardia, hyperdynamic circulation
Systolic flow murmur

IDA-specific signs:

Koilonychia (spoon-shaped nails)
Glossitis (smooth, red tongue)
Angular cheilitis (cracks at corners of mouth)
Dysphagia (Plummer-Vinson/Patterson-Brown-Kelly syndrome - post-cricoid web + IDA)
Hair thinning

Investigations

Test	Finding
FBC	Low Hb; microcytic (low MCV <80 fL), hypochromic (low MCH)
Blood film	Microcytic hypochromic RBCs, pencil cells, target cells, anulocytes
Serum ferritin	LOW (<30 µg/L) - best single test
Serum iron	Low
TIBC	HIGH (total iron binding capacity)
Transferrin saturation	Low (<20%)
Reticulocyte count	Low (hypoproliferative)
Serum soluble transferrin receptor	Raised (distinguishes from ACD)
OGD + Colonoscopy	Exclude GI malignancy (mandatory in men and post-menopausal women)
Urine dipstick	Haematuria (renal cause)
Faecal calprotectin/occult blood	GI source
H. pylori test

Differential of microcytic anaemia (TAILS):

Thalassaemia, Anaemia of Chronic Disease (ACD), Iron deficiency, Lead poisoning, Sideroblastic anaemia

Treatment

Oral Ferrous sulphate: 200mg TDS (take with vitamin C; avoid tea/calcium/antacids 2 hrs either side)
Reticulocyte response at 7-10 days (confirms diagnosis)
Hb normalises at 4-6 weeks
Continue iron for 3 months after Hb normalised (replenish stores)
IV iron (Ferinject) if oral not tolerated, malabsorption, inflammatory bowel disease
Blood transfusion if symptomatic, Hb <70, or cardiovascular compromise
Treat underlying cause (most important - if PUD, manage H. pylori; menorrhagia = gynae referral; cancer = GI surgery)

CASE 7.2 — MULTIPLE MYELOMA

PRESENTATION INTRO: "Mr. X, 68-year-old male, presenting with back pain, fatigue, recurrent infections, and kidney problems."

Symptoms - CRAB Criteria

Calcium - hypercalcaemia symptoms: polyuria, polydipsia, confusion, constipation, nausea
Renal impairment: oliguria, uraemic symptoms
Anaemia: fatigue, dyspnoea, pallor
Bone pain/lesions: back pain, pathological fractures, vertebral collapse
Recurrent bacterial infections (hypogammaglobulinaemia)
Hyperviscosity syndrome: headache, visual disturbance, bleeding (IgA/IgM myeloma)

Signs

Pallor (anaemia)
Bony tenderness (spinal/rib)
Neurological signs (spinal cord compression from vertebral collapse/plasmacytoma)
Signs of infection
Fundal changes (hyperviscosity)

Investigations

Test	Finding
FBC	Anaemia (normocytic); plasma cell leukaemia (rare)
Blood film	Rouleaux formation (RBCs stacked like coins - paraprotein)
ESR	Very high (>100)
U&E	Raised creatinine (cast nephropathy)
Calcium	Hypercalcaemia
Serum protein electrophoresis (SPEP)	M-band (monoclonal paraprotein) in gamma region
Serum immunoglobulins	Elevated IgG/IgA/IgM (one class); suppressed others
Serum free light chains (kappa/lambda)	Abnormal ratio
Urine BJP (Bence Jones Protein)	Light chains in urine (Bence Jones proteinuria)
Bone marrow biopsy	>10% plasma cells (diagnostic)
Skeletal survey (X-rays)	Lytic (punched-out) lesions (skull - "pepper-pot skull"); no osteoblastic activity
CT whole body / PET-CT	Better than X-ray for lytic lesions
MRI spine	Spinal cord compression
Beta-2 microglobulin / LDH	Prognostic markers
Cytogenetics	t(4;14), del17p (poor prognosis); t(11;14)

Treatment

Eligible for transplant (age <70, fit):

Induction: VRd (Bortezomib + Lenalidomide + Dexamethasone) x4-6 cycles
Autologous stem cell transplant (ASCT) - melphalan conditioning
Maintenance: Lenalidomide (reduces relapse)

Transplant ineligible:

Rd (Lenalidomide + Dexamethasone) or VMP (Bortezomib + Melphalan + Prednisolone)
Daratumumab (anti-CD38 monoclonal antibody) now used in frontline

Supportive:

Bisphosphonates (Zoledronic acid) - prevent bone destruction and hypercalcaemia
Radiotherapy - painful bone lesions, spinal cord compression
G-CSF - neutropenia
IVIG - recurrent infections
VTE prophylaxis (Lenalidomide = high DVT risk)
Renal supportive care

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SYSTEM 8: RHEUMATOLOGY

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CASE 8.1 — RHEUMATOID ARTHRITIS (RA)

PRESENTATION INTRO: "Mrs. X, 45-year-old female, presenting with 3-month history of symmetrical painful swelling of the small joints of her hands with prolonged morning stiffness >1 hour."

Symptoms

Symmetrical joint pain and swelling
Morning stiffness >1 hour (hallmark - improves with activity)
Joints: MCPs, PIPs, wrists, MTPs (small joints) - spares DIP joints
Fatigue, malaise, weight loss (systemic)
Functional limitation (gripping, buttons, opening jars)

Signs

Hand changes:

Swollen, tender MCPs + PIPs (boggy synovitis)
Z-thumb deformity
Boutonniere deformity (PIP flexion, DIP hyperextension)
Swan-neck deformity (PIP hyperextension, DIP flexion)
Ulnar deviation of fingers
Palmar subluxation of MCPs
Dorsal tenosynovitis
Muscle wasting (interossei)

Extra-articular features:

Rheumatoid nodules (over olecranon/pressure areas)
Vasculitis (digital infarcts, leg ulcers)
Eye: keratoconjunctivitis sicca, scleritis, episcleritis
Lung: fibrosing alveolitis, effusion, Caplan's syndrome
Heart: pericarditis, pericardial effusion
Felty's syndrome (RA + splenomegaly + neutropaenia)
Cervical myelopathy (C1-C2 subluxation)
Peripheral neuropathy

Investigations

Test	Finding
RF (Rheumatoid Factor)	Positive in 70-80% (IgM anti-IgG); also positive in other conditions
Anti-CCP antibodies	More specific (>95%) for RA - better predictor of erosive disease
ESR / CRP	Raised (disease activity markers)
FBC	Normocytic anaemia of chronic disease; thrombocytosis
X-ray hands/feet	Periarticular osteopenia, joint space narrowing, erosions (juxta-articular), subluxation
DAS28 score	Disease Activity Score (joints, ESR/CRP, VAS) - guides treatment
Synovial fluid	Inflammatory (PMN leucocytosis, raised protein, low glucose)
USS/MRI joints	Synovitis, erosions (more sensitive than X-ray)
ANA	Low titre positive (10%)

2010 ACR/EULAR Classification Criteria (score ≥6):

Joint involvement (large/small/both)
Serology (RF, anti-CCP)
Acute phase reactants
Duration (>6 weeks)

Treatment

Target to remission (T2T strategy):

First-line csDMARDs (start early):

Methotrexate 15-25mg weekly (fold with folic acid 5mg weekly) - anchor drug
Hydroxychloroquine (mild disease/add-on)
Sulfasalazine
Leflunomide

Bridging:

Prednisolone short course (rapid symptom control) + joint steroid injections

Biologics (if inadequate csDMARD response, DAS28 >5.1):

Anti-TNF: Adalimumab, Etanercept, Infliximab
Abatacept (CTLA4-Ig)
Rituximab (anti-CD20)
Tocilizumab (anti-IL-6)

JAK inhibitors:

Baricitinib, Tofacitinib, Upadacitinib (oral, if biologics failed/intolerant)

Symptomatic:

NSAIDs (short-term, with PPI cover)
Physiotherapy, occupational therapy
Splints, aids
Surgical: synovectomy, joint replacement (severe disease)

CASE 8.2 — SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

PRESENTATION INTRO: "Miss X, 28-year-old female of Afro-Caribbean origin, presenting with facial rash, joint pains, hair loss, and intermittent fever for 3 months."

Symptoms

Butterfly (malar) rash over cheeks and nose (spares nasolabial folds)
Photosensitive rash
Arthralgia/arthritis (migratory, non-erosive)
Oral ulcers (painless)
Alopecia (hair thinning/loss)
Serositis: pleurisy, pericarditis
Raynaud's phenomenon
Fatigue, fever, weight loss
CNS: seizures, psychosis, headache
Renal: haematuria, frothy urine (lupus nephritis)
Haematological: recurrent miscarriage (antiphospholipid syndrome)

Signs

Malar (butterfly) rash
Discoid lupus lesions
Alopecia
Oral ulcers (mucous membrane)
Lymphadenopathy
Splenomegaly
Pleural/pericardial rub
Peripheral oedema (nephritis)
Neuropsychiatric signs

Investigations - SLICC Criteria (≥4 of 11)

Test	Finding
ANA	Positive in >95% (sensitive but not specific)
Anti-dsDNA	Highly specific for SLE; correlates with disease activity (esp. nephritis)
Anti-Smith (anti-Sm)	Highly specific (not sensitive)
Anti-Ro/La	Neonatal lupus, Sjögren overlap
Antiphospholipid antibodies	Lupus anticoagulant, anticardiolipin, anti-β2GP1 (thrombosis/miscarriage)
Complement (C3, C4)	Low during active disease (consumed in immune complexes)
FBC	Anaemia (haemolytic or ACD), leucopaenia, lymphopaenia, thrombocytopaenia
DAT (Coombs)	Positive in haemolytic anaemia
U&E/creatinine	Renal function
Urine dipstick/PCR	Haematuria, proteinuria (lupus nephritis)
24-hr urine protein	Nephrotic range if significant nephritis
Renal biopsy	ISN/RPS class I-VI (guides treatment)
ESR	Raised (follows disease); CRP often normal in flares (if raised = consider infection)
LFTs, lipids	Drug monitoring, metabolic

Treatment

All patients:

Hydroxychloroquine 200-400mg/day (reduces flares, improves survival, cardioprotective) - monitor retinal toxicity
Sun protection (UV triggers flares)
Smoking cessation

Mild-moderate disease:

NSAIDs (joint/serositis)
Prednisolone (flares)
Methotrexate/Azathioprine (skin, joints, serositis)

Severe/renal/CNS:

High-dose IV methylprednisolone (pulse)
Cyclophosphamide IV (Class III/IV nephritis - EuroLupus protocol)
Mycophenolate mofetil (maintenance/alternative to CYC)
Belimumab (anti-BLyS biologic - approved for active SLE)
Voclosporin + mycophenolate (lupus nephritis - new)

Antiphospholipid syndrome:

Thrombosis: Warfarin (target INR 2-3, or 3-4 for arterial events)
Obstetric: Aspirin + LMWH in pregnancy

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SYSTEM 9: INFECTIOUS DISEASES

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CASE 9.1 — SEPSIS

PRESENTATION INTRO: "Mr. X, 75-year-old male with DM, presenting with high fever, rigors, confusion, reduced urine output, and hypotension following 3-day history of productive cough."

Symptoms

Fever or hypothermia
Rigors, sweating
Tachypnoea, dyspnoea
Confusion, altered mental state
Reduced urine output
Nausea, vomiting
Source-specific: cough (chest), dysuria (urine), abdominal pain (abdomen), skin (cellulitis)

Signs

Sepsis (SIRS + infection):

Fever >38°C or <36°C
Tachycardia >90/min
Tachypnoea >20/min
WCC >12 or <4 ×10⁹/L

Septic Shock (sepsis + hypotension refractory to fluid):

MAP <65 mmHg despite adequate fluid resuscitation + vasopressor requirement + lactate >2 mmol/L

Investigations

Test	Finding
Blood cultures	x2 sets (before antibiotics)
Serum lactate	>2 mmol/L = organ hypoperfusion; >4 = severe/shock
FBC	Leucocytosis/leucopaenia
CRP, Procalcitonin	Raised (bacterial infection)
U&E, Creatinine	AKI
LFTs	Hepatic dysfunction
Coagulation	DIC
Urine MC&S + dipstick	UTI
CXR	Pneumonia
Blood glucose	Hyperglycaemia/hypoglycaemia
qSOFA	≥2 = risk of organ dysfunction: Altered mentation, RR ≥22, SBP ≤100
SOFA score	Organ dysfunction scoring (ICU)

Treatment - SEPSIS 6 (within 1 HOUR)

Action	Detail
1. Give O2	Target SpO2 ≥94%
2. Blood cultures	Before antibiotics
3. IV antibiotics	Broad-spectrum (Piperacillin/tazobactam or Meropenem + local protocol)
4. IV fluids	500 mL crystalloid bolus (reassess; 30 mL/kg within 3 hrs)
5. Measure lactate	If >4 = aggressive resuscitation
6. Urine output	Catheterise + measure hourly

Septic shock (if MAP <65 after fluids):

Noradrenaline (vasopressor of choice, via central line)
Hydrocortisone 200mg/day IV (if vasopressor-dependent)
ICU admission

Source control:

Drain abscess, remove infected line/device, treat source

CASE 9.2 — HIV/AIDS

PRESENTATION INTRO: "Mr. X, 32-year-old male presenting with 3-month history of weight loss, persistent diarrhoea, white patches in his mouth, and recurrent chest infections. Blood test shows CD4 count of 80 cells/µL."

Symptoms

Acute HIV seroconversion (2-6 weeks post-exposure):

Fever, sore throat, lymphadenopathy
Maculopapular rash
Myalgia, arthralgia
(Resembles infectious mononucleosis)

Chronic HIV / AIDS (CD4 <200):

Weight loss (>10% body weight)
Persistent fever, night sweats
Chronic diarrhoea
Oral candidiasis (thrush)
Recurrent infections
Neurological symptoms

Signs

Lymphadenopathy (generalised)
Oral candidiasis (white plaques, easily scraped)
Oral hairy leukoplakia (EBV - white, cannot be scraped)
Kaposi's sarcoma (purple skin lesions - HHV-8)
Weight loss, muscle wasting
Seborrhoeic dermatitis
Retinal lesions (CMV retinitis - CD4 <50)
Signs of opportunistic infections

AIDS-defining illnesses (CD4 <200):

OI	CD4 level
PCP (Pneumocystis jirovecii pneumonia)	<200
Toxoplasmosis (cerebral)	<100
CMV retinitis	<50
Cryptococcal meningitis	<100
MAC (Mycobacterium avium complex)	<50
Cryptosporidiosis	<100
HIV encephalopathy (dementia)	Advanced

Investigations

Test	Finding
HIV Ag/Ab combo test (4th gen)	Screening test (detects p24 antigen + antibody)
HIV-1/2 differentiation + Western blot	Confirmatory
CD4+ T cell count	Disease staging: <200 = AIDS
HIV viral load	Guides treatment, monitors response to ART
Resistance genotyping	Before starting ART
FBC	Anaemia, lymphopaenia, thrombocytopaenia
LFTs, renal function	Baseline + ART monitoring
Hepatitis B/C serology	Co-infection (common)
Syphilis serology	STI co-infection
CXR	PCP (bilateral interstitial shadowing)
BAL/sputum	PCP (silver stain)
CT brain	Toxoplasmosis (ring-enhancing lesions), PML, lymphoma
LP	Cryptococcal meningitis (India ink stain, cryptococcal antigen)

Treatment

ART (Antiretroviral Therapy) - all patients, regardless of CD4:

Preferred regimen: 2 NRTIs + 1 INSTI
- Tenofovir/Emtricitabine (Truvada) + Dolutegravir (Tivicay) - most common (1 tablet/day)
- Or Bictegravir/TAF/Emtricitabine (Biktarvy - single tablet regimen)
Goal: Undetectable viral load (<50 copies/mL) within 3-6 months
Monitoring: Viral load + CD4 at 4 weeks, then 3-6 monthly

OI Prophylaxis:

CD4 count	Prophylaxis
<200	Cotrimoxazole (PCP + Toxoplasma prophylaxis)
<100	Fluconazole (Cryptococcus prevention)
<50	Azithromycin (MAC prophylaxis)

OI Treatment examples:

PCP: High-dose Cotrimoxazole + Prednisolone (if PaO2 <9.3 kPa)
Toxoplasmosis: Pyrimethamine + Sulfadiazine + Folinic acid
CMV retinitis: Ganciclovir / Valganciclovir
Cryptococcal meningitis: Amphotericin B + Flucytosine x2 weeks → Fluconazole

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SYSTEM 10: PSYCHIATRY / ACUTE MEDICINE

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CASE 10.1 — ACUTE ALCOHOL WITHDRAWAL / DELIRIUM TREMENS

PRESENTATION INTRO: "Mr. X, 48-year-old male admitted for elective surgery, found tremulous, sweaty, and agitated on day 2 post-admission. He drinks 30 units/week."

Symptoms / Timeline

Time after last drink	Features
6-24 hrs	Tremor, anxiety, nausea, sweating, tachycardia
24-48 hrs	Seizures (generalised tonic-clonic)
48-72 hrs	Delirium Tremens (DT): Confusion, agitation, hallucinations (visual - "pink elephants"), hyperthermia, autonomic instability

Signs

Tremor (fine → coarse)
Diaphoresis, tachycardia, hypertension
DTs: Fever, severe agitation, visual/tactile hallucinations, autonomic instability
Wernike's encephalopathy signs: ophthalmoplegia, ataxia, confusion (thiamine deficiency - EMERGENCY)

Investigations

Test	Finding
CIWA-Ar score	Alcohol withdrawal severity (guides treatment)
Glucose	Hypoglycaemia
FBC	Macrocytosis, thrombocytopaenia
LFTs	GGT (alcohol marker), raised ALP/ALT/AST
U&E	Electrolyte disturbance (hypoMg, hypoK, hypoP)
Thiamine / B12 / folate	Deficiency
Coagulation	Prolonged (liver disease)

Treatment

Thiamine FIRST (before glucose - prevents Wernicke's):

IV Pabrinex (Thiamine + B vitamins) 2 pairs TDS x3-5 days (IM or IV diluted)

Chlordiazepoxide (benzodiazepine) fixed dose schedule:

High dependency: Chlordiazepoxide 40mg QDS → taper over 5-7 days
CIWA-guided dosing for symptom-triggered approach

Lorazepam IV (if seizures or cannot take oral)

DTs: High-dose IV benzodiazepine + ICU
Treat hypoglycaemia, electrolyte replacement
Monitoring: CIWA-Ar score, BMs, vitals

Wernicke's encephalopathy:

IV Pabrinex 2 pairs TDS x5 days minimum
DO NOT give glucose before thiamine

CASE 10.2 — PARACETAMOL OVERDOSE

PRESENTATION INTRO: "Miss X, 22-year-old female, presenting 4 hours after deliberate ingestion of 30 tablets of paracetamol (500mg) with alcohol."

Symptoms

Early (0-24 hrs): Often asymptomatic or mild nausea/vomiting/malaise 24-72 hrs: Liver injury - RUQ pain, vomiting 72-96 hrs: Hepatic failure - jaundice, coagulopathy, encephalopathy, renal failure Day 4+: Recovery or fulminant liver failure → liver transplant

Signs

Early: May be unremarkable
Late: Jaundice, RUQ tenderness, hepatomegaly, features of liver failure

Investigations

Test	Finding
Paracetamol level	At 4 hrs post-ingestion (plot on nomogram)
LFTs (ALT/AST)	Rise after 24 hrs; ALT may reach >10,000 U/L in severe hepatotoxicity
INR/PT	Best marker of liver synthetic function (worsening INR = poor prognosis)
U&E, Creatinine	AKI (renal tubular damage)
ABG	Metabolic acidosis (lactic acidosis = severe)
FBC
Blood glucose	Hypoglycaemia (advanced liver failure)

King's College Criteria (liver transplant listing):

Paracetamol: pH <7.3 OR (INR >6.5 + Creatinine >300 + Grade 3-4 encephalopathy)

Treatment

Within 1 hr of ingestion (if >150mg/kg or >12g):

Activated charcoal 50g PO (reduces absorption)

IV N-Acetylcysteine (NAC) - main antidote:

Start if level above treatment line on nomogram (or staggered/unknown time)
Regimen: 150 mg/kg IV in 200 mL 5% glucose over 1 hr → 50 mg/kg over 4 hrs → 100 mg/kg over 16 hrs
Side effects: Anaphylactoid reaction (treat with antihistamine, slow infusion)

Hepatic failure:

Refer to liver unit
Lactulose, vitamin K, glucose monitoring
Liver transplant if King's criteria met

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SYSTEM 11: OBSTETRICS & GYNAECOLOGY

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CASE 11.1 — ECTOPIC PREGNANCY

PRESENTATION INTRO: "Miss X, 26-year-old female, presenting with sudden-onset right iliac fossa pain, PV bleeding, and dizziness. LMP was 6 weeks ago."

Symptoms

Triad: Amenorrhoea + unilateral pelvic pain + PV bleeding
Dizziness, syncope (haemoperitoneum if rupture)
Shoulder tip pain (referred diaphragmatic pain from haemoperitoneum)
Nausea, vomiting
Urinary symptoms

Signs

Tachycardia, hypotension (rupture = haemodynamic shock)
Lower abdominal tenderness (unilateral > bilateral)
Cervical excitation (pathognomonic - extreme tenderness on moving cervix = "chandelier sign")
Adnexal mass
Closed cervical os (differentiates from miscarriage)

Investigations

Test	Finding
Urine/serum βhCG	Positive (confirms pregnancy)
Serial βhCG	Ectopic: rises <66% in 48 hrs (normal pregnancy doubles every 48 hrs)
Transvaginal USS	Empty uterus + adnexal mass/fluid (free fluid in POD = haemoperitoneum)
FBC	Anaemia (haemoperitoneum)
Group & Save	Transfusion preparation
Progesterone	<20 nmol/L suggests non-viable pregnancy

Treatment

Ruptured ectopic = SURGICAL EMERGENCY:

Resuscitate: large-bore IV access, O2, IV fluids, cross-match
Emergency laparoscopy/laparotomy → salpingectomy (remove tube)

Stable, unruptured ectopic:

Medical: Methotrexate IM (single or multi-dose) if βhCG <5000 IU/L, tube intact, no cardiac activity
Expectant management: Very carefully selected cases (βhCG falling, <1000 IU/L)
Surgical laparoscopy (preferred if βhCG >5000, patient preference, contraindications to MTX)
Anti-D prophylaxis (Rh-negative patients)
Follow βhCG weekly until negative

CASE 11.2 — PRE-ECLAMPSIA / ECLAMPSIA

PRESENTATION INTRO: "Mrs. X, 28-year-old primigravida at 34 weeks gestation, presenting with headache, visual disturbances, and epigastric pain. BP 165/110 and 2+ proteinuria on dipstick."

Symptoms

Headache (frontal, persistent)
Visual disturbances (scotomata, flashing lights - photopsia)
Epigastric/right upper quadrant pain (HELLP syndrome)
Nausea, vomiting
Oedema (facial, hands - beyond normal pregnancy oedema)
Eclampsia: seizures in above context (or up to 4 weeks postpartum)

Signs

BP ≥140/90 after 20 weeks gestation (on 2 readings 4 hrs apart)
Oedema (facial, pitting)
Hyperreflexia, clonus (CNS irritability)
Papilloedema (severe)
Epigastric tenderness (HELLP)
Proteinuria ≥2+ or PCR >30

Investigations

Test	Finding
BP	≥140/90 or ≥160/110 (severe)
Urine PCR	>30 mg/mmol (significant proteinuria)
FBC	Thrombocytopaenia (HELLP: <100 ×10⁹/L)
LFTs	Raised (HELLP - haemolysis, elevated liver enzymes)
Coagulation	DIC risk
U&E/Creatinine	Renal impairment
Uric acid	Raised
CTG	Fetal wellbeing
USS (fetal biometry + Doppler)	IUGR assessment

HELLP Syndrome: Haemolysis + Elevated Liver enzymes + Low Platelets - obstetric emergency

Treatment

Antihypertensive (reduce BP to <150/100):

Labetalol IV (first-line for acute severe hypertension in pregnancy)
Hydralazine IV (alternative)
Nifedipine PO (oral option)

Seizure prevention and treatment:

IV Magnesium sulphate (Pritchard or Zuspan protocol): Loading 4g IV over 5-10 min, then 1g/hr maintenance
Antidote for Mg toxicity: IV Calcium gluconate 1g (if respiratory arrest, reflexes lost)
Eclamptic seizure: MgSO4 + airway protection + left lateral decubitus

Steroids (if <34 weeks):

IM Betamethasone 12mg x2 doses 24 hrs apart (fetal lung maturity)

DEFINITIVE TREATMENT = DELIVERY:

Severe pre-eclampsia at ≥34 weeks: deliver promptly
<34 weeks: balance risks, managed on obstetric HDU

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SYSTEM 12: ORTHOPAEDICS / ACUTE MSK

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CASE 12.1 — SEPTIC ARTHRITIS

PRESENTATION INTRO: "Mr. X, 55-year-old male, presenting with acutely hot, red, exquisitely tender, swollen right knee, unable to weight-bear."

Symptoms

Acute onset hot, red, tender, swollen joint
Severe pain with ANY movement (passive or active)
Inability to weight-bear
Fever, rigors, malaise
Recent source: skin infection, dental procedure, septicaemia

Signs

Fever
Warm, red, swollen joint with effusion
Extreme pain on passive movement (key sign - distinguish from gout)
Reduced range of movement
Lymphadenopathy

Investigations

Test	Finding
Joint aspiration (URGENT)	MUST be done before antibiotics
Synovial fluid WCC	>50,000 cells/µL (mostly PMNs) - suggests septic; >100,000 strongly suggests septic
Synovial fluid Gram stain	Organisms
Synovial fluid culture	Gold standard
Blood cultures	x2 sets
FBC	Leucocytosis
CRP/ESR	Markedly elevated
Uric acid	Exclude gout (can coexist)
X-ray joint	Soft tissue swelling; exclude fracture/AVN
Bone scan/MRI	Osteomyelitis extension

Most common organisms: Staphylococcus aureus (most common all ages); Neisseria gonorrhoeae (young sexually active adults); Streptococcus species; Gram negatives (immunocompromised/IV drug user)

Treatment - ORTHOPAEDIC EMERGENCY

IV Flucloxacillin 2g QDS (Staphylococcus/Streptococcus) + IV Cefotaxime if Gram negative/gonococcal suspected
MRSA risk: IV Vancomycin
Total duration: 4-6 weeks (IV 2 weeks, then switch to oral)
Surgical: Washout/debridement (arthroscopic lavage) - most joints require this
Physiotherapy after resolution

QUICK REFERENCE SUMMARY TABLE

System	Must-Know Cases	Key Distinguishing Feature
Cardiac	STEMI, AF, PE, IE, HF	ECG + Troponin; DUKE criteria; Wells score
Respiratory	Pneumonia, COPD, TB, Asthma	CURB-65; GOLD staging; RIPE therapy; PEFR
GI/Liver	UGIB, Pancreatitis, Cirrhosis	Blatchford; Ranson; Child-Pugh/MELD
Neurology	Stroke, Meningitis, DKA	NIHSS; LP CSF; ABCDE resus
Endocrine	DKA, Hypothyroid, Addison's	pH/ketones/glucose; TSH; Synacthen
Renal	AKI, Nephrotic	KDIGO stages; Light's criteria
Haematology	IDA, Myeloma	Ferritin; CRAB + M-band
Rheum	RA, SLE, Gout	Anti-CCP; ANA/anti-dsDNA; crystals
Infectious	Sepsis, HIV	Sepsis 6; CD4; ART
OBG	Ectopic, Pre-eclampsia	βhCG; MgSO4; HELLP

This covers all major system cases with full clinical templates for a 4th-year medical sub-internship. Each template follows the standard presentation format: Symptoms → Signs → Investigations → Treatment, which is what examiners and consultants expect in clinical rounds and OSCEs.

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