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🩺 Case Discussion 2 – Sudden Shortness of Breath (by pace your MRCP – Dr Tanzeel Bukhari) 🧠 Scenario: A 62-year-old woman presents with sudden onset shortness of breath while walking to the bathroom. She describes pleuritic chest pain, mild cough, and feels anxious. O/E: RR 28/min, HR 112/min, BP 128/82, SpO₂ 90% on air; chest is clear, calves slightly tender. ❓ Question: What are the top differentials, and what is the best next investigation? --- ✅ Answer: 🔹 Most likely diagnosis: Pulmonary embolism (PE) — sudden dyspnoea + pleuritic pain + tachycardia + calf tenderness 🔹 Other differentials: Pneumothorax (less likely: chest clear, stable BP) Pneumonia (no fever, cough mild) Anxiety/hyperventilation (SpO₂ too low for this) 🔹 Best next investigation: CT Pulmonary Angiography (CTPA) If unstable → bedside Echocardiography for RV strain 💡 PACES Tip: For sudden breathlessness + clear chest, always think PE first.

*🟢 ONLINE COURSE NO. 64 – ADMISSIONS OPEN!* *📅 08 Dec – 26 Dec 2025* 🎯 PACES MRCP (UK) & CLINICAL EXAM MRCPI 🚨 At a very affordable fee ✅ 15-Day Intensive Online Course ✅ Covers ALL 7 SKILLS in detail (as in our weekly free sessions) ✅ Practice & discussion of 90+ exam cases (including recent diets), covering:  • 45 cases of consultations  • 45 cases of communications. ✅ Personalized feedback to sharpen weak areas ✅ Ideal for beginners & upcoming exam candidates 🎓 Slots Available: 🔹 Active participation – First come, first served 🔹 Listener slots also available 📩 Join Us! 📱 WhatsApp: +92 334 6036496 📧 Email: drtanzeelbukhari@gmail.com 🚀 Join, Learn, Practice & Succeed! GOOD LUCK

*🩺 Management Essential 2 – Acute Severe Asthma (Adult)* (by pace your MRCP – Dr Tanzeel Bukhari) Acute severe asthma is a medical emergency. Early structured management saves lives. *🔹 Immediate Management* (ABCDE-based) 1️⃣ High-flow oxygen to maintain SpO₂ 94–98% 2️⃣ Continuous nebulised salbutamol (or back-to-back nebs) 3️⃣ Add ipratropium nebuliser every 20–30 min 4️⃣ Give IV hydrocortisone (or oral prednisolone if able) 5️⃣ Consider IV magnesium sulphate if poor response 6️⃣ Start frequent PEFR monitoring 7️⃣ Assess for exhaustion (silent chest, rising CO₂ → life-threatening) *🔹 Investigations* Peak flow ABG if no improvement Chest X-ray (if complications suspected) *🔹 When to admit to HDU/ICU* Persistent hypoxia Rising PaCO₂ Silent chest Altered consciousness Failure to respond to initial therapy *💡 PACES Tip:* Always mention oxygen, bronchodilators, steroids, magnesium, and admission criteria. This shows structured emergency management.

*🧠 Mnemonic 2 – Causes of Hypercalcaemia (CHIMPANZEES)* (by pace your MRCP – Dr Tanzeel Bukhari) Use the classic mnemonic CHIMPANZEES to recall the major causes of hypercalcaemia: C – Calcium supplements H – Hyperparathyroidism (primary/tertiary) I – Iatrogenic (thiazides, lithium) M – Milk-alkali syndrome P – Paget’s disease A – Acromegaly / Addison’s disease N – Neoplasms (myeloma, bone mets) Z – Zollinger–Ellison syndrome E – Excess vitamin D E – Excess vitamin A S – Sarcoidosis / granulomatous diseases --- *💡 PACES Tip:* When a patient presents with bones, stones, groans, or psychiatric overtones, always think hypercalcaemia and quote CHIMPANZEES.

Photo from Dr Tanzeel Bukhari

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Photo from Dr Tanzeel Bukhari

Photo from Dr Tanzeel Bukhari

*🟢 ONLINE COURSE NO. 64 – ADMISSIONS OPEN!* *📅 08 Dec – 26 Dec 2025* 🎯 PACES MRCP (UK) & CLINICAL EXAM MRCPI 🚨 At a very affordable fee ✅ 15-Day Intensive Online Course ✅ Covers ALL 7 SKILLS in detail (as in our weekly free sessions) ✅ Practice & discussion of 90+ exam cases (including recent diets), covering:  • 45 cases of consultations  • 45 cases of communications. ✅ Personalized feedback to sharpen weak areas ✅ Ideal for beginners & upcoming exam candidates 🎓 Slots Available: 🔹 Active participation – First come, first served 🔹 Listener slots also available 📩 Join Us! 📱 WhatsApp: +92 334 6036496 📧 Email: drtanzeelbukhari@gmail.com 🚀 Join, Learn, Practice & Succeed! GOOD LUCK

Photo from Dr Tanzeel Bukhari

Photo from Dr Tanzeel Bukhari

Photo from Dr Tanzeel Bukhari

*🟢 ONLINE COURSE NO. 64 – ADMISSIONS OPEN!* *📅 08 Dec – 26 Dec 2025* 🎯 PACES MRCP (UK) & CLINICAL EXAM MRCPI 🚨 At a very affordable fee ✅ 15-Day Intensive Online Course ✅ Covers ALL 7 SKILLS in detail (as in our weekly free sessions) ✅ Practice & discussion of 90+ exam cases (including recent diets), covering:  • 45 cases of consultations  • 45 cases of communications. ✅ Personalized feedback to sharpen weak areas ✅ Ideal for beginners & upcoming exam candidates 🎓 Slots Available: 🔹 Active participation – First come, first served 🔹 Listener slots also available 📩 Join Us! 📱 WhatsApp: +92 334 6036496 📧 Email: drtanzeelbukhari@gmail.com 🚀 Join, Learn, Practice & Succeed! GOOD LUCK

*🚨 Clinical Red Flag 2 – Sudden Severe Headache (“Thunderclap Headache”)* (by pace your MRCP – Dr Tanzeel Bukhari) *A sudden, maximal-intensity headache reaching its peak in less than 1 minute is a medical emergency.* *🔴 What this may indicate:* Subarachnoid haemorrhage (SAH) Cerebral venous thrombosis Intracranial bleed Pituitary apoplexy Cervical artery dissection *🔴 Red-flag features:* Neck stiffness Vomiting Photophobia Sudden collapse or seizure Reduced consciousness *📝 Immediate Action:* ➡️ Urgent CT head ➡️ If CT normal but suspicion high → Lumbar puncture after 12 hours ➡️ Admit and monitor closely

*🔬 Investigation Pearl 2 – Suspected Heart Failure* (by pace your MRCP – Dr Tanzeel Bukhari) *💡 BNP / NT-proBNP is the fastest way to rule out heart failure in clinic or ED.* BNP < 100 pg/mL → Heart failure very unlikely BNP > 400 pg/mL → Heart failure likely, requires urgent echo NT-proBNP > 2000 pg/mL → Suggests significant cardiac dysfunction *Why this matters in PACES:* If you say “I will check NT-proBNP” when examining a patient with dyspnoea + ankle swelling, examiners immediately see structured diagnostic reasoning. *Quick Tip:* *BNP rises in HF, renal impairment, sepsis, and AF — always interpret with context.*

*🩺 Symptom Snapshot 2 – Palpitations* (by pace your MRCP – Dr Tanzeel Bukhari) *1️⃣ Atrial Fibrillation* 💡 Irregularly irregular pulse, triggered by exertion, alcohol, infection, or thyroid disease. *2️⃣ Supraventricular Tachycardia (SVT)* 💡 Sudden onset and offset, pounding heartbeat, may feel neck pulsations (frog sign). *3️⃣ Ventricular Ectopics* 💡 “Skipped beat” or “thump,” worse at rest, improves with mild exercise, often benign.