Beruflich Dokumente
Kultur Dokumente
Third edition
Table of contents
Table of contents ............................................................................................................................. 2
History taking Medicine ............................................................................................................... 6
General review:............................................................................................................................ 7
Notes .......................................................................................................................................... 12
Chest pain ACUTE ................................................................................................................. 14
Chest pain CHRONIC ............................................................................................................ 16
Headache.................................................................................................................................... 18
Blood results / Macrocytic Anemia / B12 Deficiency................................................................. 21
Difficulty swallowing ................................................................................................................ 23
Elevated liver enzymes .............................................................................................................. 24
Drinking / Alcohol ..................................................................................................................... 26
Fever / Tired .............................................................................................................................. 28
Diarrhea ACUTE .................................................................................................................... 29
Diarrhea CHRONIC ............................................................................................................... 30
ASTHMA .................................................................................................................................. 32
COPD management ................................................................................................................... 35
Ankle swelling Bilateral ......................................................................................................... 36
Ankle swelling Unilateral ....................................................................................................... 37
Congestive heart failure CHF ................................................................................................. 38
Heart racing ............................................................................................................................... 40
Fall ............................................................................................................................................. 42
Peripheral vascular disease: ....................................................................................................... 44
Urinary symptoms: .................................................................................................................... 45
Anuria ........................................................................................................................................ 46
Hematuria .................................................................................................................................. 47
Renal stones ............................................................................................................................... 48
Incontinence............................................................................................................................... 50
Lump Neck Swelling .............................................................................................................. 51
Lump Breast............................................................................................................................ 52
Dizziness.................................................................................................................................... 55
INR Counselling ..................................................................................................................... 57
Patient is receiving blood counsel for adverse reactions ........................................................ 59
Counselling Ventilator............................................................................................................ 61
Ethical questions ........................................................................................................................ 62
HIV post-test counselling .......................................................................................................... 63
Lung Nodule .............................................................................................................................. 64
High Creatinine.......................................................................................................................... 66
Impotence / Erectile Dysfunction .............................................................................................. 67
Rheumatology History Taking................................................................................................ 68
Multiple Sclerosis ...................................................................................................................... 69
Obesity....................................................................................................................................... 70
Epilepsy Counselling ................................................................................................................. 71
Medical note .............................................................................................................................. 73
Pre-diabetes Counselling ........................................................................................................ 74
Emergency Medicine..................................................................................................................... 75
Emergency Room ...................................................................................................................... 76
Trauma ....................................................................................................................................... 77
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General review:
Introduction:
Chief complaint
History of present illness
Past medical history
Family history
Social history
Introduction
Chief complaint
Analysis of
CC
HPI
Impact
Red flags
TIME: Os Cf D
Character: PQRST
Chronic diarrhea: dehydration
Anemia: fatigue
Cancer: metastasis
Constitutional symptoms
Risk factors
Differential
diagnosis
Allergy
Medications
PMH: diseases (DM, HTN, heart attack, stroke, cancer)
LMP / Last tetanus shot
Events: hospitalization / surgery
PMH
A
M
P
L
E
FH
SH
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Introduction:
- Knock the door
- Go to the examiner give stickers use alcohol rub (disinfective)
- Stand at the edge of the chair
- Good evening Mr , I am Dr , I am the physician in charge today,
o < 18 years: use first name
o > 18 years: use Mr / Mrs / Ms
- I understand that you are here because of ,
Examples:
- History Taking: Good evening Mr , I am Dr , I am the physician on duty now, and I
understand that you are here today because of . In the next few minutes I will ask you some
questions about your cc, to figure out a working plan that can help you. If you have any
concerns or questions, please fell free to stop me and let me know.
-
1- Chief complaint
[A] If the CC not known
- How can I help you today?
1. Start to ask based on the age:
MALE
FEMALE
> 65 yrs
Do you take meds on regular basis? Do you have a list of it? Or the
bottles? Do you take sleeping pills?
Do you have difficulties with sleeping?
Do you have difficulties with your balance1, any falls?
Do you have difficulties with urination (incontinence / retention)?
Do you have changes in your vision / hearing?
Do you have changes in your mood / memory?
50s
Do you have problem drinking use CAGE
Depression2 identify through social history
ED / Impotence
30s
Psychiatric problems
SAD social history
Teen / 20s
Premature ejaculation
Abortion
STDs
STDs
Eating disorders
2. Special conditions:
Fatigue
Insomnia
Headache
Abdominal pain
Vaginal bleeding
1
2
Domestic abuse
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Chest pain
SOB
Heart racing
Dizziness
Numbness
Clarify:
1. Start first open-ended questions:
- What do you mean?
- Can you tell me more about this
2. Active listening:
- Do not interrupt
- Do not duplicate
3. Body language: nod your head
Panic attack
NOT clear
Vague symptoms: dizziness, tired
When the patient uses medical terms:
abortion, jaundice, palpitation
When the patient uses the words: change /
difficulty
Clarify:
- Use closed ended questions
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Severity: on a scale of 10, 1 being the mildest pain you have ever had and 10 is the most
severe, how much do you rate this one?
o If bad pain empathy: this must be difficult
Timing:
o Does it change with time; is it more in morning or towards the end of the day?
o Any variation?
Triggers:
o What brings your headache?
o Is it related to: stress / lack of sleep / over sleep / flashing lights / smells?
o If female: is it related to your periods? Are you taking any meds or OCPs?
o Any diet triggers?
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Notes
EMPATHY:
If during history taking you noticed the patient is in pain empathy: I can see you are in pain,
please bear with me for few minutes and I will give you a pain medication as soon as I can
- In the short cases (5 minutes) use at least 1-2 empathy statement
- In the long cases (10 minutes) use at least 3 empathy statements
-
I have a concern!
Whenever the patient says: I have a concern: STOP the interview!
- Can you tell me your concerns!
- Why are you concerned?
Worried / occupied patient!
Whenever the patient shows non-verbal clues of being worried / occupied:
- I can see that you are worried / occupied! Would you like to tell me more about your worries
or concerns?
-
Question types:
Types of questions you can use: open-ended, closed-ended, choices
Types of questions you can NOT use: leading questions, stacking questions
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Position: where did it start? Can you point with one finger on it?
Radiation: does it shoot anywhere? Your jaw, your shoulders, your back?
What or :
Breathing / position
How did you come to the clinic today? Ambulance did they give you
aspirin / nitrates? Did it help you?
Impact
Atherosclerosis:
SOB? How many pillows do you use? Do you wake up gasping for air?
Any swelling in your LL? How high does it go? Is it related to position?
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Risk Factors:
Pericarditis:
o
Recent flu like symptoms
o
Medications (Isoniazide / Rifampicin)
o
Hx of surgery
o
Hx of heart attack
o
Hx of kidney disease / puffy face / frothy urine
o
Hx of TB
o
Hx of autoimmune disease
Pulmonary Embolism:
o
Recent long flight
o
History of malignancy
o
Family history of blood clots
o
Female: pregnancy / OCPs / HRT
Chest Pain
Acute
Chronic
Minutes hours
Hours days
Intermittent
Continuous
Cardiac:
Cardiac:
Cardiac:
- CAD
- Pericarditis
- Unstable angina
- Aortic dissection
- Unstable angina
Non-cardiac:
Non-cardiac
- Cancer
- Tension
- Pneumonia
- Herpes zoster
pneumothorax
- Pleurisy
- Trauma
Panic attack
Pulmonary embolism Panic attack
GIT:
GIT:
- GERD
- GERD
- PUD
- PUD
- Esophageal spasm
- Esophageal spasm
Questions:
Investigations: ECG / Cardiac enzymes
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But first I would like to ask you, how do you feel now?
OsCfD: Onset / setting: what were you doing?
PQRST:
Position: where did it start? Can you point with one finger on it?
Radiation: does it shoot anywhere? Your jaw, your shoulders, your back?
What or :
Breathing / position
Is it related to activity? How many blocks were you able to walk? And
now?
Exertion
Golf (leaning forward)
Stress (emotional)
Coffee / dairy products
Cold air
Smoking / Alcohol
Heavy meals
Heavy / late meals
Sexual activity
Pregnancy (progestin)
Impact
Effect
Atherosclerosis
Chronic cough
CHF
Change in the voice
Red flags
Constitutional Fever / night sweats / chills
symptoms
How about your appetite? Any weight changes?
Any lumps or bumps in your body?
Risk factors
CAD
Differential Same system Nausea / vomiting
diagnosis
Sweating / feeling tired
SOB if yes, analyze (OsCfD)
Do you feel your heart racing?
Did you feel dizzy / light headedness / LOC? Are you tired?
Did you notice swelling in your ankles? Legs? Calf muscles?
Near by
CHEST:
systems
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Counselling:
Concern: The patient has a concern; is this IHD? Is his heart endangered?
This is quite a reasonable concern? What made you think about that?
Especially you have many risk factors that may predispose to heart attack. Right now the
physical exam is ok; it is less likely your condition is due to heart problem. But we still
need to check your heart more, we will do some lab works and an electrical tracing for
your heart (ECG), then if we find that we still need, we may send you to have a stress
ECG, in which, we trace your heart while you are exercising. Then we know for sure the
condition of your heart.
However, we would like to take measures to try to decrease your risk of developing heart
attack, e.g. exercise / diet / smoking / cholesterol.
On the other hand, the most likely diagnosis of what you have is a medical condition
called GERD. GERD stands for Gastro-Esophageal Reflux Disease, any idea about
that? Do you know anything about GERD?
Explain with a drawing: the esophagus (food pipe) / lower esophageal sphincter /
physiologic mechanism to keep it competent / in GERD weak sphincter acid
refluxes / irritates the esophagus / impact (short term and long term)
Treatment:
o
Avoid triggers
o
Life style modifications:
Raise the head of the bed
Smaller meals
Do not eat late
smoking
o
Medications: proton pump inhibitors (PPIs), e.g. pantoprazole
o
Side effects of PPIs:
In general, proton pump inhibitors are well tolerated, and the incidence of
short-term adverse effects is relatively uncommon
Common adverse effects include: headache (in 5.5% of users in clinical
trials), nausea, diarrhea, abdominal pain, fatigue, and dizziness. Long-term
use is associated with hypomagnesemia
Because the body uses gastric acid to release B12 from food particles,
decreased vitamin B12 absorption may occur with long-term use of protonpump inhibitors and may lead to Vitamin B12 deficiency
Infrequent adverse effects include rash, itch, flatulence, constipation, and
anxiety
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Headache
HPI:
OsCfD: gradual onset / all the time / increasing / for few days
PQRST:
temporal area / vague deep pain / severe
o
Severe: empathy: this must be difficult, were you able to sleep
o
Triggers:
What brings your headache?
Is it related to: stress / lack of sleep / flashing lights / smells / diet?
If female: is it related to your periods? Are you taking any OCPs?
Bothered by light
Nausea / vomiting
2- Subdural hematoma:
Trauma / fall
Cranial nerves:
o
Any change in smelling perception?
o
Any difficulty in vision / vision loss?
o
Any difficulty in hearing / buzzing sounds?
o
Difficulty finding words? Aphasia?
o
Difficulty swallowing?
Brain:
o
Any dizziness / light headedness / LOC?
o
Any tremors / jerky movements / hx of seizures?
UL/LL:
o
Any weakness / numbness / tingling in your arms / legs
o
Any difficulty in your balance / any falls?
Spine:
o
Any difficulty with urination / need to strain to pass urine?
o
Any change in bowel movements?
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5- Temporal arteritis:
When you touch this part of your head, is it painful? Can you comb your hair?
Do you know your blood pressure? Have you had it checked before?
Eyes: any hx of glaucoma, red eye, pain in your eyes? Do you usually wear eyeglasses?
Do you see well? Any vision problems? When was last time you saw your optometrist?
Do use too much of advil (or other NSAIDs)? For how long?
Were you used to take large amounts of coffee and then you stopped abruptly?
OCPs?
Temporal Arteritis:
Investigations:
TA biopsy
Doppler
ESR
CT head
Polymyalgia Rheumatica:
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PRIMARY HEADACHE
Intermittent / episodic
Headache
Tension
Duration
Days
Quality
Pressing / tightening /
bilateral
Place
Associated
symptoms
Aggravating
factors
Others
Stress
Physical injury
Treatment
- Acetaminophen
- NSAIDs
- Physiotherapy / ms
massage / heat
compresses (neck)
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Migraine
Hours
Mostly unilateral /
pulsating / interferes with
daily activities
Mostly unilateral
Photophobia / phonophobia
Physical activity / motion
Light / sound
Family history
Types:
+ Classical: with aura
+ Non-classical: no aura
Acute phase:
- Acetaminophen
- NSAIDs (ibuprofen)
Cluster
Minutes
Comes in series / severe
pain / hyperaesthesia
Around the eyes / nose
Red eyes / lacrimation /
rhinorrhea / sweating
Smoking / alcohol
Smell / exercise
- Oxygen
- NSAIDs
- Triptans / ergotamine
Prophylactic:
- Remove precipitant
- Ca channel blockers
- Triptans (somatriptan)
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Investigations:
If abnormal blood results or x-ray: explain the results to patient, to decrease the patient
anxiety. The blood tests you had show that you have special kind of anemia that we call
Macrocytic anemia in which the size of the red blood cells (which are a component of
your blood) is larger than usual, there is different causes for this.
o
If the patient panicked? Is it serious doctor?
Do you have any concerns?
There are different causes that may lead to this result, some of them are
serious, could be, we need to do more investigations.
3- I would like to ask you some questions to see how did this (anemia) affect you:
CONSEQUENCES of anemia:
Anemia symptoms:
o
Did anyone comment that you are pale, recently?
o
Did you notice any in your activity level?
o
Heart racing / SOB / chest pain with exercise?
o
Any dizziness / light headedness / fainting?
Neuro symptoms:
o
Any tingling / numbness / in your feet?
o
Difficulty in your balance / any falls?
o
Any difficulty concentrating / memory problems?
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4- I would like also to ask more questions to find out what might be the cause:
CAUSES of Vit B12 deficiency:
Diet intake: Are you vegetarian? For how long? Do you take supplements?
Gastric causes:
o
Did you have any surgeries in your stomach? When?
o
History of long standing PUD? Any heaviness / fullness after meals /
indigestion? (Lack of acidity)
o
Were you ever yourself or any member of your family diagnosed with what is
called autoimmune disease; by this I mean a condition called pernicious
anemia, or rheumatoid disease / lupus?
Terminal ileum:
o
Did you have any bowel surgery before?
o
Were you diagnosed with Crohns disease before? Any repeated attacks of
diarrhea? Any foul smelling bulky stools?
Alcohol:
o
Do you drink alcohol? How much? For how long?
Meds:
Do you take medications on regular basis? What kind?
o
Have you ever been diagnosed with epilepsy? Do you take anti-epileptics?
o
Do you see a psychiatrist? Do you take a mood stabilizer?
o
Any hx of chemotherapy? Have you ever taken a drug called methotrexate?
Hematological causes:
o
Any recent bleeding (nose / gum / coughing / vomiting blood)? Any bruises /
dark urine / tarry stools?
o
Any fever / night sweats / chills? Change in appetite / weight loss? Lumps and
bumps in your body (for LNs)? Bony pains? Any repeated infections?
Parasites:
o
Have you ever consumed raw fish (chronic intestinal infestation by the fish
tapeworm: Diphyllobothrium)?
5- PMH
6- FH
7- SH
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Difficulty swallowing
What do you mean by difficulty swallowing?
Do you feel food is stuck? Can you point where it is usually stuck?
Dysphagia
(esophageal)
Progressive
All the time and
Progressive, solids
then fluids
Mechanical
Cancer OR stricture
Intermittent
On and Off
Achalasia:
respiratory
symptoms
Fluids first
Then solids
Solids only
(Large bolus)
Achalasia
Scleroderma
Esophageal spasm
Scleroderma:
reflux / tight skin of
fingers / change
hand color when
exposed to cold
(Reynauds
disease)
Mechanical Dysphagia:
Analysis
OsCfD: gradual, progressively, to solids then fluids / PQRST / What /
of CC
Associated symptoms:
Near-by systems:
o
Any chest pain / tightness
o
Any cough / change in your voice / neck swelling (thyroid lump)
Impact
Weight loss
Red flags
Constitutional symptoms: fever/ night sweats/ chills / change in appetite / loss
of weight / lumps & bumps
Risk factors:
GERD / PUD:
o
Hx of heart burn
o
Were you ever diagnosed with a condition called GERD / PUD
o
Have you ever checked with a camera or a light (endoscope)
inserted into your stomach
Smoking / Alcohol
Radiation to chest
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Explanation: there is increase in one of the markers used to assess / check the liver
functions, it may indicate that there is an injury to your liver, I am happy you came here
today to discuss it so that we can figure this out.
3- I would like to ask you some questions to see how did this affect you:
CONSEQUENCES of liver injury:
Acute phase:
o
Any yellowish discoloration / itching / dark urine/ pale stools
o
Recently, have you noticed any fever / flu-like symptoms / muscle/joint aches
o
Constitutional symptoms: sweats / chills / appetite / weight / lumps
Chronic manifestations:
o
Did you notice any increase in the size of your abdomen? Puffiness in your face?
Swelling in your legs/ ankles?
o
Bruises in your body?
o
Vomited blood? Blood in stools?
o
WITH ALCOHOL: did you notice changes in memory and concentration? Any
weakness / numbness? Balance and falls?
4- I would like to ask you more questions to find what might be the cause:
CAUSES of liver injury:
Now, I would like to ask you some questions to see if you were exposed to liver disease
without being aware of that, some of these questions may be personal, but it is important to
ask (start from least offensive to most offensive)
Including the alcohol, during which Drinking assessment
5- PMH:
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Now, I would like to ask you some questions to see if you were exposed to liver disease without
being aware of that, some of these questions may be personal, but it is important to ask (start
from least offensive to most offensive)
Oral
Surgical
Risky behaviour
SAD?
o
Do you smoke?
o
Drink alcohol? How about the past? Drinking assessment
o
Have you ever tried recreational drugs? Any injected drug use? When was the
last time?
With whom do you live? For how long have you been together?
Before being with your current partner, did you have other partners?
When did you start to be sexually active? How many sexual partners did you have from
that time till now?
What type of sexual activity do you practice? Did you practice safe sex all the time? And
by that I mean using condoms!
Within the last 12 months, have you had any other sexual partners?
When do you need to take extensive
sexual history? Risky behaviour!
Liver enzymes / Jaundice
Fever / Tired
LNs
Discharge
PAP results
HIV test results
Liver investigations
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Drinking / Alcohol
Drinking assessment
Use / abuse
MOAPS
Drinking hx
How much?
CAGE
Mood
Organic
Anxiety
Psychosis
Self-care / suicide
Impact
Medical
Social
Liver
Home
Memory / conc. Work
B12
Heart
Legal
Use / Abuse:
How much?
o
2 bottles of wine a day? 12 beers a day? Have you drunk more than 6 drinks in
one setting? Have you ever exceeded the amount you intended to drink?
o
Do you drink alone or with other people?
o
Did you ever drink to the extent of black out?
o
What do you feel if you do not drink? Any shaking / heart racing / sweating?
Have you ever had seizures before? Were you hospitalized? Did you have
delirium tremens?
o
Do you avoid going to places where you do not have access to alcohol?
CAGE:
o
Did you ever think that you need to cut down on your drinks?
o
Do you get annoyed by other people criticizing your drinking?
o
Do you feel guilty for your drinking habits?
o
Early morning drink?
Problem drinking: 2 of CAGE list for males OR 1 for females
MOAPS:
Mood:
How is your mood? Interest? If ok do not proceed
o
If not ok MI PASS ECG
Anxiety:
o
Are you the person who worries too much?
o
Do you have excessive fears or worries?
Psychosis:
o
Do you hear voices or see things that others do not?
o
Do you think that someone else would like to hurt you?
Self care / suicide
o
Any chance you might harm yourself or somebody else?
o
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Impact:
I am going to ask some questions to check what effects does alcohol have on your life?
Social:
o
With whom do you live? For how long? How is the relation? Is there any
problems? Is it related to your drinking habits?
o
How do you support yourself financially? Where do you work? For how long?
How is the relation with your coworkers / manager?
Do you miss working days because of your drinking habits?
Do you need to drink at work?
Legal:
o
Did you have any legal issues related to your drinking?
o
Fights? Arguments? Were you arrested before because of drinking?
o
Were you charged before for DUI (driving under influence)?
Alcoholic beverages:
Beer:
o
Alcohol percent around 5%
o
Pitcher (60 oz) = 3 pints (pint = 20 ounces)
o
Ounce (oz) = around 28-30 ml
Wine / Champaign:
o
Alcohol percent around 12%
o
Bottle: 750 ml
o
Glass: 150 ml
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Fever / Tired
Intro
CC
But first I would like to ask you, how do you feel now?
Fever
Do you have other concerns?
Analysis
OsCfD
Did you measure it? How often? How? What is highest?
And medications? Did it help?
Any flu / illness / sickness
Any diurnal variation? Any special pattern? Is it more every 3rd or 4th day?
(malaria)
Impact
Are you able to function?
Red flags
Constitutional symptoms
Differential CNS: headache / neck pain / stiffness / nausea / vomiting / vision changes /
diagnosis
bothered by light / weakness / numbness
ENT:
The liver will be put at the end as a transition to ask about risky behaviour (see liver enzymes case)
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Diarrhea ACUTE
Analysis of
CC
Impact
Red flags
Differential
diagnosis
OsCfD
COCA
B/Mucous
Yes organic
On the surface?
AS
Pain OCD / PQRST
Stress? What do you do for life? Any stress? Does the diarrhea with
stress? How about your mood?
Infectious: travel / camping / with whom do you live? Any other person
at home with diarrhea?
PMH
FH
SH
Bloody diarrhea DD:
GE (gastroenteritis)
IBD (inflammatory bowel disease)
Bleeding peptic ulcer
Investigations for clostridium difficile
CBC / differential / lytes and chemistry
Stool culture for parasites
Stool assay for clostridium toxin
Endoscopy
Blood grouping and cross matching
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Diarrhea CHRONIC
The same as acute diarrhea, except the impact and red flags
Introduction
CC
Analysis of
CC
Impact
Red flags
Differential
diagnosis
OsCfD
COCA
B/Mucous
Yes organic
On the surface?
Pain OCD / PQRST
AS
Stress? What do you do for life? Any stress? Does the diarrhea with
stress? How about your mood?
Infectious: travel / camping / with whom do you live? Any other person
at home with diarrhea?
PMH
FH
SH
Rheumatic diseases: IBS / ankylosing spondylitis / psoriasis / reactive arthritis
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Counselling:
Explanation:
o
From what you have told me, the most likely explanation for your diarrhea is the
medical condition known as Irritable Bowel Syndrome, it is like unhappy colon
o
What do you know about IBS?
o
We do not know the exact mechanism behind this disease, and it is a common
condition, a lot of people have it, this is a long term disease, but it is treatable.
o
What I need to do is to do physical exam, and do some blood works and stool
analysis to rule out other causes, how do you think about that?
o
Is it serious condition doctor?
It is not serious, as it does not affect life expectancy, and around 80% of
patients improve over time
Management:
o
Psychotherapy:
Establish good relationship with the patient
CBT (cognitive behavioural therapy)
If mood is low depression counselling, it might be a mood problem
o
Life style modifications:
Stress management and relief
Relaxation techniques such as meditation
Physical activities such as yoga or tai chi
Regular exercise such as swimming, walking or running
Diet modification: lactose-free diet or a diet restricting fructose is sometimes
recommended
If drinks too much alcohol advise to decrease alcohol
o
Medications
Abdominal pain:
Hyoscyamine (antispasmodic): 0.125 to 0.25 mg PO or SL q4h or PRN
/OR/ extended-release tablets: 0.375 to 0.75 mg orally every 12 hours
(do not exceed 1.5mg in 24 hours)
Amitriptyline (10 mg qhs)
Diarrhea:
Imodium up to 8 tab / day
Lomotil
Constipation:
fibre content in diet
Metamucil (psyllium): bulk-producing laxative and fibre supplement
SSRIs
o
Alternative medicine:
Probiotics
Herbal remedies, e.g. peppermint oil:
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ASTHMA
Mr comes to your office as post-ER visit follow-up, he had asthmatic attack three days ago.
He went to ER; he was treated and discharged with advice to see his family physician.
Introduction
EVENT
Asthma history
Triggers
Infection
Medications
Outdoor
Indoor
Stress
PMH and FH
Asthma Management
1- Confirm diagnosis:
Symptoms:
o
Cough (dry / more at night / more with exercise / induced by allergens)
o
Wheezes (noisy breathing)
o
Chest tightness
Examination: wheezes
Diagnosis:
o
Chest x-ray: R/O pneumonia / infection / cancer
o
Pulmonary Function Tests (PFTs):
FEV1/FVC < 80% of expected obstructive lung disease
Give bronchodilators, repeat PFTs after 20 min, if > 12% Asthma
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2- Management:
Environment control: avoidance of irritant and allergic triggers (e.g. avoid smoking /
change -blocker for treatment of HTN)
Patient education: the allergic nature of the disease and triggering factors
Symptoms
< 2 times / week
Mild
persistent
Moderate
Daily
Severe
Continuous /
Uncontrolled
Treatment
Short acting 2-agonist:
1-2 puffs (PRN and
before exercise)
Short acting 2-agonist
(Ventolin 100 mcg 12 puffs qid)
LABA
(Serevent 50 mcg 1
puff bid)
Add LABA or LTRA
(Singulair 10 mg PO
qhs)
Notes
Does not need daily
medication
Low dose ICS
(Flovent 125
mcg 1 puff bid)
Moderate dose
ICS
(Flovent 250
mcg 1 puff bid)
High dose ICS
(Flovent 250
mcg 2 puffs
bid)
Oral
prednisone
ICS
: Inhaled Corticosteroids; 1 puff = 100 mcg
LABA : Long-acting beta2-adrenoceptor agonist
LTRA : Leukotriene receptor antagonist
Color
Blue
Blue
Orange
Active ingredient
Salbutamol
Salmeterol
Fluticasone propionate
Advair
Purple
Pulmicort
Brown
Fluticasone
Salmeterol
Budesonide
Symbicort
Red
Atrovent
Spiriva
Singulair
Budesonide
Formoterol
Green
Ipratropium bromide
Spiriva Tiotropium bromide
Handihaler
Tablets Montelukast
/ puff
100 mcg
50 mcg
125 mcg
250 mcg
500 mcg
250 mcg
50 mcg
100 mcg
200 mcg
400 mcg
400 mcg
12 mcg
20 mcg
18 mcg
4 mg
10 mg
Class
Short acting 2-agonist
LABA
ICS
Notes
ICS
LABA
ICS
ICS
LABA
Anti-cholinergic
Long-acting, 24 hrs, anticholinergic bronchodilator
Leukotriene receptor
antagonist (LTRA)
Bronchodilators:
o
Beta 2 agonists: salbutamol 100 mcg 4 puffs q 15-20 min x 3 AND
o
Ipratropium bromide 4 puffs q 15-20 min x 3
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COPD management
Prolong survival
Smoking cessation
Vaccination: influenza virus, pneumococcus (Pneumovax)
Home oxygen: to prevent cor pulmonale and decrease
mortality if used > 15 hrs/day (indications: PaO2 < 55
mmHg; or < 60 mmHg with cor pulmonale or
polycythemia)
Ventolin (q6h PRN) + Atrovent (1-2 puffs q6h)
LABA (Serevent 50 mcg/dose) Atrovent /or/
LACA (Spiriva): 18 mcg qAM + must stop Atrovent
Oral
Bronchodilators by nebulizer
o
Short acting beta2-agonists used concurrently with anti-cholinergics
o
Salbutamol and Ipratropium bromide via nebulizers x 3 back-to-back
Ventilator support
o
Non-invasive: NIPPY, BiPAP
o
Conventional mechanical ventilation
Antibiotics:
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Impact
Red flags
Differential
diagnosis
AS
Local symptoms:
Nail changes
Other swellings in your body:
How about your belly? Did you need to the size of your belt?
PMH
FH
SH
Case: patient with face swelling, BP 150/90, protein in urine, ketones, no blood, no glucose, no
WBCs
Diagnosis: nephritic syndrome (minimal changes)
Investigations:
Prednisolone
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Impact
Red flags
Differential
diagnosis
If pain PQRST
AS
Local symptoms:
Nail changes
Other joints? Toes? Other ankle?
How does this affect your life?
Constitutional symptoms for infection / cancer
Differential diagnosis of UNILATERAL ankle swelling:
Any trauma, any twist in your ankle?
Gout; previous attacks, screen kidney for kidney stones
Infection, sepsis, cellulitis; fever, pus, discharge, tenderness
Gonorrhea septic arthritis; Sexual history, penile discharge? Unprotected sex
recently?
DVT
Specific cause within this system (e.g. gout)
Tell me more about your diet? Too much protein?
How about alcohol?
Medications? Pain meds (aspirin) / diuretics (furosemide, thiazides)?
Hx of cancer / chemotherapy (cytotoxic drugs) / radiation?
Family hx of gout / kidney stones?
PMH
FH
SH
DVT: see the physical examination section
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Impact
Red flags
DD
PMH
FH
SH
Clarification
No newly dx
Cough / crackles?
Right ventricle:
Any swelling in your LL? How high does it go? Related to position / standing?
Weight gain?
Compliance:
Are you receiving treatment? Which medications do you take? How much? For how long? Any
change in medications? Change in dose?
Do you take it on regular basis? Any chance that you may skip one or more doses?
Did you start new medication? Rx or (OTC) over the counter? e.g. indomethacin
Are you under regular F/U? How often? When was the last time? Were you symptoms free at that
time?
Diet:
Any chance of salty food, e.g. pickles, canned food, dried meet and fish
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Medical:
Do you take medications on regular basis? Any new medication? Advil?
Any hx of thyroid dx, any sweating / diarrhea?
Any hx of heart disease / HTN ( A Fib) / heart attack / CAD (ischemia) / did you feel your
heart bouncing (arrhythmias)? Any congenital or valvular disease / Chest pain / tightness /
dizziness / light headedness / LOC?
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Heart racing
For few weeks
Introduction But first I would like to ask you, at the moment, how do you feel?
CC
Analysis of
Clarification When do you say your heart is racing; what do you mean?
Or is skipping beats
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The patient daughter has a concern: my mother was diagnosed with AF,
Should I worry about this?
1.
2.
Atrial fibrillation
Stable
< 48 hours
If in doubt TEE
> 48 hours
Rate control:
-blockers
Unstable
SOB
BP < 90/60
Chest pain
Confusion
Cardioversion:
Electrical: 150 joules for A Fib (50 joules for A Flutter)
Pharmacological: procainamide; 1 g / 1 hr infusion
Anti-coagulation:
Assess stroke risk: determine CHADS2 score in patients with non-valvular AF
Risk factor
Points
CHADS2 score
Anti-coagulation
CHF
1
0-1
Aspirin 81-325 mg daily
Hypertension
1
2 moderate risk
Warfarin
factors or any high risk
Age > 75 yrs
1
factor (prior stroke,
Diabetes
1
TIA or embolism,
Stroke / TIA
2
mitral stenosis,
prosthetic valve)
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Fall
Orthostatic hypotension
76 years old male patient came to clinic because he fell few days ago. He was getting out of bed,
when he fell to the ground
Introduction
HPI: analysis of CC
Associated
Symptoms
For any
Fall,
LOC
or seizure
During
Before
After
Impact
Red flags
DD
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Counselling:
Inform the patient
The most likely explanation to what happened is a condition called postural orthostatic
hypotension. It means drop in the blood pressure with change of posture.
Investigations:
o
Blood works / CBC / differential / lytes / kidney and liver function tests
o
ECG
Preventive measure:
Contact the psychiatrist to check the poly-pharmacy, to discuss with him the possibility
of decreasing the dose or changing medications.
Meanwhile, if you are changing positions, do this slowly, on steps, e.g. from lying down,
sit for a couple of minutes on the bed before standing up, and before you stand up, push
your feet against the ground for few seconds.
I will give you brochures and web sites in case you need to read more.
Notes:
The patient will have a list of medications:
Lipitor
-blocker
Lorazepam
Oxazepam I can see that you are taking 2 sleeping pills, who prescribed them to you?
The same doctor or no?
Metformin
B12 / B complex
If the patient looks sad / depressed you look down for me, any chance you are depressed
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Impact
Red flags
DD
PMH
FH
SH
OsCfD
PQRST
P: unilateral or bilateral
Diabetes mellitus
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Urinary symptoms:
Any dripping?
After you pass urine, do you feel that you emptied your bladder completely or do you
need to go again?
Irritative (frequency UB disease):
Do you need to rush to washroom? Are you able to make it all the time?
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Anuria
Introduction
Analysis of CC
Impact
Red flags
DD
PMH
FH
SH
Were you ever diagnosed with prostate disease? Screened for prostate
diseases? (DRE or PSA)
Smoking? Alcohol?
Renal stones: Have you ever had a renal stone? Any history of colicky pain in
flanks? Have you ever passed a small crystals or stone during voiding? Hx or
repeated UTIs?
Medications: glaucoma / anti-psychotic meds / anti-cholinergic drugs; like those
used for incontinence; e.g. Ditropan (Oxybutynin), Detrol (Tolterodine)
2 Neuro:
Back problem: trauma metastasis cauda equine (spoiled himself with stools
/ buttocks numbness)
Cancer prostate
Ca bladder (hematuria)
AMPLE
DM / anemia / polycystic kidney disease / renal stones
SAD
Surgery: open surgery / TURP / minimally invasive (stent / laser ablation / cryosurgery)
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Hematuria
Introduction
Analysis of
CC
Impact
Red flags
DD
PMH
FH
SH
Investigations:
Diurnal variation
What or
Painful or Painless
Is it first time? Or did it happen before? When and how were you
diagnosed? How about treatment?
Associated symptoms:
Obstructive symptoms
prostate disease
Irritative symptoms
UB disease
Urine analysis (changes): COCA Blood
Local symptoms:
Any problems with passing stools? What? When?
Any masses in the groin / pelvic mass / pain?
Abdominal pain? Distension?
Metastasis
Renal failure
Generalized swelling / face puffiness / itching
Sexual
Sexual dysfunction
Constitutional symptoms for infection / cancer
Risk factors for cancer prostate / bladder / RENAL
Were you ever diagnosed with prostate disease? Screened for prostate
diseases? (DRE or PSA)
Smoking? Alcohol?
Renal stones: Have you ever had a renal stone? Any history of colicky pain
in flanks? Have you ever passed a small crystals or stone during voiding?
Hx or repeated UTIs?
Medications: blood thinners / aspirin / bleeding from other sites?
Pseudo-hematuria:
Medications: Rifampicin
(1) Kidney: urinalysis (casts / crystals / C&S / cytology) / ultrasound (abd/pelvic) / IVP / KFTs
(2) Bladder: cystoscopy
(3) Prostate: PSA / TRUS
(4) Others: CBC / differential / INR
Case: patient on warfarin for A. fib for 2 yrs; went to walk in clinic for sore throat and was prescribed
Biaxin, developed hematuria. Diagnosis: coagulopathy.
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Renal stones
Risk Factors
Sedentary lifestyle
Medications: thiazides
Screening labs
o
CBC: elevated WBC in presence of fever suggests infection
o
Electrolytes, Cr, BUN to assess renal function
o
Urinalysis: R&M (WBCs, RBCs, crystals), C&S
Imaging
o
Kidneys, ureters, bladders (KUB) x-ray to differentiate opaque from non-opaque
stones (e.g. uric acid, indinavir) / 90% of stones are radiopaque
o
CT scan: no contrast; distinguish radiolucent stone from soft tissue filling defect
o
Abdominal ultrasound: may demonstrate stone (difficult for ureters) / may
demonstrate hydronephrosis
o
IVP (not usually done): anatomy of urine collecting system, degree of
obstruction, extravasation
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Treatment Acute:
Medical:
o
Analgesics (Tylenol #3)
o
NSAIDs help lower intra-ureteral pressure
o
antibiotics for UTI
o
(antiemetic + IV fluids) for vomiting
Interventional:
o
Ureteric stent (cystoscopy)
o
Percutaneous nephrostomy (image-guided)
Admit if necessary:
o
Intractable pain
o
Intractable vomiting
o
Fever (? infection)
o
Compromised renal function
o
Single kidney with ureteric obstruction / bilateral obstructing stones
Treatment Elective:
Medical:
o
Conservative if stone < 5 mm and no complications
o
Fluids to increase urine volume to > 2 L/day (3-4 L if cystine)
o
Specific to stone type:
Calcium oxalate stones: thiazides / potassium citrate (alkalinization of urine)
Calcium struvite: antibiotics for 6 wks (stone must be removed to treat infection)
Uric acid: allopurinol / potassium citrate (alkalinization of urine to pH 6.5 to 7) /
shockwave lithotripsy not effective
Cystine: alkalinize urine (bicarbonate / potassium citrate) / penicellamine / captopril
(forms complex with cystine) / shockwave lithotripsy not effective
Interventional:
o
Procedural / surgical: If stone is > 5 mm or presence of complication
o
Kidney
Extracorporeal shockwave lithotripsy (ESWL) if stone < 2.5 cm
Percutaneous nephrolithotomy; indications:
+ Size > 2.5 cm
+ Staghorn
+ UPJ obstruction
+ Calyceal diverticulum
+ Cystine stones
o
Ureter
ESWL is the primary modality of treatment
Ureteroscopy (extraction or fragmentation) if failed ESWL / Ureteric stricture
o
Bladder
Transurethral cystolitholapaxy
Remove outflow obstruction (TURP or stricture dilatation}
Management of UTI:
Investigations:
o
Urine for culture and sensitivity
o
Blood: CBC / differential
o
Imaging (if suspect complicated pyelonephritis or symptoms do not improve with 72
hours of treatment): Abd/pelvic U/S / IVP / Cystoscopy / CT
Non-pregnant:
o
Septra (sulfamethoxazole and trimethoprim) DS (800/160): 1 tab bid x 7 days
o
/OR/ Ciprofloxacin 500 mg bid x 7 days
Pyelonephritis:
o
Ceftriaxone (third-generation cephalosporins): 1 g IV q24hrs x 2 days
o
Then continue oral ciprofloxacin x 7 days
Abscess: + drain
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Incontinence
Obstructive / 62 years old female, with hx of 3 years of urinary incontinence
Introduction
Empathy how do you feel right now?
Analysis of
OsCfD
CC
What or : lifting objects / coughing / straining
Is it first time? Or did it happen before? When and how were you
diagnosed? How about treatment?
Impact
Red flags
DD
Associated symptoms:
If at any time there is a frequency or
Obstructive symptoms
some new symptom analyze it
Irritative symptoms
first then resume!
Urine analysis (changes): COCA
Frequency in UTI
Blood
Local symptoms:
Any problems with passing stools? What? When?
Any masses in the groin / pelvic mass / pain?
Any perineal skin lesions?
How does it affect your life? Daily activities?
Constitutional symptoms for infection / cancer
Risk factors (MGOS):
Menopausal symptoms, and HRT
M
LMP
Gynaecological history
G
Previous abdominal or pelvic surgeries
Obstetric: How many pregnancies? Route of delivery?
O
Sexual: Repeated infections / dryness / dyspareunia
S
Overflow incontinence
Urge incontinence
Detrusor overactivity: CNS lesion, inflammation / infection (cystitis),
bladder neck obstruction (tumour, stone)
Stress incontinence
Urethral hypermobility: childbirth, pelvic surgery, aging
Intrinsic sphincter deficiency (ISD): pelvic surgery, neurologic
problem, aging and hypoestrogen state
Diagnosis:
History
Urodynamics
Stress test
Treatment of urge incontinence
Treatment of stress incontinence
Weight loss
Kegels exercises
Medications: anti-cholinergics;
Bulking agents
Tolterodine (Detrol), Oxybutynin
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Associated (local)
symptoms
Impact
Red flags
Differential
Diagnosis
PMH
FH
Physical exam
History of cancer
History of cancer / lymphadenopathy
Vital signs
Neck exam / Thyroid exam if the swelling is central
LNs / Lymphatic system / LNs in groin / pelvic exam
Liver / Spleen
Notes:
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Lump Breast
Introduction
Analysis of CC:
The lump
Breast Cancer
Sclerosing adenosis
Fibrocystic changes
Lipoma
Fibroadenoma
Neurofibroma
Fat necrosis
Papilloma / papillomatosis
sarcoidosis)
Galactocele
Abscess
Duct ectasia
Silicon implant
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Non-proliferative lesions:
o
Aka fibrocystic changes, chronic cystic mastitis, mammary dysplasia
Benign condition characterized by fibrous and cystic changes in the breast. No risk
of breast cancer / Age 30 to menopause / pre-menstrual.
Breast pain, focal areas of nodularity or cysts often in upper outer quadrant
Treatment: Evaluation of breast mass and reassurance / Analgesia (ibuprofen, ASA) /
If > 40 years old: mammography every 3 years or biopsy
Proliferative lesions:
o
Fibroadenoma:
Most common benign breast tumour in women under age 30
Risk of subsequent breast cancer is increased only if fibroadenoma is complex, there
is adjacent atypia or a strong family history of breast cancer
Clinical features: nodules: smooth, rubbery, discrete, well-circumscribed, nontender, mobile, hormone-dependent. Needle aspiration yields no fluid
Investigations: Core or excisional biopsy required
Treatment: Generally conservative; serial observation. Consider excision if size 2-3
cm, rapidly growing on serial US, if symptomatic or pt preference
o
Intra-ductal Papilloma
Solitary intra-ductal benign polyp
Present as nipple discharge (most common cause of spontaneous, unilateral bloody
nipple discharge), breast mass, nodule on U/S
Treatment: excision of involved duct to ensure no atypia
Other lesions:
o
Fat Necrosis
Uncommon, result of trauma (may be minor commonly a tight bra, positive history
in only 50%), after breast surgery (i.e. reduction)
Firm, ill-defined mass with skin or nipple retraction, tenderness
Regress spontaneously, but complete imaging biopsy to R/O cancer
o
Mammary Duct Ectasia
Obstruction of a subareolar duct duct dilation, inflammation, and fibrosis
May present with nipple discharge, bluish mass under nipple, local pain
Risk of secondary infection (abscess, mastitis)
Resolves spontaneously
o
Abscess
Lactational vs. periductal / subareolar
Unilateral localized pain, tenderness, erythema, subareolar mass, nipple discharge,
nipple inversion
Rule out inflammatory carcinoma, as indicated
Treatment: initially broad-spectrum antibiotics and I&D (incision and drainage), if
persistent total duct excision (definitive)
If mass does not resolve: fine needle aspiration (FNA) to exclude cancer, U/S to
assess for presence of abscess
Breast Cancer:
1/9 women in Canada will be diagnosed with breast cancer in their lifetime
Risk factors:
Prior history of breast cancer
1st degree relative with breast cancer (greater risk if relative was premenopausal)
Increased risk with high breast density, nulliparity, first pregnancy >30 years old,
early menarche (< 12 yrs), late menopause (> 55 yrs), >5 years HRT
Decreased risk with lactation, early menopause, early childbirth
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Investigations
o
Mammography
Screening: every 1-2 years for women age 50-69 / If positive family history in 1st
degree relative: every 1-2 years starting 10 years before the youngest age of
presentation
Diagnostic: investigation of patient complaints (discharge, pain, lump)
Follow-up after breast cancer surgery
Findings indicative of malignancy: mass that is poorly defined, spiculated border,
micro-calcifications, architectural distortion, normal mammogram does not rule out
suspicion of cancer based on clinical findings
o
Other radiographic studies:
Ultrasound differentiates between cystic and solid
MRI high sensitivity, low specificity
Galactogram / ductogram (for nipple discharge): identifies lesions in ducts
Metastatic workup as indicated (usually after surgery or if clinical suspicion of
metastatic disease) bone scan, abd U/S, CXR, head CT
Diagnostic Procedures
o
Needle aspiration: for palpable cystic lesions; send fluid for cytology if blood or cyst
does not completely resolve
o
Fine needle aspiration (FNA): for palpable solid masses; need experienced practitioner
for adequate sampling
o
U/S or mammography guided core needle biopsy (most common)
o
Excisional biopsy: only performed as second choice to core needle biopsy; should not be
done for diagnosis if possible
Genetic Screening: consider testing for BRCA 1/2 if:
o
Patient diagnosed with breast AND ovarian cancer
o
Strong family history of breast / ovarian cancer (e.g. Ashkenazi Jewish)
o
Family history of male breast cancer
o
Young patient ( <35 years old)
Pathology
o
Non-invasive: ductal carcinoma in situ (DCIS): completely contained within breast ducts,
often multifocal / 80% non-palpable, detected by screening mammogram.
Treatment: lumpectomy with wide excision margins + radiation OR mastectomy if
large area of disease, or high grade
o
Invasive:
Invasive ductal carcinoma (most common 80%): hard, infiltrating tentacles
Invasive lobular carcinoma (8-15%): 20% bilateral. Does not form micro
calcifications, harder to detect mammographically (may benefit from MRI)
Paget's disease (1-3%): ductal carcinoma that invades nipple with scaling,
eczematoid lesion
Inflammatory carcinoma (1-4%): ductal carcinoma that invades dermal lymphatics,
most aggressive form of breast cancer.
Clinical features: erythema, edema, warm, swollen, tender breast lump
Peau d'orange indicates advanced disease (III-b IV)
Treatment of breast cancer:
Stage
Primary treatment options
Adjuvant systemic
therapy
0 (in situ)
BCS + radiotherapy
None
I
BCS (or mastectomy) + axillary node dissection +
May not be needed
radiotherapy
II
Chemotherapy and /
or hormone therapy
III
mastectomy + axillary node dissection + radiotherapy
Inflammatory
IV
Surgery as appropriate for local control
BCS = breast-conserving surgery
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Dizziness
Causes
Vertigo
Symptoms
Imbalance
N&V
Auditory
Neurological
Nystagmus
Non-vertigo
Peripheral
Benign paroxysmal
positional vertigo
Mnire's disease
Vestibular neuritis
Labyrinthitis
Acoustic neuroma
EAR
Mild-moderate
Severe
Common
Central
Stroke
TIAs
Brain tumour
MS
Cerebellar lesion
Unidirectional
Common
Bidirectional
(horizontal or
rotatory)
Clarification
Analysis of CC
Impact
Red flags
DD
Syncope
Vertigo
Cerebellar
lesion
Cardiac
Arrhythmias
CAD / MI
CHF
Aortic stenosis
Postural
hypotension
Non-cardiac
Vaso-vagal
episode
Panic attack
Somatization
Brain / Neuro
Severe
Variable
(horizontal or
vertical)
Do you feel
You have blackout (syncope)
OR the room is spinning around you (vertigo)
OCD
Timing: when / frequency
What or : certain position
Did you lose consciousness?
Did you fall to ground? Did you hit your head?
Constitutional symptoms
Vasovagal attack: LOC / while straining or urinating / nausea / do you feel
warning signs before the dizziness?
Cardiac (tight AS / arrhythmia): heart racing / chest pain / immediate (no
warning signs)
Hypotension: antihypertensive meds; change of dose or new medication
Postural hypotension: diabetes / dehydration / parkinsonism
Neuro (stroke / TIAs): vision changes / loss, speech impairment, weakness
Condition
Benign Paroxysmal
Positional Vertigo
Duration
Seconds to minutes
Hearing loss
Tinnitus
Mnire's disease
Vestibular neuritis
Labyrinthitis
Acoustic neuroma
Minutes to hours
Hours to days
Days
Chronic
Fluctuating
Unilateral
Unilateral
Progressive
Whistling
+
Other features
Certain
positions
Nystagmus
Ear fullness
Recent AOM
Ataxia
CN VII palsy
PMH / FH / SH
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Condition
Benign
Paroxysmal
Positional
Vertigo
(BPPV)
Mnire's
disease
Vestibular
neuritis
Management
Acute attacks of transient vertigo lasting
seconds to minutes initiated by certain
head positions, accompanied by torsional
(rotatory) nystagmus
Diagnosis:
History
Positive Dix-Hallpike manoeuvre
Labyrinthitis
Acoustic
neuroma
OSCE-guide-III.doc
Investigations:
CT head
If meningitis is suspected: lumbar puncture, blood cultures
Treatment:
IV antibiotics
Drainage of middle ear
mastoidectomy
Investigations:
MRI with gadolinium contrast is the gold standard
Audiogram SNHL (sensori-neural hearing loss)
Vestibular tests: normal or asymmetric caloric weakness (an
early sign)
Treatment
Expectant management if tumour is very small or in elderly
Definitive management is surgical excision
Other options: gamma knife, radiation
Dix-Hallpike Positional Testing: the
patient is rapidly moved from a sitting
position to a supine position with the
head hanging over the end of the table,
turned to one side at 45 holding the
position for 20 seconds. Onset of
vertigo is noted and the eyes are
observed for nystagmus
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INR Counselling
Analysis
Impact
Red flags
DVT
Warfarin / Blood thinners
Decision
Causes / Complications
Conclusion
Analysis:
History:
o
o
o
o
o
o
Give the information: Your measurement today shows INR of 1, any idea why?
o
Compliance: Are you still taking your warfarin? On regular basis? Did you stop your
medication? Why?
o
Forget: Do you take your medications on your own, or does someone else help you? Any
chance that you missed a dose?
o
New medications: Did you start a new medication? What? Why? When?
o
Diet: Do you eat a lot of spinach? Or dark green vegetables? (rich in vit K)
Impact:
Now, I would like to ask you some questions to check if you have relapse of your DVT or bleeding,
then we will go from there
DVT relapse:
Because you stopped your medication, I would like to make sure that there is no relapse
o
DVT: Have you had any pain / swelling / redness in your calf muscles?
o
PE: Have you had any SOB, chest pain, heart racing?
o
Stroke: Any confusion? Vision changes? Difficulty finding words? Weakness?
Bleeding:
o
Did you notice any bleeding?
o
Did you notice bleeding from your gums / nose / coughing or vomiting blood / bruises in
your body / dark urine / urine in stools?
o
Any weakness / numbness / difficulty finding words / vision difficulty?
o
Did any one tell you that you look pale? Do you feel fatigued?
Based on what you have told me, there are no obvious serious consequences, if it is ok with you, we
can discuss your situation now!
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Complication:
o
Relapse 8%: without treatment, and that is concerning!
Whenever we treat the patient, our target is to decrease the relapse rate to 0.8%
which is 1/10 of the risk without treatment
o
These clots are not fixed, and sometimes they get dislodged from your leg and travel
along your blood vessels, all the way to the lungs (chances are 3%):
If large enough might cause sudden death
If showers of small clots you may not feel anything right now, but it later will
cause what we call pulmonary HTN, which is a debilitating disease, with serious
consequences and we do not have treatment for it right now
o
Always in medicine, we try to balance the benefits and the side effects, and in this
condition, the benefits largely outweigh the risks.
Decision:
If the patient decides that he will restart the treatment:
We will need to measure the INR daily (till we reach our target) then twice a week, then weekly,
then every 2-4 weeks
NOTES:
Numbers to remember:
o
Relapse (recurrence) of the DVT: 8% without treatment and 0.8% with treatment.
o
Possibility of DVT clots and PE: 3%
o
Chances of having bleeding with warfarin: 1%, and almost near 0% chance of having
intra-cranial bleeding without having an extra-cranial bleeding.
The initial DVT counselling should have been done in the first time, when the patient was
diagnosed; which includes:
o
General knowledge about DVT
o
Causes and risk factors
o
INR follow up
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Now, what do you mean by wrong blood? Is it the same bld group or no? Cross matched or not?
Do we have the patient name on the units?
o
It is the same group but with other patient name
o
Doctor, please do not tell the patient!
I see you have concerns here, but we need to stabilize the patient first. Then we will speak about
that. However, we need to investigate before making decisions.
Can you tell me when did this happen? How much did he receive?
Could be! There are different possibilities; I need first to check you.
o
Whose mistake is this? Is it the nurse mistake?
Usually in the blood transfusion process, there are many steps; any one of those might go wrong.
It is early now to judge. I need first to make sure you are ok and stable, and then I will file an
incidence report. Investigations will be done, and you will be informed with the results.
ABCD
Let us make sure you are safe and stable first.
AB:
Can you please open your mouth? Mouth is clear with no swelling. Do you have any itchiness or
swelling in your mouth?
Trachea is central, no engorged jugular veins. Can I listen to your heart please! Normal heart
sounds.
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C:
D:
History
Now, I would like to ask you some questions:
The most common reaction that might happen is called febrile reaction. This is not serious
reaction and it is self limited. It might happen again, so if it happens, next time we give you
Tylenol before the transfusion.
Another adverse effect, which is less common but more serious, it is called anaphylactic
reaction. This is a form of severe and serious sensitivity reaction, in which the blood pressure
drops suddenly, and there is a swelling of the tongue, lips, and mouth, with difficult breathing. We
do not have a method to predict it. However, based on your symptoms, your physical exam and
vital signs it is less likely you have that.
The third adverse effect is called hemolytic reaction, and it happens if the patient receives blood
that belongs to another blood group. It causes damage to blood cells which leads to back pain and
flank pain, and could have serious consequences.
Again, based on your symptoms, physical exam and vital signs, your condition does not cope with
this reaction too. And the fact that you received blood from the same blood group makes it less
likely you will have hemolytic reaction.
We prepared medications to deal with any reaction and we will keep you for a while to monitor
you, to make sure that will not happen.
Plan
Call the blood bank to withhold the other units (previously cross-matched)
File an incident report
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Counselling Ventilator
Mr Johnson is 75 years old gentleman, his life-long wife for 50 years has a terminal COPD, with
severe pneumonia, and she is on ventilator for the last 3 weeks, and it is not possible to wean her
from ventilator, you called him to inform him about the condition.
Listen carefully
Offer time if he needs to discuss it with other close family members, or if he needs to arrange
any thing (e.g. I am just giving you information, and we can arrange a meeting with the
family within 2 days so that I can explain to them).
What if she does not want to be on ventilator but he would like to leave her on the ventilator?
Mr Johnson, I am sorry to tell you that, actually it is not our decision or your decision, it
is her choice. And she expressed her wishes before; she decided that she does not want to
have this poor quality of life. We have to respect her wishes.
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Ethical questions
Patient has the right to access his/her medical file, we can not withhold it
Patient wants to leave you as family physician it is his right, and he/she has the right to
take all his/her medical data and file
If you want to terminate a patient from not seeing you as family physician:
o
Give proper notice period
o
See him/her for emergency
Confidentiality; when to break confidentiality? To report for the ministry of transportation for
example:
o
Dementia / delirium
o
Vision problems
o
Seizure disorders
o
Schizophrenia (case-based)
o
Heart attack 1 month not allowed to drive
o
Alcoholic with liver failure (based on Childs criteria: albumin / ascites / INR /
bilirubin)
Report for child safety CAS (Children Aid Society)
o
Even if POTENTIAL or SUSPECTED
o
Child neglect / abuse
Patient wants to leave hospital against medical advice; e.g. patient has just had a heart attack,
and still insists to leave the hospital!
o
I would like to make sure he is competent, not under influence of alcohol or any
substance, and to rule out suicidal ideation
o
I would explain to the patient: diagnosis / treatment / side effects of treatment /
complications of not receiving treatment / alternatives
o
I will document this, and I will ask the patient to sign a LAMA (leaving against
medical advice), and I will let him go
Biological parent wants to know the medical details of his/her son, who is adopted by another
family!
o
In order to determine whether I should release any information or no, I would
like first to know who has the legal custody (guardian) of this child. It might be
the adopting father, a social worker (case manager)
Any unconscious patient ask for DNR or advanced directives
MMS exam score < 24 patient is incompetent;
o
You have a case of patient, who had surgery, is taking medications, but he
developed delirium post-operative and now he wants to discontinue his
medications NO; he is delirious, incompetent to change decisions, he already
consented to take the medications before he entered this delirium.
o
What if this patient broke his leg; do you want to operate him without consent?
This is a new condition; we do not know what would be his competent wishes
look for SDM (substitute decision maker).
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Usually you are covering for other physician to give the test result which means this is a new pt
to you.
Be sensitive, empathetic, and flexible
Introduction:
Your Dr. is away, I am covering for him/her, and I have your file with me, I just need to understand the
situation here,
Was there anything made you worried about your own health?
What kind of thoughts are going through in your mind? What concerns you the most right
now?
AIDS: dont have AIDS, will not die tomorrow or so. Prognosis is variable, but many people carry
it without feeling it for quite long time, years
Consequences of HIV:
Repeated infections / LNs
Tired / fatigue
Memory dementia
Depression
Causes of HIV:
SAD shared needles
Sexual:
o
Risky behaviour
o
Confidentiality how to inform the partner?
Get the background info: duration of the relationship, how close to each other,
Partner has to know: Risk of infection / Needs to be tested
Will know anyway, either from public health or him. Prefer him to tell, offer help to
tell.
Education: emphasize the importance of safe sex: advice use barrier contraceptive methods all the
time with all partners in the future to prevent the transmission.
CT brain:
enhanced multiple rings toxoplasmosis with HIV
DD:
TB / toxoplasmosis / CMV / CNS lymphoma
Management:
refer to infectious disease specialist
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Lung Nodule
Introduction:
Why X-ray was taken? When?
When was last normal X-ray? Do we have it?
Give the test result:
Solitary Lung Nodule. Definition: a round or oval, sharply circumscribed radiographic lesion, size
up to 3-4 cm, which may or may not be calcified, and is surrounded by normal lung. Can be
benign or malignant
Consequences:
Local symptoms: cough, phlegm, haemoptysis, SOB, wheezing
Constitutional symptoms: fever, chills, night sweat / change of appetite, weight loss, fatigue /
pumps or lumps in the neck or elsewhere in the body
Causes:
Smoking
Exposure to chemicals / smokes at work
T.B.: Contact with sick person (T.B.) / Recent travel / T.B. skin test
Sarcoidosis: associated symptoms; joint pain, skin rash
History of lung disease
History of cancer
HIV status
Family History of T.B. or Lung cancer
Management:
Investigations
o
CXR: always compare with previous CXR
o
CT densitometry and contrast enhanced CT of the thorax
Sputum cytology / stains
TB skin test
o
Biopsy: bronchoscopic or percutaneous(CT-guided) or excision (thoracoscopy or
thoracotomy): if clinical and radiographic features do not help distinguish between
benign or malignant lesion
If at risk for lung cancer, biopsy may be performed regardless of radiographic
features
If a biopsy is non-diagnostic, whether to observe, re-biopsy or resect will depend on
the level of suspicion
o
PET scan not yet routine but can help distinguish benign from malignant nodules
Watchful waiting: repeat CXR and/or CT scan at 3, 6, 12 months
Algorithm:
Evaluation of a Solitary Pulmonary Nodule; check previous CXR
o
Looks benign or unchanged repeat CXR q 3-6 months for 2 years
o
Significant risk factor on history or looks malignant or changed CT chest
Cause (infection or cancer) stage and treat
Calcification observe
No diagnosis trans-thoracic needle biopsy
Inflammatory treat the cause
Cancer stage and treat
Still NO diagnosis resect for diagnosis
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High Creatinine
Introduction:
Why the test was done?
Itching
Pallor
Fatigue
Bone pain
Causes:
Renal:
Hypertension
Diabetes
o
Repeated kidneys infection
o
Poly-cystic kidneys
o
Medications: NSAIDs / gold / penicellamine / ACEIs
Post-renal:
o
Kidney stones
o
Bladder cancer
o
Prostate problem
o
o
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Introduction:
ED is a common problem in men, with a broad DD, encompassing organic & psychogenic causes.
This is often a difficult topic for men to discuss with their doctor. Confidentiality.
Many endocrine disorders and systemic diseases cause ED by influencing libido, autonomic
pathways and/or blood flow.
Organic causes:
o
Medical causes: history of DM, HTN, hyperlipidemia, peripheral vascular disease,
intermittent claudication
o
Neuro: back trauma / constitutional symptoms (back metastasis) / back pain / weakness,
numbness / history of MS,
o
Low testosterone: changes in secondary sex characteristics, e.g. hair pattern changes /
history of gynecomastia / galactorrhea / history of thyroid disease / pituitary disease (
visual defect, headache)
o
Medications; e.g. anti-depressants, hormonal treatment, opioids, MAO inhibitors
o
SAD: smoking / alcohol / recreational drugs
Psychogenic causes:
o
Any problems with their partner(s)
o
History / screening of depression
o
Any recent changes in life (home, work, socially) / anxiety attacks? Any stress? Past lifebackground, upbringing,
Counselling:
Unfortunately, many organic causes are irreversible, but we have treatment options:
o
Testosterone preparations (if low testosterone)
o
Viagra or Cialis
o
Penile self-injection
o
Vacuum rubber ring device
o
Penile prosthesis
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PQRST /
Associated Symptoms:
Morning stiffness
o
Inflammation: morning stiffness (>30 min), better with use, constitutional
symptoms
o
Non-inflammatory: worse with use, worse at end of day, can have some stiffness
but usually not prolonged
Constitutional symptoms
Extra-articular features:
Seropositive (e.g. RA, SLE, Sjogrens, scleroderma, inflammatory, myositis)
Seronegative (Ankylosing spondylitis, psoriatic arthritis, enteropathic arthropathy,
reactive arthritis)
o
Eyes: iritis, scleritis, conjunctivitis, dry eyes
o
Oral ulcers
o
Respiratory: pleural effusion, pleuritis, pulmonary fibrosis, pulmonary nodules
o
Cardiac: pericarditis, pericardial effusion, conduction defects
o
GIT: GERD, inflammatory bowel disease, malabsorption, bloody diarrhea
o
Dermatology: malar rash, discoid, nodules, telangiectasias, sclerodactyly,
calcinosis, alopecia, periungal erythema, psoriasis, nail pitting, onycholysis,
erythema nodosum, pyoderma gangrenosum
Crystal arthropathies
o
Mono-arthritis (red, hot), chronically can be poly-arthritis: gout (tophi, alcohol
history, renal failure, drugs)
o
CPPD (hyperparathyroidism, hypomagnesemia, hemochromatosis, Wilsons
disease, hypothyroidism)
Septic arthritis: usually mono-arthritis, fever, red, hot. Gonococcal arthritis can be
migratory, with tenosynovitis and skin pustules
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Multiple Sclerosis
Middle aged man (or woman) with episodes of numbness in one leg.
History:
Review of systems
Diagnosis:
MS
Dysphagia, dysarthria
Constitutional symptoms
History of headache
Sarcoidosis
HIV status
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Obesity
Weight analysis: now and how about one year ago? Maximum and minimum weights?
Diet: detailed history; how many meals, how much, bedtime meals,
Counselling:
Encouragement: admire patient, it is important for your general health, requires a lot of effort;
it is very difficult process, very common multiple tries.
Methods:
Exercises:
o
Program: 3-5 times per week /+/ 30-50 min each time
o
Set up personal instructor to guide
Medications: locally to absorb fats or centrally working on the satiety centre; do not like
to start with
Surgical procedures, in very advanced cases and there is medical impairment, we can
discuss it later.
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Epilepsy Counselling
Introduction
Analyze
epilepsy history
Triggers
MOAPS
HEAD SSS
Why does the patient want a note from doctor for a drivers license?
Usually Dr does not give such note unless there is underlying condition!
Age of onset? / When was the diagnosis? / What was the diagnosis?
How frequently do the attacks occur?
How long does each attack last? LOC
Aura prior to attack?
When was last attack? Similar to previous ones?
What happens during an attack? Does the patient shake / all over / partly /
roll up eyes/ bite tongue?
How do you regain consciousness / how do you feel after the attack
Which medication does the patient take? Compliance? When was the drug
level checked?
Any other medications that might interact with epileptic drugs?
Sleep deprivation / Long screen time before sleep?
Alcohol? Stimulants?
Are you under stress
Scan the mood and anxiety
Home / Education / SAD (do you take stimulants)
The diagnosis of epilepsy requires the occurrence of at least 2 unprovoked seizures 24 hours apart
Most of patients have no clear reason to explain why they are having this, but it tends to run in the
family (idiopathic) or structural brain damage (post-meningitis)
Other conditions that should be considered include: Syncope (arrhythmias), Vascular (TIAs),
Metabolic (hypoglycemia), Psychiatric (conversion, panic attacks, malingering)
Prognosis: The patient's prognosis for disability and for a recurrence of epileptic seizures depends
on the type of epileptic seizure and the epileptic syndrome in question. Regarding morbidity,
trauma is not uncommon. Regarding mortality, seizures cause death in a small proportion of
individuals. Most deaths are accidental due to impaired consciousness
Plan:
Diagnostic workup
Patient education
Treatment
Pregnancy
Diagnostic workup:
o
Two imaging studies must be performed after a seizure. They are neuro-imaging
evaluation (MRI or CT) and electroencephalography (EEG).
o
Lumbar puncture for CSF examination has a role in the patient with obtundation or in
patients in whom meningitis or encephalitis is suspected.
o
Metabolic screen
o
Serum studies of anticonvulsant agents (e.g. phenytoin); if therapeutic level but side
effects or poor seizure control add another drug (carbamazepine / valproic acid)
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Patient education:
o
Dangerous activities: to prevent injury, educate patients about seizure precautions. Most
accidents occur when patients have impaired consciousness. Restrictions apply on:
Driving (report to ministry of transportation), must be seizures-free for more than 1
year
Diving, swimming, hiking, mountain climbing
Taking unsupervised baths, better take shower not bath, with open door
Working at significant heights, operating machines and the use of fire and power
tools.
o
Avoid the triggers for seizure attack:
Alcohol will exacerbate (chronic alcohol: blood level of anti-epileptics due to
metabolism / excess alcohol: seizure threshold)
Stress; if the patient is having stress / anxiety / alcohol issues: counsel and offer
social support
Sleep deprivation / long screen time before sleep
Head trauma,
Forgetting to take medication on time
Taking other medications that interact with the treatment
o
Life style:
You have to take the treatment almost for your whole life
Talk with your physician about any new medication you want to take
Medications are teratogenic, females to take proper contraceptive measures
Patient might choose to wear a bracelet indicating he has epilepsy
If a seizure will happen: go to the ER
Regular follow-up visits and monitoring of anti-convulsion level in blood
Treatment:
o
The mainstay of therapy for people with recurrent unprovoked seizures is an
anticonvulsant. If a patient has had more than 1 seizure, administration of an
anticonvulsant is recommended. However, standard of care for a single, unprovoked
seizure is avoidance of typical precipitants (e.g. alcohol, sleep deprivation); no
anticonvulsants are recommended unless the patient has risk factors for recurrence
o
Medications will be taken for long term, there are many options, will start with one
medication, if no full control, we may increase the dose and/or add another drug
o
Side effects of medications: movement disorders (ataxia, dysarthria), teratogenic, liver,
kidney, drowsiness, poor concentration
o
Discontinuation: After a person has been seizure free for typically 2-5 years, physicians
consider discontinuing the medication. About 75% of relapses after discontinuation occur
in the first year, and at least 50% of patients who have another seizure do so in the first 3
months. Therefore, patients to observe strict seizure precautions (including not driving)
during tapering and for at least 3 months after discontinuation. Authors recommend that
anticonvulsants be gradually discontinued over 10 weeks
Pregnancy:
Are you sexually active?
Do you take use contraception?
o
No Are you planning to get pregnant? Yes! Let us talk about pregnancy and the meds
you will start. Can you postpone the pregnancy for a while? It is better to have good
control of seizures for a while; to get any seizure during pregnancy will pose great risk
for both of you and baby. And the medications can cause serious malformation to the
baby
o
Yes is it OCPs? Yes! There might be drug interaction, so for the time being you need
to continue to use your pills and add another method (mechanical) till you contact your
gynecologist
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Medical note
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Pre-diabetes Counselling
What is DM?
Introduction
Impact
Red flags
Pre-diabetes: does not mean that you have diabetes, but it shows that you have an
increased chance of having it, about 15% per year. It also shows increased risk of
you having complications in the large blood vessels causing heart diseases, strokes
and peripheral vessel diseases
Diabetes:
Explain the role of insulin in helping cells to utilize glucose, two types of DM,
type I and type II.
With one reading we can not say that you are prone or have DM, so let me ask
few questions, to see if you have the symptoms of DM!
Symptoms of
hyperglycemia
Symptoms of
Ketoacidosis
Symptoms of
If patient is on insulin: sweating, shaking, palpitation, fatigue,
hypoglycaemia
headache, confusion, seizures
Complications of
Micro-vascular: nephropathy / neuropathy / retinopathy
high blood sugar
Macro-vascular: CAD / peripheral arterial dis / impotence
Lifestyle: too much simple sugars, lack of exercises, overweight, family history
Medications: steroids / beta blockers (-blockers are contraindicated in DM: it causes
hyperglycemia / and it masks hypoglycemia)
PMH
Medications: used long term steroids, thiazides, phenytoin, clozapine or other antipsychotics, HTN, Cholesterol, CAD, CVD, kidney, hospitalization
FH
DM in first degree relatives
SH
Sexual function: any concerns
Smoking
From the conversation we had, it looks like you are likely to get DM. However I am going to examine
you and do blood tests (FBS, Hb A1C which shows your blood sugar level over the past 3 months,
lipid profile, micro albumin / Cr ratio, ECG).
I strongly recommend you to work on lowering your chance of having diabetes by half by: watching
your diet (healthy balanced diet, avoid saturated fats and simple sugars, choose low glycemic content
foods), exercising (30 -45 min of moderate exercise for 4-5 days/wk) and life style changes (limit Na,
alcohol, caffeine, stop smoking).
I can refer you to diabetes educational program if you wish.
Treatment targets:
Hb A1C < 7
FBS 4 6
Lipids: LDL < 2, Triglycerides < 1.5 or TC/HDL < 4
BP < 130/80
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Emergency Medicine
Emergency Medicine
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Emergency Medicine
Emergency Room
Trauma
ATLS: Advanced Trauma
Life Support protocol
Primary survey:
- Any trauma (kicked, car
accident, thrown from
height, )
- Manage over the phone:
trauma or meningitis
- Secondary survey: patient
in the ER after car
accident, primary survey
was done, do the
secondary survey
N.B. if knife: leave it in place,
fix with gauze
Non-trauma
Cardiac
Chest pain:
- MONA -blockers
- STEMI: catheterization,
thrombolytics
- No ST elevation: heparin,
angiography
Arrhythmias:
- V Fib
- V Tachy
ACLS: Advanced Cardiac
Life Support code
Heart block: old patient
- DNR
- Advanced directive
Non cardiac
-
Management:
Trauma
I
A
B
C
D
AMPLE
Head to toe
Management
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Medical
I
A
B
C
D
OCD
PQRST
Associated symptoms
Risk factors
PMH
Focused physical exam
Management
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Emergency Medicine
Trauma
I: introduction:
- Because it is a trauma case, I would like to activate the ATLS protocol
- I would like also to get protection for me and my team; gloves, gowns, goggles and
masks
-
I understand that you are here because you had a car accident
How are you feeling / doing right now?
o
I would like to make sure that you are stable, I will check with the nurse and we
will start the management then I will be asking you more questions.
o
I can see that you are in a lot of pain, please bear with me for few minutes, and I
will give pain killer as soon as I can.
o
Doctor, where is my wife? How is she doing? Was she with you? I can see that
you are concerned about your wife, I will look for her and I will get back to you
as soon as I can, meanwhile my first concern is to make sure you are stable
Trachea
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Emergency Medicine
+ If BP and HR / other signs of tension pneumothorax nurse, I need to put a large needle
(16 / 14 G) in the 2nd intercostal space at MCL (upper border of the 3rd rib);
The other line is to withdraw samples for: CBC/differential/lytes /+/ blood grouping and
cross matching / and prepare 6 units of blood (4 matched and 2 O) /+/ stat glucose /+/
INR/PTT/LFT /+/ Bun/creatinine /+/ toxic screen/alcohol level /+/ continuous cardiac
monitoring/cardiac enzymes and ECG
Can you please inform me with the vitals; after the bolus fluid is
done and every 5-10 minutes or if there is a change in the vitals
Look for the source of bleeding
Abdomen:
Inspect the abdomen bruises
I am going to look at and feel your
Palpate the abdomen rigidity and guarding
abdomen
If positive; I am suspecting intra-abdominal
bleeding, I would like:
Thomas splint
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Emergency Medicine
I would like to get trauma X-ray series: for neck, chest, LSS and pelvis
D:
D1: Deficits / Disability D2: Detoxification
Neuro screen /
I am going to shine light in your eyes?
Can you please squeeze my fingers, do
not let them go
Can you wiggle your toes?
Do you feel me touching you here,
here, and here
Glasgow coma scale eyes
AVPU
D3: Drugs
Alert
Verbal
4
3
Pain
2
Unresponsiveness
AMPLE
A Do you have any allergies?
M Do you take any medications on regular basis?
PMH, any history of HTN, heart attack, stroke, DM, any long term disease
P
L Last meal
Last tetanus shot
LMP
E Event:
Can you describe to me want happened?
Car accident! Were you the driver or passenger / front passenger?
Were you wearing your seat belt?
Did you hit your head? Did you lose your conscious?
Do you remember what happened, before and after the accident?
Conclusion:
I am suspecting an intra-abdominal bleeding; we are waiting for (surgeon, orthopedics surgeon)
to intervene
Summary:
If you are done go for secondary survey:
Introduction to examiner
Expose the patient
Hello
Examine him head to toe, looking for fractures,
Neck collar
more detailed neurological examination
Introduction to patient
A/B / C / order x-rays / D / AMPLE
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Emergency Medicine
NOTES:
FLUIDS:
- Trauma / GIT bleeding: we always start with 2 L bolus
o
If the patient is stable for the beginning do not give anything more
o
It the patient was not stable, but becomes stable after the first 2L bolus give
maintenance fluids
o
If patient was not stable, and remains unstable start bld transfusion: 1 unit of
packed RBCs for every 3 units of fluids, and continue till you find source of
bleeding
Stable
2 L bolus
Stable
Give nothing
Unstable
2 L bolus
Stable
Give fluids for maintenance
Unstable
2 L bolus
Unstable Start blood transfusion 2 RBCs
Then continue 1 (RBCs) : 3 (NS)
-
Anaphylactic shock:
o
0.5 L bolus
o
Give epinephrine / steroids / anti-histaminics (Benadryl)
Acute abdomen (pancreatitis / DKA):
o
1-2 L bolus
o
Followed by 1 L / hour till the urine output improves
Heart attack:
o
KVO (keep vein open) 100 cc / hour
If trauma, BP, HR with warm extremities neurogenic shock (spinal cord injury)
give only 2 L of fluids then give vasopressors
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Emergency Medicine
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Emergency Medicine
Hypoglycemia
Hyperglycemia
Stat 100 mg thiamine IV
Stat insulin 10 units IV
Stat 50 ml D50 (Dextrose 50%) IV
Stat 100 mg thiamine IV
If no IV line glucagon IM
2 L fluids
At that time, the patient will Orient her; your blood sugar was low, your class-mates
start to regain her conscious brought you here, you are in the ER in hospital, you are
doing well now, how do you feel right now?
Patient states that she is
Reassure her
worried she will lose her
I can help by giving you a doctors note
exam / or other important
This is a very serious condition, you need medical
appointment!
attention for some time it is not safe to leave
D1: Brief neurology
Start D5 (Dextrose 5%): 250 ml / hr
D3: Dextrose
Nurse, I would like to monitor her blood glucose
every 5-10 minutes
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Emergency Medicine
Impact
Red flags
DD
PMH
Counselling:
- What is your understanding about diabetes mellitus?
Pathophysiology:
- It is a condition related to our blood sugar. Whatever we eat, the food contains different
components, including sugar. The food travels through the food pipe to our stomach, to our
bowels where it is absorbed and goes to all our body. Our organs (brain / muscle) use this sugar as
source of energy. In order for muscles to use this sugar, it needs a key to enter into cells, this key
is the insulin.
- We have two types of DM, type I and type II.
- Patients with DM type I, their body does not produce insulin, so we need to compensate for that
by giving it from external source.
Complications:
- High blood sugar is harmful for our bodies, because it affects all our blood vessels, the small and
big ones, and may give a lot of complications! It might cause kidney, eye, or nerves injury and
harm on the longer term.
- On the other hand, low blood sugar is even more dangerous; do you know why? Because our brain
can not survive without blood sugar for more than 5-7 minutes, it is the only source of energy to
our brains.
Prevention:
- What happened to you is a very serious condition, and it might happen again. The best way to treat
is to prevent this from happening; by:
o
Make sure that you always eat after your insulin dose
o
Monitor your blood sugar frequently
o
If you exercise, adjust your insulin dose based on your blood sugar level
- Now, if this happens again, do you know how to identify it before you totally lose your conscious?
o
Whenever you feel hungry / sweating / shaky / dizzy / heart racing
o
You need to stop, and immediately eat a candy / chocolate / juice
o
So, you need to keep glucose tablets in your bag, to take it in case of emergency
If you are at home; keep monitoring your blood sugar,
If you are out; reach to the nearest ER
Emergency measures:
- If you exercise, there is a special type of injections (glucagon emergency kit); if your blood sugar
drops suddenly, use it, or other people can use it to inject you.
- That is why it is important that you have a bracelet that mentions you are diabetic, so if you lose
conscious and some one finds you, they can identify the situation and provide help.
Follow-up:
- You should see your family physician within few days, and he can refer you to diabetes clinic,
for more education and assessment.
- I will still give you some brochures and web sites in case you would like to know more.
Notes: If you are the family physician, what referral will you do for a diabetic patient?
- Diabetes clinic / Foot specialist / Dietician
- If DM type I > 5 years, OR type II at any time: Ophthalmologist / Nephrologist / Neurologist
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Emergency Medicine
Very brief introduction to wife, I will make sure he is stable then I will ask
you more questions
Mr ;
Patient is unresponsive, I will start my primary survey:
can you hear me
A: can you open your mouth (open and comment) / trachea central / JV
not engorged
STABILIZE
B: listen to lungs and apex / normal air entry on both sides / normal
heart sounds
C: can I get the vitals please! Normal! 2 large IV lines please
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Emergency Medicine
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Emergency Medicine
ABCD
MONA
Oxygen
Aspirin
Nitrates
Morphine
-blockers
No ST elevation
ST elevation
Chest pain presents with heart racing / SOB / nausea / vomiting / sweating
History will be: chest pain analysis / cardiac symptoms / risk factors
If blood pressure is low: we only give oxygen / aspirin / and plavix
If inferior MI (II, III, aVF) I need 15 lead ECG / do not give -blockers
Risk of bleeding with thrombolytics is 1%, but being serious, this needs consent
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Emergency Medicine
ABCD
Brief history
Another ECG
Normal ECG
Do physical exam:
Vitals / compare BP in both arms ? aortic dissection
General status of the patient
Eyes / mouth
Heart and chest examination
LL edema
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Emergency Medicine
ST elevation
ST elevation:
Lateral MI
Inferior MI
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Emergency Medicine
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Emergency Medicine
Manage as the first case the chest pain with normal ECG
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Emergency Medicine
Heart Block
2 cases:
- One of them is DNR (must be dated, valid, and signed)
- The other case is: do not intubate / do not defibrillate. You can still pace maker
1- Introduction:
- Is this is the last ECG for this patient? I do not see any signs of V. fib or V. tachy. I
would like to see the patient first to make sure he is stable, and then I will look at the
ECG.
- Mr I am Dr working in the ER, do you hear me?
- I would like to activate the ACLS code please / start primary survey
Check the mouth, listen for patent air way
Give 4L O2 via
A
What is the O2 please
nasal canula
B
Trachea central, chest is moving
Monitor O2 for
Listen to lungs, heart
need to intubation
I would like to get the vital signs please;
C
2 large IV lines; for IV fluids and to withdraw samples
2- Glasgow Coma Scale [if < 8 intubate (ask about DNR)]
- This patient Glasgow coma scale is
- What is this patient code status? Any advanced directives?
o Is it signed, dated and valid?
o What does he have?
- We will respect his wishes, we will not (if DNR do nothing)
- If no DNR:
D2 Third degree heart block:
1 mg atropine any changes?
Pace maker:
- Rate: 20 more than his base heart rate
- Leads on sternum and apex
D1 Brief neurological scan, pupils,
Collateral
Do we have his file?
history
Can we contact his family physician? Or family member?
Does he have a med alert?
Do we have paramedics report?
Can we check his belongings? He is taking , thiazides and digoxin
+
I need to get his K level / digoxin level and I would like to check the dose for
digi-bind and digi-fib
Physical
Neuro exam
exam
Cardiac exam
Notes:
- For any unconscious patient: ask about advanced directives or DNR! What is this patient
code status?
- Whenever the examiner or the nurse tries to give you an ECG at the room entrance,
assess for V. fib or V. tachy and report: there are no signs of V. fib or V. tachy. I would
like to see the patient first to make sure he is stable.
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Emergency Medicine
Headache
Introduction
CC
Analysis of CC
Associated
symptoms
PMH
FH
SH
Management
CT scan stat LP
Others: Chest x-ray / Urinalysis
Blood works (CBC / differential / lytes)
Septic workup (samples / C&S)
OSCE-guide-III.doc
? subarachnoid
hemorrhage
? meningitis
(FEVER)
Treatment of
meningitis:
vancomycin 1 g IV
q12h + ceftriaxone
2 g IV q12h
ampicillin 2 g IV
q4h (if >50 years or
hx of alcohol use or
immunocompromise
)
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Emergency Medicine
But first I would like to ask you, how do you feel now?
Analysis: OsCfD: gradual, started colicky, and now continuous dull pain /
PQRST / What or (position / eating / bowel movements / vomiting)
Screen for obstruction:
Nausea/ vomiting
o
Relation to pain, which started first, does it relief pain
o
COCA + Blood (coffee ground material)
Impact
Screen dehydration (dizziness / light headedness / thirsty / LOC)
Bowel movements
What did you eat yesterday? Place that you are not used to?
Anybody else ate with you and suffered from the same problem
Renal: flank pain / burning sensation / going more to washroom / stone
Liver: yellowish discoloration / itching / dark urine/ pale stools
Hx of HTN / SOB / cough / phlegm (aortic dissection)
PMH / FH / SH
X-ray findings of small intestinal obstruction: (1) Multiple air/fluid levels, (2) Dilated loops
of small intestine, (3) No air under the diaphragm.
Management: (1) NPO / NG tube, (2) Oxygen mask, (3) IV fluids, (4) Stat surgical consult,
(5) Foleys catheter, (6) Correct electrolytes.
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Emergency Medicine
CBC / ESR
Syphilis serology
What is the treatment of pelvic inflammatory disease?
Fever
CT scan (optimal method of investigation). 97% sensitive, very useful for assessment of
severity and prognosis. Very helpful in localizing an abscess
Sigmoidoscopy/colonoscopy:
o
Not during an acute attack, only done on an elective basis
o
Take biopsies to rule out other diagnoses (polyps, malignancy)
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Emergency Medicine
Management: (1) NPO / NG tube, (2) Oxygen mask, (3) IV fluids, (4) Stat surgical consult
(5) IV antibiotics (IV ciprofloxacin 500 mg BID / IV Metronidazole 500 mg TID)
Indications for surgery for diverticulitis:
After 1 attack if: (a) immuno-suppressed, (b) abscess needing percutaneous drainage
Impact
Red flags
DKA
DD causes of
DKA
Management of
DKA
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Emergency Medicine
Acute Abdomen
Patient came to ER with abdominal pain / vomiting / diarrhea / BP 90/60 / HR 120
Acute pancreatitis / dissecting aortic aneurysm (no vomiting) / perforated peptic ulcer
Introduction
Analysis
Impact
Red flags
DD
PMH
I can see that you have a lot of pain, bear with me for few minutes and I will
give you a pain killer as soon as I can.
In the moment, I would like to make sure you are stable
What are the vitals pleas?
Stable
Unstable
Proceed to
I am going to start my primary survey ABCD
When you send blood works: add lipase / amylase
history
Did you vomit blood? How about coffee ground? (if yes: order
blood)
Os Cf D / PQRST / / relation to position / breathing / eating
Vomiting COCA + Blood
Change in the bowel movements
Dehydration
How do you feel right now? What are the vitals please?
Constitutional symptoms
Liver / GB
Yellowish discoloration / itching / dark urine / pale stools?
Recent flu-like illness?
Do you have hx of gall bladder stones? Repeated attacks abd
pain?
Stomach
Hx of PUD? GERD? Acidic taste / heart burn?
Alcohol? How much? When was the last time? Did u drink >
usual?
Gastroenteritis (What did you eat yesterday? Place that you
are not used to? Diarrhea / blood in stools? Anybody else ate
with you and suffered from the same problem?)
Medications If vomited blood: Do you take steroids / NSAIDs / blood
thinners?
Kidney
Flank pain? Burning sensation? Dark urine? Frequency?
Aorta
Hx of HTN / atherosclerosis / DM / cholesterol / smoking /
SOB
Trauma
Did you have trauma?
Medications / allergies / long term disease?
Cullens sign: peri-umbilical ecchymosis. It arises from spread of retroperitoneal blood associated with: pancreatitis / ruptured
ectopic preg / ruptured aortic aneurysm / ruptured spleen / perforated duodenal ulcer
8
Grey-Turner sign: ecchymoses of the skin of the flanks, also with retroperitoneal bleeding
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Emergency Medicine
Auscultation
Percussion
Palpation
In order for me to examine you properly, I need to get good look at your
abdomen, for that reason, can you please lie on your back!
Do you feel relieved like that, I understand. It will be only few minutes,
do you want to give it a try? Slowly! Do you want me to help you! It is
crucial to reach a proper diagnosis!
If still refusing offer 2 mg morphine S.C. Finally she will lie down.
ASK FOR X-RAY (3 view x-ray abdomen) ? perforation
Obstruction
Patient is obviously in severe pain, I will not be able proceed with examination
Management
I am suspecting pancreatitis
DD:
Perforated PUD:
vomiting coffee ground material
Aortic dissection: NO vomiting / severe pain shooting to the back
Acute pancreatitis:
Paralytic ileus
Tetany
Ethical question:
The patient girl friend is on the phone, she is asking about his condition?!
I can assure you that he is well taken care of, and we will do our best to help him,
All the details of his medical information is absolutely confidential, and I can not release
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Emergency Medicine
Impact
Red flags
DD
PMH
FH
SH
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Emergency Medicine
With pain
Painless
Diverticulosis
Angiodysplasia
Aspirin
Hemorrhoids
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Emergency Medicine
ECG
Normal
V fib /+/ V tachy /+/ Torsades du pointes
A fib /+/ Atrial flutter
ST elevation:
o Pericarditis: all leads
o MI:
V 2/3/4 V5/6, aVL: antero-lateral MI (left coronary)
II, III, aVF: inferior MI (right coronary, posterior and inferior surfaces)
Hear block third degree /+/ Bundle branch block
Hyperkalemia /+/ Hypokalemia /+/ Hypercalcemia
Digitalis toxicity
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Emergency Medicine
1. Rate:
Regular: 300/number of big squares (R-R)
Irregular: Number of Rs x 6
2. Rhythm check for P wave in lead II
Tachyarrhythmias:
Sinus tachycardia
Irregular irregularities: A. Fibrillation
Saw teeth (regular irregularities): A. Flutter
Rapid SVT
Ventricular arrhythmias: Premature ventricular beats / V. Tachy / V. Fib / Torsades de
pointes
Bradyarrhythmias: (< 60/min)
Sinus bradycardia
Heart block:
- 1st degree: P-R intervals increasing, but every P QRS.
- 2nd degree:
Mobitz type I: P-R intervals increasing, with missing QRS
Mobitz type II: P-R intervals constant, with missing QRS
- 3rd degree: P-P has a rate, and the R-R has another rate
3. Axis
Normally, QRS in leads I, II, III are positive (upwards ).
Right axis deviation: QRS in I is negative (downwards ); I and III facing.
Left axis deviation: QRS in II, III is negative (downwards ); I and III opponents.
Diagram showing how the polarity of the QRS complex in leads I, II, and III can be used to
estimate the heart's electrical axis in the frontal plane:
Lead I negative and aVF positive: Rt axis deviation / Lead I positive and aVF negative: Lt axis
deviation.
4. Bundle Branch Block:
Normally QRS in V1 is downwards , if in V1: QRS is upwards & wide: RBBB.
Wide QRS in V6 (M mountain): LBBB.
A mnemonic to remember ECG changes is WiLLiaM MaRRoW, i.e. with LBBB there is W in
V1 and M in V6 and with a RBBB there is M in V1 and W in V6
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Emergency Medicine
5. ST segment:
Angina
6. Others:
Hypokalemia
ST segment depression, inverted T waves,
large U waves, and a slightly prolonged PR
interval.
OSCE-guide-III.doc
Hyperkalemia
1- Flat P wave
2- Wide QRS
3- Spiked T wave
Emergency Medicine
Phone calls
THE SEIZING CHILD PHONE CALL
The mother is on the phone, panicked as her child is seizing for 3 minutes
Introduction
+ Reassurance
Stabilize
After
Fever
Rule out
BINDE
PMH
FH
Counselling
Notes:
Febrile seizure vs. meningitis: 1st time send the ambulance, 2nd time: send the ambulance if:
the seizure is > 15 minutes or > 2 attacks in 24 hours
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Emergency Medicine
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Emergency Medicine
OSCE-guide-III.doc
Physical Examination
Physical Examination
OSCE-guide-III.doc
Physical Examination
Introduction:
- Good evening Mr , I am Dr I am the physician working in the clinic today / I am the
physician in charge in the ER now. I understand that you are here because you have been
having For the next few minutes I am going to do physical exam for your and I will
need to ask you questions during my exam. Also, I will be asking you to do some
movements and manoeuvres, if you feel any discomfort or pain, please do not hesitate to
let me know and stop me
- If you have any questions or concerns please feel free to ask me / to bring it up
- If SOB: during my exam, if you feel that you can not continue, please stop me
If there is history taking and then physical exam:
- I will be asking you some questions, then I will do physical exam. Hopefully towards the
end, we reach a working plan
Vital signs:
- If vitals are given: based on the vitals, the patient is stable, I would like to proceed. Or
the patient is unstable! Or comment: with mil fever
- If the vitals are missing one; e.g. the temperature: ask about it specifically
- Vitals are not gives:
o I would like to get the vitals before I start!
o I am going to start my exam by measuring your vital signs that is your blood
pressure, heart rate. And I will start by measuring your heart rate
OSCE-guide-III.doc
Physical Examination
Abdominal examination:
Introduction / Vital signs / General inspection of the patient: pt is sitting comfortably
- Inspection
- Auscultation: bowel sounds / bruits (aortic / renal / iliac)
- Percussion
- Palpation: superficial / deep / special tests
Respiratory examination:
Introduction / Vital signs / General inspection of the patient: pt is sitting comfortably
- Inspection: face / hand / neck / chest / back
- Palpation: tenderness / tactile fremitus / chest expansion
- Percussion: dullness / percussion note / diaphragmatic excursion
- Auscultation: regular / special tests
o Then end with cardiology exam
Cardiac examination:
Introduction / Vital signs / General inspection of the patient: pt is sitting comfortably
- Inspection: face / hand / neck / chest / heart (PMI)
- Palpation: apex / left para-sternal areas for heaves / valvular areas for thrills
- Auscultation: in Z format A-P-T-M
o Leg exam for edema
o Lung bases
- If full CVS exam peripheral vascular assessment: abdominal bruits / legs pulses
palpation / chest exam
Musculoskeletal examination:
Introduction / Vital signs / General inspection of the patient: pt is sitting comfortably
- Inspection: SEADS (scars / erythema / atrophy / deformity / swelling) / specific findings
(bulk of muscles / bony symmetry)
- Palpation: (TTC) tenderness / temperature / crepitus / effusion
- ROM: active (if normal, NO need to do the passive) / passive / against resistance
- Special test: mechanical (shoulder / elbow / hip / knee / ankle)
o To complete my exam, I would like to do:
Neurological exams:
Introduction / Vital signs / General inspection of the patient: pt is sitting comfortably
- Orientation: what is your name sir? Where are you? Time? Place?
- Cranial nerves
- Upper and lower extremities:
o Inspection
o Palpation / bulk
o Tone
o Motor power
o Sensory
o Reflexes
- Gait / Romberg test
- Cerebellar signs / Coordination
- Cortical sensations: two points discrimination
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Physical Examination
Abdominal examination:
- Introduction
- Vital signs
- General inspection of the patient:
o By general inspection, pt is lying down comfortably, no obvious distress
o Can I take a look at your eyes, would you please look downwards? No jaundice.
Upwards please? No pallor
o Would you please open your mouth: no signs of dehydration or vomiting
o Can I take a look at your hand?
Temperature is fine / and skin is moist
Normal capillary refill (< 3 seconds)
No obvious clubbing
- I am going to drape you now!
o Bed flat
o Can you please put you hands to your sides
o Allowing the patient to bend his/her knees so that the soles of their feet rest on
the table will also relax the abdomen!
-
Percussion: now, I am going to tap on your abdomen, can you point to your painful are.
I am going to start away from there:
o Percuss in 2 X 2 lines, and percuss to side for ascites
o No percussion dullness / normal tympanic percussion note / no percussion
tenderness / no ascites
Palpation:
o I am going to feel your abdomen. Start away from the painful area:
I am checking (name the 4 quadrants or the 9 areas of the abdomen);
(NO) tenderness, guarding or rigidity
o I am going to apply more pressure now: no obvious masses, no organomegaly
o I am going to feel your kidneys now (bimanual) no enlargement, no
tenderness of the kidneys
o I am going to do some special tests:
Murphys sign (Rt costal margin) can you take a deep breath
Rebound tenderness: I am going to press and release my hand, can you
tell me which causes more pain! (any point except McBurneys)
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Physical Examination
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Physical Examination
Liver Examination
Patient vomited blood 20 minutes ago, perform focused examination for liver cell failure
- Because the patient is vomiting blood, I would like to ask for protection for me and my
team please (gloves / gowns / masks / goggles)
- Introduction / Vital signs
- Orientation: I am going to ask you some questions which are part of my physical exam.
Do you know where you are now? What is the time? Do you know why you are here?
Patient is oriented to people, time and place
- General:
o
o
o
o
o
o
o
Inspection:
o
2 X 2 lines tap
Liver: MCL (from above downwards and from down upwards) liver span
Spleen: ant axillary line last intercostal space / ask pt to take deep breathe in / then repercuss for the spleen
Ascites: from midline to the side, no dullness so there is no need to perform the
shifting dullness (to be clinically palpable: ascites > 500 ml)
Palpation:
o
Percussion:
o
o
o
Auscultation
o
o
Liver: start from the right iliac fossa and go upwards, while the patient is breathing in and
out (push during inspiration, do not move your hand from the patient) margin of liver
is not palpable, not tender, and not nodular.
Spleen: patient elevates his LEFT side 45, support from left back. Start from above the
umbilicus towards the spleen spleen is not palpable
OSCE-guide-III.doc
Physical Examination
Because the patient is bleeding, I would like to ask for protection for me and my team
please (gloves / gowns / masks / goggles)
Introduction
Vital signs
General:
o Patient is lying comfortably no signs of obvious distress
Nose: open the speculum antero-posteriorly
Use the otoscope for ENT (nose / ear / mouth)
o Look for bruises / petichae if you find them continue hematological exam
OSCE-guide-III.doc
Physical Examination
Questions:
- Diagnosis:
o ITP (Immune Thrombocytopenic Purpura)
Most common cause of isolated thrombocytopenia
Diagnosis of exclusion (i.e. isolated thrombocytopenia with no clinically
apparent cause)
- Investigations:
o CBC: thrombocytopenia
o Peripheral blood film: decreased platelets, giant platelets
Bleeding time: increased / PT and aPTT: normal
Anti-platelets antibodies
o Bone marrow: increased number of megakaryocytes (critical test to rule out other
causes of thrombocytopenia for age > 60 years; e.g. myelodysplasia)
o Markers of hemolysis: increased unconjugated bilirubin, increased LDH,
decreased haptoglobin
o Kidney function tests (urea / creatinine for HUS)
- Treatment:
o Steroids (methylprednisolone 1 g/d for 3 days, then prednisone 1.5 mg/kg/day)
o Immunoglobulins (if low platelet count): IVIG 1 g/kg/d X 2 days
o Splenectomy
o Vaccination (pneumococcus, meningococcus, HIB)
- DD:
o ITP (Immune Thrombocytopenic Purpura)
o TTP (Thrombotic Thrombocytopenic Purpura)
o HUS (Hemolytic Uremic Syndrome):
ITP
TTP
HUS
Remitting / relapsing
Predominantly adults
Predominantly children
course
Thrombocytopenia
Severe thrombocytopenia
Mild fever
Micro-angiopathic
Micro-angiopathic
hemolytic anemia
hemolytic anemia
Splenic discomfort
(MAHA)
(MAHA)
(mild engorgement)
Renal failure
Renal failure
Neurological symptoms
(headache, confusion,
focal deficits, seizures)
Fever
CBC and blood film: decreased platelets and schistocytes
Investigations
(both TIP, HUS) PT, aPTT, fibrinogen: normal
Markers of hemolysis: increased unconjugated bilirubin.
increased LDH, decreased haptoglobin
Negative Coombs' test
Creatinine, urea, to follow renal function
Stool C+S (HUS)
Plasmapheresis steroids
Management
(both TIP, HUS) Platelet transfusion is contraindicated (increased microvascular thrombosis)
Plasma infusion: if plasmapheresis is not immediately
available
TTP mortality 90% if untreated
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Physical Examination
Chest Examination
- Introduction
- Vital signs; especially: tachypnea / temperature
- General inspection of the patient; comment on respiratory distress
- Inspection:
o General:
Chest:
Tactile fremitus: can you say 99 for 4-5 times, whenever you feel my hands on
your chest normal tactile fremitus
OSCE-guide-III.doc
Physical Examination
Pneumonia
Mortality
<5%
<10%
<30%
Pneumonia severity index: another clinical index (scored on age, resp rate, co-morbidities ),
used to determine whether to admit the patient to the hospital or not.
COPD
CHF
Cirrhotic
Cancer
Leukemia / lymphoma
9
Especially in the presence of risk factors: group home / hospital infection / immunocompromised
OSCE-guide-III.doc
Physical Examination
Case: HIV positive man C/O: SOB for 1 week / cough / fatigue
? Pneumonia (? PCP)
OSCE-guide-III.doc
Physical Examination
Impact
Red flags
Introduction
HR and BP (lying down)
Sit up, relax for 2 minutes
Neck
Heart
Carotid
JVP
Inspection
Palpation
Auscultation
Abdominal exam
Lower limbs exam
- Introduction
- Vital signs; especially: BP / HR
o Ask the patient to lie down, I am going to assess your blood pressure twice, one
while lying down, the other after you sit up
I will start by measuring HR for 10 seconds; your HR today is which is
normal
Do the BP: get the systolic by pulse palpation, then increase 30 mmHg, then
auscultate your BP today is
o Can you please sit up on the edge of the bed, (feet dangled)? I need you to relax
for 2 minutes, before I proceed to other measurements, during which I am going
to ask you some questions:
OSCE-guide-III.doc
Physical Examination
General exam:
o Comment on the general status / respiratory distress of the patient
o Assess the radial pulse bilaterally: pulse is normal, regular, equal on both sides,
with no delay
o Hands: normal capillary refill / no clubbing / warm moist skin
o I would like to do fundoscopic examination (I am going to shine a light in your
eyes to examine the back of your eyes): looking for disc edema / cotton wool
exudates / retinal hemorrhage / nipping of the veins
I am going to put the bed in 45 position; examine your neck:
o Carotids:
JVP:
Chest inspection:
o Chest is symmetrical, no obvious pulsations
o PMI (point of maximum intensity) is not obvious / or is obvious
Palpation:
o Palpate the apex and locate it apex is palpable at in the MCL, not
hyperdynamic (vol ovrld), not sustained (pres ovrld), not displaced
o Palpate the left para-sternal area by knuckles: no Rt ventricle heave
o Palpate the Aortic / Pulmonary areas by finger tips no thrills
Auscultation:
o In Z format A-P-T-M: normal S1, S2, no murmurs
o Flip the bell; check the apex for S3, S4
o While listening to the left para sternal area: can you please take a deep breathe in,
exhale it out and hold, and lean forward no enhancement of aortic
insufficiency murmurs
o Listen to the lung bases no basal lung crackles
I am going to put the bed flat now:
o Abdominal exam: inspect for pulsations / auscultate for bruits
o Lower limb exam:
OSCE-guide-III.doc
Physical Examination
Secondary Hypertension
A 25 years old young man with HTN;
Cardiac
Coarctation of the aorta
Cocaine (nasal septum)
Renal
Poly-cystic kidney
Renal artery stenosis
Endocrine
OCPs
Cushing disease / syndrome
Pheochromocytoma
Primary hyperaldosteronism
Hyper / hypo thyroidism
Notes:
OSCE-guide-III.doc
Physical Examination
Hypertension
Predisposing Factors
Family history
Sedentary lifestyle
Smoking
fatty diet
Alcohol consumption
Male gender
African American
Stress
Age >30
Dyslipidemia
Diagnosis:
Visit ONE:
o
If hypertension urgency or emergency (sBP > 210 or dBP > 120) or end organ damage
(e.g. confusion) diagnose HTN
o
Else (provided 2 more readings during same visit)
Search for target organ damage: history (cardio-vascular risk factors) / examination
Investigations:
CBC / Na+, K+ / fasting blood sugar / lipids (total cholesterol, HDL, LDL, TG)
ECG / Echocardiogram
For secondary HTN: TSH / Plasma aldosterone / renin levels / 24 hours urine
for metanephrines / VMA
Life style modifications ( salt / alcohol / cholesterol / exercise)
Follow-up visit within 4 weeks
Pharmacological:
o
First line: Diuretics; e.g. hydrochlorothiazide 12.5 25 mg PO od Except:
DM:
ACEIs; Ramipril 2.5 5 mg PO od
Gout:
Amlodipine (5 mg PO od) OR Candesartan (4 8 mg PO od)
Elderly (especially if IHD):
ACEIs
-blockers:
metoprolol 25 mg bid
Especially if CHF / EXCEPT: asthma / bradycardia
Pregnant:
Hydralazine: 10 mg PO qid for few days then 25 mg PO qid
OR -methyl dopa: 250 mg PO bid
If > 3 cardiovascular RF: statins / ASA
o
If partial response to standard dose monotherapy, add another first-line drug
Do NOT give -blockers and Ca ch blockers may cause heart block
Do NOT give ACE and ARBs both K+,
Available combinations: Altace plus (ramipril + diuretic) / Diovan H
o
Notes on ACEIs:
Contraindications of ACEIs: Angio edema / Bilateral renal artery stenosis
ACEIs are nephroprotective except in acute renal injury nephrotoxic
If patient on ACEIs developed cough switch to ARBs
OSCE-guide-III.doc
Physical Examination
Brief cardio-pulmonary
hx
Vitals
General
Neck
Chest
Trachea
JVP
Inspection
Palpation
Percussion
Auscultation
Indications for intubation: ABG showing poor PO2 (60s) / elevated PCO2 (80s) / acidosis / GCS
score < 8
10
A positive Homans' sign does not positively diagnose DVT (poor positive predictive value), and also negative Homans' sign does
not rule out the DVT diagnosis (poor negative predictive value), and there is theoretical possibility of dislodging the DVT.
OSCE-guide-III.doc
Physical Examination
DVT
Clots clinical probabilities / risk factors (Virchow's Triad):
Vascular injury (endothelial damage); e.g. recent surgery
Venous stasis; immobilization (post-MI, CHF, stroke, post-operative, obesity, long
travel or flight, chronic venous insufficiency) inhibits clearance and dilution of
coagulation factors
Hyper-coagulability; aging, surgery, trauma, malignancy, antiphospholipid antibody
syndrome, hormone related (pregnancy, OCP, HRT, SERMs)
DD: muscle strain or tear, lymphangitis or lymph obstruction, venous valvular insufficiency,
ruptured popliteal cysts, cellulitis, and arterial occlusive disease
OSCE-guide-III.doc
Physical Examination
Clinical Probability of PE
Low
Intermediate
High
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score > 4
score 4
Simplified Wells
PE likely
PE unlikely
Physical Examination
Notes:
1. Use D-dimers only if low clinical
probability, otherwise, go straight to spiral
CT or V/Q
2. If using V/Q scan (CT contrast allergy or
renal failure):
Negative V/Q scan rules out the diagnosis
Inconclusive V/Q scan requires leg US
duplex to look for DVT (q2d)
High probability V/Q scan only rules in the
diagnosis if have high clinical suspicion
CXR of PE: may be normal / wedge-shaped infiltrate / unilateral effusion / raised hemidiaphragm
Treatment of PE:
Admit for observation (patients with DVT only are often sent home on LMWH)
Oxygen: provide supplemental O2 if hypoxemic or short of breath
Pain relief: analgesics if chest pain narcotics or NSAIDs
Acute anticoagulation: therapeutic-dose SC LMWH or IV heparin start ASAP
o Anticoagulation stops clot propagation, prevents new clots and allows
endogenous fibrinolytic system to dissolve existing thromboemboli over months
o Get baseline CBC, INR, aPTT renal function liver function
o For SC LMWH: dalteparin 200 U/kg once daily or enoxaparin 1 mg/kg bid no
lab monitoring avoid or reduce dose in renal dysfunction
o For IV heparin: bolus of 75 U/kg (usually 5,000 U) followed by infusion starting
at 20 U/kg/hr aim for aPTT 2-3 times control
Long term anticoagulation:
o Warfarin start the same day as LMWH/heparin start at 5 mg PO od overlap
warfarin with LMWH/heparin for at least 5 days and until the INR is in target
range of 2-3
o LMWH instead of warfarin for pregnancy; active cancer, high bleeding risk
o Duration of long-term anticoagulation treatment:
If reversible cause for PE (surgery, injury, pregnancy, etc.): 3-6 months
If PE unprovoked OR ongoing major risk factor (active cancer):
indefinite
IV thrombolytic therapy:
o If patient has massive PE (hypotension or clinical right heart failure)
o Hastens resolution of PE but may not improve survival or long-term outcome
Interventional thrombolytic therapy (massive PE is preferentially treated with
catheter directed thrombolysis by an interventional radiologist, works better than IV
thrombolytic therapy and fewer contraindications)
IVC filter: only if recent proximal DVT + absolute contraindication to
anticoagulation
OSCE-guide-III.doc
Physical Examination
Palpation
Abdomen
Neurology
Burger test
Special tests
Investigations:
CBC
ECG
Foot care
Graded exercise
OSCE-guide-III.doc
Physical Examination
Diabetic Foot
Diabetic patient with long hx of diabetes, has an ulcer for few days
Introduction
Vitals
General
Inspection
Palpation
Abdomen
Neurology
Burger test
Special tests
Balance (if
DM focused
exam case)
OSCE-guide-III.doc
Gait ataxia
Romberg test: positive (with open eyes: pt can balance himself by vision;
while with closed eyes: pt loses balance
Physical Examination
Neurological Examination
o
o
o
-
Introduction
Vital signs
General inspection of the patient: pt is sitting comfortably
Orientation: what is your name sir? Where are you? Time? Place?
Cranial nerves
Upper and lower extremities:
o Inspection
o Palpation / bulk
o Tone:
Just relax please, let me do everything for you. I am going to check the
tone in your Rt arm
Tone is normal, no hypo or hyper tonia
o Motor power (5 0)
5
full power
4
less than full power (like Lt hand in Rt handed person)
3
can do the movement against gravity
2
can do the movement with the gravity eliminated
1
muscle twitches, not able to initiate movements
0
no power no movements
o Sensory:
Light touch:
Pin prick or piece of cotton
First check on forearm or sternum
Can you close your eyes please
Distal to proximal
Bilateral sensation is equal bilaterally
Posterior column (B12 deficiency / alcohol / syphilis):
Vibration sense: tuning fork / test on sternum / tell me when it
stops / start distal / if intact move on / if not intact go proximal
on the next joint
Proprioception: eyes closed / start with the big toe or thumb / is
it moving or not? / is it up or down?
o Reflexes:
0
absent
1
weak (hyporeflexia)
2
normal
3
hyper reflexia
N.B. Babinski reflex: I am going to tickle the bottom of your foot:
Planter flexion: normal response
Big toe dorsiflexion and toes fanning: UMNL (e.g. stroke)
OSCE-guide-III.doc
Physical Examination
Gait ATAXIA
o Can you take few steps for me please?
o Protect the patient, surround him with your arms, and walk with him
Romberg test
o Can you put your legs together!
o Can you close your eyes please!
o Watch (protectively) for few seconds!
Ataxia due to peripheral neuropathy (B12 deficiency / DM / syphilis):
with eyes closed
Cerebellar ataxia: no with closed eyes (always on)
Cerebellar signs (stroke / alcohol / tumours / para-neoplastic / ):
o Nystagmus:
Can you follow my finger please (move it side to side)
Physiological: transiently then corrected
Central: horizontal or vertical
Peripheral: horizontal only. Conditions: benign positional vertigo
/ acute labyrinthitis / drugs
o Finger to finger:
Patient hand must be extended
Move the examiner hand
Check both upper limbs
o Finger to nose test: lesion in the cerebellum on the same side.
Intentional tremors
Loss of coordination
o Heel to shin: lesion in the cerebellum on the same side
Cortical sensations: two points discrimination
Mini-mental status exam
OSCE-guide-III.doc
Physical Examination
Vital signs
Comment on the patient general condition
CN I:
- Do you have problems with smells?
Can you please close your eyes?
- What is that? Coffee / ammonia
- What is that? Ammonia / coffee
CN II:
The optic nerve:
- Visual acuity: Do you wear glasses? reading / color (Snellen chart at 1 foot distance 35
cm)
- Visual fields: eye by eye / by confrontation (when you see my fingers wiggling)
- Pupillary reflex: I am going to shine light in your eyes, please look straight to the wall,
each eye: direct and consensual (afferent: CN II, efferent: CN III)
- I would like to do fundoscopy examinations, looking for: disc edema, retinal hemorrhage,
neovascularisation, nipping of the veins
CN III, IV, VI:
- By inspection; both eyes are symmetrical, no deviation, no nystagmus, no head tilting, no
ptosis (CN III: opens, CN VII: closes)
- I would like you to follow this pen, without moving your head please, and if you see
things double or blurred at any time, please let me know move the pen in large Hshaped manner, then conversion
- Normal extra-ocular muscles movements, no nystagmus or double vision
CN V:
- Motor:
o By inspection: no atrophy of the temporal or masseter area
o Can you please clench, feel the temporalis and masseter
o Can you open your mouth against my hand?
- Sensory:
o This is a piece of cotton, and this is how it feels, I am going to touch your face,
and whenever you feel it, please tell me. Can you close your eyes please?
o Touch the face in symmetrical areas; cover the ophthalmic, maxillary, and
mandibular areas. Does it feel the same?
o Facial sensation of the trigeminal nerve is intact and equal on both sides
- Reflexes:
o Corneal reflex (afferent: CN V, efferent: CN VII)
OSCE-guide-III.doc
Physical Examination
OSCE-guide-III.doc
Physical Examination
Tremors
? Parkinson disease
Introduction
Vital signs
General comment
Inspection
Tremors
Treatment of Parkinsonism:
Pharmacologic
OSCE-guide-III.doc
Physical Examination
Thyroid Exam
Introduction
Vital signs
General
Thyroid Exam
Inspection
Palpation
Percussion
Auscultation
11
12
BP, HR
Can you stretch your hands:
- Fine tremors
- Palms for sweating
- Nail changes
- Hair loss (hypothyroidism)
Examine the eyes:
- Exophthalmos stand by the patient (stand behind the right shoulder
and look from above)
- Lid lag (can you follow my finger without moving your head from
above downwards)
Proximal muscle weakness:
- Can you shrug your shoulders (bilaterally against my hand) please
Knee reflex: brisk11 reflex
Peritibial myxedema: indicates hyper-thyroidism
Patient is sitting on a chair
Can you swallow12 please? no apparent thyroid enlargement
Thyroid gland:
- From behind the patient, bi-manually
- Then while swallowing a sip of water thyroid movement is normal,
I do not feel any masses, nodules, and no tenderness
Lymph nodes:
- Sub-mandibular and cervical
DIRECT percussion on upper part of sternum
Checking for retro-sternal extension (no retro-sternal dullness)
BOTH lobes
For thyroid bruits
Reflexes grades:
0 absent
1 hypo
2 normal
3 hyper (brisk)
4 hyper with clonus (ankle)
Whenever you ask the patient to swallow, give a sip of water, it is difficult to swallow on an empty mouth
OSCE-guide-III.doc
Physical Examination
Dermatomes
OSCE-guide-III.doc
Physical Examination
Neck Examination
Patient complaining of pain in the neck
Vitals
General
Inspection
Palpation
ROM
Powers
Special tests
Neurological
screen
Part of my exam is to check your upper extremities, can you roll up your sleeves please!
Inspection
Upper extremities are symmetrical, normal bulk, no atrophy / SEADS
Palpation
I am going to feel your shoulder; deltoid, biceps, triceps, forearm, thenar,
hypothenar are symmetrical / no deformity / no atrophy
Motor
Power
Deltoid C5
Biceps C5/6
Triceps C7/8
Sensory
C4: deltoid
C5: biceps lateral aspect
Test light
C6: thumb
C7: middle finger
C8:
touch
little finger
T1: elbow medial aspect
Reflexes Biceps and brachio-radialis C5/6
Triceps C7/8
Radial pulse
Pulse
Post encounter: what is the level of the lesion?
C6 nerve root lesion (C5-C6): weak biceps, weak biceps reflex
C7 nerve root lesion (C6-C7): weak triceps, weak triceps reflex
Diagnosis: Osteoarthritis of the cervical spine at level
X-ray findings: osteophytes of the cervical vertebrae / narrowing of disc space / subchondral
sclerosis (increased bone formation around the joint), subchondral cyst formation
Management:
NSAIDs / acetaminophen
Physiotherapy
OSCE-guide-III.doc
Physical Examination
NSAIDs
Wrist splint
Surgical decompression
OSCE-guide-III.doc
Physical Examination
Ulnar
Radial
Ulnar aspect of little finger pad Dorsal web space of thumb
Flex DIP of little finger (FDP), Extend wrist and thumb,
extensor carpi radialis
(extensor pollicis longus)
Abduct index finger (first
dorsal interosseous)
Structures lacerated
Diminished ulnar territory sensation
Allen test shows (no) refill from the ulnar circulation
FDS weakness in little finger and ring finger
Ulnar nerve
Ulnar artery
Flexor retinaculum, ulnar two divisions of FDS
Management: clean and explore wound under local anesthesia and sterile conditions. Consult plastic
surgery for micro-vascular repair. If at night, may suture the skin and arrange for pt to be seen by plastic
surgeon next day.
OSCE-guide-III.doc
Physical Examination
Back Pain
Acute
Acute on top
of chronic
Chronic
Herniated disc
Muscle spasm
Neurological exam
Mechanical exam
P
A
I
N
OSCE-guide-III.doc
parathesia
age > 50 years old
IV drug user
neuro-motor deficits
Physical Examination
Analysis
Impact
Red flags
DD
PMH
FH
SH
OSCE-guide-III.doc
How about lying down? Stretch your back? Coughing?
Moving? Leaning forward or backward?
Any medication? Did it help?
How does it affect you?
Mets to lungs / liver / brain
Constitutional symptoms
Overweight
In addition to your pain, did you notice any other symptoms:
Weakness, numbness, tingling
Difficulty with balance, falls
Any difficulty passing urine? How about bowel
Cauda equine
movement? Did you find that you soiled yourself?
Any numbness in the buttocks area?
Do you have morning erection? Any sexual dysfunction?
Cancer prostate / bladder
Cancer prostate
Physical Examination
Impact
Red flags
DD
PMH
FH
Quality: stiffness
Timing: is it worse in morning? Improves with time? Or is it worse
at the end of the day?
Does it shoot to your thighs? Toes?
Which is bothering you more; your back or your legs?
How about lying down? Stretch your back? Coughing? Moving?
Leaning forward or backward?
Any medication? Did it help?
AS
Pain other joints (knees / hips / hands) / distribution? Osteoarthritis
Sero
Pain other joints (knees / hips / hands) / distribution? Ankylosing
negative
Eye pain, redness / mouth ulcers
spondylitis
symptoms
Skin changes / nail changes / hx of psoriasis
Repeated attacks of abd pain / diarrhea
Urethral discharge
How does it affect you?
Mets to lungs / liver / brain
Constitutional symptoms
Overweight
In addition to your pain, did you notice any other symptoms:
Weakness, numbness, tingling
Difficulty with balance, falls
Any difficulty passing urine? How about bowel movement? Did you Cauda equine
find that you soiled yourself?
Any numbness in the buttocks area?
Do you have morning erection? Any sexual dysfunction?
Trauma
Injury to back
Osteoarthritis
Ankylosing spondylitis
Other rheumatic disease
SH
Osteoarthritis: older patient / worse at evening
Ankylosing spondylitis:
ESR:
No cure
OSCE-guide-III.doc
Physical Examination
Neurological screen
Physical examination
Introduction
Can you stand up please?
Vital signs
Inspection
Gait / balance / stance
Ask the patient to stand up from sitting position
Posture: normal cervical, thoracic, lumbo-sacral curvatures
Adams forward bend test (if scoliosis: the scapula will be higher)
- No scoliosis or kyphosis
SEADS
Palpation
Temperature
Tenderness: spinal processes, para-vertebral muscles, sacro-iliac joints
(medial to dimples of Venus)
ROM
Can you touch your toes with your fingers? Without bending knees
Can you arch your back? Without bending knees (stand supported by the
bed foot: will not fall, less possibility of knee bending)
Slide your arms on both sides (Rt and Lt)? (stand against wall, normally
the tips of finger travel > 10 cm)
Cross your arms? Turn to the Rt and Lt (pt sitting on bed)
Modified Schober's test: (midline, between the dimples of Venus) + 5
cm below + 10 cm above bend forward N> 6 cm diff.
Special tests
Occiput-to-wall distance (tragus & nose same level): normally zero
Straight leg raise (irritation of the roots of sciatic n: L4/L5/S1/S2):
elevate the lower extremity straight, when it is painful where it does
hurt? straight leg test positive
Decrease the angle, try to dorsiflex foot Lasgue sign
Cross straight leg raise test: elevate the other LL trigger pain
Fabers test (figure 4 test): to check sacro-iliac joint pathology
Femoral nerve stretch (done for patients c/o pain radiating to the anterior
aspect of the thigh): patient prone, knee flexed,
Motor
Hip flexion (L1/L2/L3) / extension (S1/S2)
Knee flexion (L5/S1/S2) / extension (L2/L3/L4)
Ankle dorsiflexion (L4/L5) / plantar flexion (S1/S2)
Can you walk on your heals?
Normal L4/L5 muscles
Can you walk on your toes? Normal S1/S2 muscles
Sensory
S1: little toe
L5: first web
L4: medial malleolus
L3: knee med
L2: thigh ant
L1: groin
T10: umbilicus
Reflexes
Knee (L2/L3/L4 mainly L4) / Ankle (S1/S2 mainly S1) / I would like to do
the Babinski reflex (positive in UMNL)
Pulse
Dorsalis pedis
Other clinical examinations: DRE; to rule-out cauda equina (sphincter weaknesses, reduced anal
tone)
N.B. dimples of Venus correspond to PSIS
OSCE-guide-III.doc
Physical Examination
Ankle Twist
Young man comes with ankle twist; history and physical examination are normal, no fractures,
and no lacerations. In the next 10 minutes counsel him about the treatment
History
Inspection
Palpation
ROM
Power
Special tests
Investigations: x-ray
Ottawa ankle rules; for ankle series:
o Pain in the malleolar zone and any one of the following:
An inability to bear weight both immediately and in the emergency
department for four steps
Bone tenderness along the tip of the medial or lateral malleolus
Ottawa foot rules; for foot series
o If there is any pain in the mid-foot zone and any one of the following:
An inability to bear weight both immediately and in the emergency
department for four steps
Bone tenderness at the base of the fifth metatarsal
Bone tenderness at the navicular bone
Management:
Complete tear should be evaluated by orthopedics stat orthopedics consult
RICE: rest (and crutches) / ice for 20 min QID x 3 days / compression (by tensor bandage) /
elevation
Pain medication: NSAIDs; e.g. Ibuprofen 400 mg, PO, q6h.
Show him how to wrap it, remove the wrap, and ask him to wrap it again (to make sure he
knows how to). Remember: from distal to proximal and 1/3 width overlap.
Show him how to use the crutches.
OSCE-guide-III.doc
Physical Examination
Shoulder Joint
History
- Trauma to shoulder / neck? X-ray done? What is your occupation?
- Neurological deficits? How does it affect your life?
Vital signs
General
Patient condition (restlessness, discomfort, willingness to move)
Inspection
- Both shoulders symmetrical / clavicle level / scapula level / deltoid
- SEADS (Swelling / Erythema / Atrophy / Deformity / Scars)
Palpation
- Temperature: compare
- Tenderness: sternal notch / sterno-clavicular joint / clavicle / acromioclavicular joint / deltoid / long head of the biceps / insertion of the rotator
cuff muscles / spine of the scapula / medial border of scapula / spinal
processes of the cervical spine
- Crepitus
ROM
- Active ROM: can you copy me please:
- Abduction and comment on painful arc test
- Adduction and comment on drop arm test
- Forward flexion (180) /+/ Backward extension (60)
- External rotation /+/ Internal rotation
- Another faster way to check:
- Hands behind your neck (abduction / ext rotation)
- Hands behind back (adduction / int rotation) between shoulder blades;
touch the tip of the contra-lateral scapula.
- Passive ROM: If patient is unable to complete the whole range of
movements actively, complete the ROM passively and comment (in
inflammation: passive ROM is > active ROM)
Power
- Like the ROM, but against resistance
Special tests
1 Painful arc (between 60 and 120)
All these tests are done to
2 Drop arm test complete tear of supratest for subacromial
spinatous tendon
impingement of supra3 Neers test
spinatous
4 Hawkins test
5 Jobes test (empty can test)
6 Lift-off test: try to push my hand away from
Sub-scapularis
your back
Yergasons test; palm face up test: shake
For bicepital tendinitis
hands, try to let your palm face upwards, I
will resist you, and press on your shoulder
8 Speeds test: supine, semi-flexed, do not let
me push your arm down
9 Stability testing:
For joint stability
+ Push ant / post
+ Pull down sulcus sign
10 Apprehension test (ant and post): for
dislocation
To complete my exam, I would like to do:
- Check the pulses of the upper limb (radial / ulnar / brachial)
- Brief neurological examination of the upper limb
- One joint above and one joint below examination (cervical spine / elbow)
- The other shoulder examination
7
OSCE-guide-III.doc
Physical Examination
Abduction
External rotation
Internal rotation
Lift-off test
Impingement syndrome:
- The most common symptoms in impingement syndrome are pain, weakness and a loss of
movement at the affected shoulder
Treatment:
- Mild: RICE / NSAIDs / PT. Rest (cessation of painful activity), ice packs and NSAIDs
may be used for pain relief. Physiotherapy (PT) focused at maintaining range of
movement and avoiding shoulder stiffness.
- Moderate: therapeutic injections of corticosteroid and local anesthetic may be used for
persistent impingement syndrome
- Severe: surgery
Investigations:
- U/S
Possibilities:
- Normal shoulder exam
- Frozen shoulder
-
Bicepital tendinitis
Repeated ant dislocation
Rotator cuff tear
o Complete tear
o Partial tear
Rotator cuff tendinitis
Sub-deltoid bursitis
Elbow
ROM: flexion / extension /+/ pronation / supination
Tennis elbow (lateral epicondylitis)
With the elbow fully extended, there are points of tenderness over the lateral epicondyle
(origin of the extensor carpi radialis brevis muscle).
Cozen's test: pain with passive wrist flexion and resistive wrist extension.[
X-rays are used to confirm and distinguish possibilities of existing causes of pain that are not
related to Tennis Elbow, such as fracture or arthritis.
Golfer's elbow (medial epicondylitis)
The common tendinous sheath is inserted into the medial epicondyle of the humerus
Treatment:
o NSAIDs: ibuprofen, naproxen or aspirin /+/ Heat or ice
o A counter-force brace or "elbow strap" to reduce strain at the elbow epicondyle, to
limit pain provocation and to protect against further damage.
OSCE-guide-III.doc
Physical Examination
Hip Joint
+ Middle-age male with septic arthritis
+ Elderly female with osteoarthritis
Vital signs
General
IV antibiotics, empiric therapy, (based on age and risk factors; oxacillin [2 g IV q4h for 4 weeks], or
vancomycin [if suspecting MRSA; 20 mg/kg IV q8h, for 8 wks], combined with ceftriaxone for gram
ve, if suspecting Gonococcal: ceftriaxone; IV for 2 wks then oral for 2 wks), adjust pending C&S
For major joints such as knee, hip, or shoulder: urgent decompression and surgical drainage
OSCE-guide-III.doc
Physical Examination
Knee Joint
Inspection
Palpation
ROM
Power
Special tests
For medial: maximally flexed knees, externally rotated foot extend while
applying varus force (from inside outwards)
For lateral: maximally flexed knee, internally rotated foot extend while
applying valgus force (from outside inwards)
DD
Tenderness
Investigations
Treatment
OSCE-guide-III.doc
ACL
- Knee giving way
- Inability to continue activity
MCL
- Can not descend
stairs
OsgoodSchlatter disease
Chondromalacia patellae
Pain on tibial tuberosity ( by kneeling) Pain on lateral movement of patella
X-ray (AP / LAT / skyline)
Benign self-limited condition
Non-impact activities
Continue activity as tolerated
NSAIDs
NSAIDs
Physiotherapy
Physiotherapy
Surgery for refractory cases
Physical Examination
OSCE-guide-III.doc
Physical Examination
HPI
Os Cf D
COCA Blood
Associated
symptoms
DD
Menstrual
M
Gynecological
G
Obstetric
O
Sexual
S
PMH
FH
SH
OB/GYN cases
History taking:
- Vaginal discharge
- Vaginal bleeding
- Amenorrhea
- Infertility
Counselling:
- OCPs
- HRT
- C-section (wants to have c-section or wants to have vag delivery after c-section)
- Abortion
- 22 years old pregnant anti-natal counselling
- 39 years old found she is pregnant, counsel her
- 30 yrs old pregnant (36 wks), HTN/+++ ptn in urine counsel for pre-eclampsia
- PAP smear; 16 years old wants to arrange for a PAP smear
- PAP smear: 38 year old had abnormal PAP smear
OSCE-guide-III.doc
Physical Examination
When was your LMP? First day? Was your LMP similar to the previous ones?
Are they regular or not? How often do you have periods?
How long does it last? How many days?
How about the amount? Is it large / small? How many pads/day? Any blood clots?
Are your periods painful? [not painful anovulatory (PCOS/infertility)]
Any spotting / bleeding between periods?
When was your first period? Was it regular? For how long it was not regular? Normal to be
irregular for up to 18-24 months.
Gynecological:
-
Do you have history or were diagnosed with any gynecological disease (e.g. polyps)?
Do you have history of pelvic surgery or instrumentation (e.g. D&C)?
Do you use contraception? What method? Since when? When was the last time?
Screening:
-
Have you ever had Pap smear before? When was the last time? Any reason (if long time)? What
was the result?
(>40 yrs) have you had mammogram done before? When? (Is it painful doctor? Could be; we
need to apply pressure on the breast to get better image)
(>65 yrs) have you had your bone mineral density (BMD) done? Any reason?
Obstetrical GTPAL:
-
Have you ever been pregnant before? Any abortions (termination)? Or miscarriages (spontaneous
abortion)?
Number of babies you delivered? Any twins? Any children with congenital abnormalities?
For each delivery: was it full term or pre-term? Vaginal or CS? Any complications like high blood
pressure / high blood sugar?
Family history of: repeated abortions / CS / congenital anomalies / twins
Sexual history:
-
What if the male partner does not like condoms? Is it ok to consider it safe sex? Yes, provided
that:
- Scan the partner for STIs first
- Strict monogamy relation (no extra-marital affairs)
- Use alternative reliable contraception (e.g. OCPs)
OSCE-guide-III.doc
Physical Examination
NO
Yes
Social issue
N.B. to make sure the mother and baby are stable: ABCDE
Activity of the baby
Bleeding
Contractions / pain
Dripping / Discharge
EDD (expected date of delivery)
OSCE-guide-III.doc
Physical Examination
Vaginal Discharge
Teenager / 5 minutes case
CC
How can I help you?!
Analysis of CC
Os Cf D
COCA Blood / color / fishy odour?
-
- Related to periods
- Related to sexual intercourse (bact vaginosis: discharge post-coitus)
- LMP / regular / how often / similar to previous ones?
M
Same system
HPI
- Any pain? With intercourse?
AS
- Itching? Redness?
? Candida
DD
- Any blisters / warts / ulcers13?
- Inguinal swellings?
- Urine changes? Dysuria, frequency?
Nearby systems
- Bowel movements changes? GIT symptoms
- Abdominal pain OCD / PQRST /
- ? PID Adnexal tenderness / fever
- Dissemination to liver (pain Rt upper abd)
DD
- Constitutional symptoms
- Sore throat? Mouth ulcers? Red eyes?
- Joint swelling/pain? Skin rash? Reiters
G
- IUD
- PAP smear!
- History of STI / PID?
O
Complete sexual history for both partners
S
PMH
- Any medications? Recent use of antibiotics
- Allergies
- DM
FH / SH
- How do you support yourself?
- HEAD SS / SAD
Conclusion: STI because of risky sexual behaviour
Physical examination including pelvic, speculum exam / PAP smear / swabs for C&S including those
for Chlamydia & Gonorrhea / saline slide microscopy / KOH / Whiff test
DD: Gonorrhea, Chlamydia, Candidiasis (whitish), Bacterial vaginosis (thin gray, clue cells),
Trichomonas (frothy yellowish / greenish discharge, motile organism).
Treatment:
o Gonorrhea: Ceftriaxone 250 mg IM single dose
o Chlamydia: Azithromycin 1g orally single dose
o Candidiasis: Miconazole 200 mg vag supp, 1 vag supp od qhs x 3 d
o Bacterial vaginosis: Metronidazole 500 mg PO bid x 7 d
If pregnant: Amoxicillin 500 mg PO tid x 7 d
o Trichomonas: Metronidazole 500 mg PO bid x 7 d
Follow up with in 4 weeks
Her partner(s) to be notified and to come for treatment, ask about sexual health (fever, discharge)
Advice regarding safe sex (condoms, multiple partners, STIs)
Chlamydia and Gonorrhea are reportable diseases
HIV testing and other STIs screening if high risk sexual behaviour
Advise regarding PAP smear regularly, vaccination against HPV
13
Blisters: HSV (Herpes Simplex Virus) / warts: HPV (Human Papilloma Virus) / ulcers: syphilis
OSCE-guide-III.doc
Physical Examination
Middle age / risky behaviour / old abnormal Pap smear cervical cancer.
A 48 years patient with vag bleeding and all symptoms will be negative dysfunctional uterine
bleeding (DUB); intermittent / lose track of periods / no pain with periods.
A 52 years pt / constipation / OCP/HRT / no pregnancies14 endometrial cancer / constitutional
A 62 years pt with intermittent bleeding / small amount with secretions atrophic vaginitis;
(menopausal symptoms / dyspareunia / itchy vulva) Rule out cancer (endometrial biopsy)
estrogen vaginal cream
DD: Fibroid / Cervical polyp / hyper/hypo-thyroidism / Trauma / Coagulopathy / PCOS
Investigations: pregnancy test -HCG / progesterone challenge test / hysteroscope / PAP / U/S /
endometrial biopsy / TSH
14
Cervical cancer for prostitutes (risky behaviour) and endometrial cancer for nuns (no pregnancies)
OSCE-guide-III.doc
Physical Examination
Patient usually sleeping in a left lateral position with oxygen, very anxious, crying
Reassure her & ask her to bear with you for a while to get to the bottom of her problem
Ask about her feelings & empathize (impact on her and her partner)
Analysis of CC
HPI
M
AS
DD
G
O
S
PMH
FH
SH
Timing: OS Cf D
first time or happened before
COCA / fresh blood vs. clots if large amounts impact anemia /
dehydration symptoms (pallor, SOB, dizziness, fainting, heart racing)
Threatened abortion
Separation of part of the placenta
Will do physical and obstetric examination. Vaginal exam only after U/S excludes placenta previa
- 50/50% chance to keep or loose the baby
- Admit to the hospital
- Investigations: continuous vitals monitoring / CBC / INR / PTT /
- Arrange for continuous fetal heart monitoring, U/S
fibrinogen / Rh status / blood grouping and cross matching / US /
and biophysical profile
fetal monitoring
- Management: O2, IV fluid, LLP, if fetus is still in
- Management:
distress, arrange for C/S
- If she is improving / the fetus is not distressed: she will go home,
Placenta previa
Placenta abruption
resume normal activity, come back if more blood or more pain
Painless
Painful (contractions)
- Otherwise: bed rest / steroids / fetal monitoring / Rhogam / platelets
Incomplete abortion: 3 findings on vag exam would confirm the diagnosis: (1) Cervix dilated, (2)
Ruptured membranes, (3) Product of conception passed
OSCE-guide-III.doc
Physical Examination
Causes:
o
progesterone: luteal phase defect (estrogen-dependent DUB)
o
PCOS
o
Endocrinal ( TSH / prolactin)
o
Stress, weight loss, exercise
o
Liver and kidney disease
o
o
o
o
o
o
o
Beta-hCG
CBC, serum ferritin
Coagulation profile (esp. adolescent): rule out von Willebrand's disease
TSH, free T4
Prolactin if amenorrhea
FSH, LH
Day 21 (luteal phase) progesterone to confirm ovulation
Serum androgens (especially free testosterone)
Pelvic U/S: detect polyps, fibroids; measure endometrial thickness (postmenopausal)
Sonohysterogram (SHG): very sensitive for intrauterine pathology (polyps, submucous
fibroids}
Hysterosalpingography (HSG)
Pap test
Endometrial biopsy: women > 40 years are at higher risk of endometrial cancer
Must do endometrial biopsy in all women presenting with postmenopausal bleeding
to exclude endometrial cancer
D&C: not for treatment; diagnosis only (usually with hysteroscopy)
OSCE-guide-III.doc
Physical Examination
Treatment of AUB:
Treat underlying disorders / if anatomic lesions and systemic disease have been ruled out,
consider dysfunctional uterine bleeding (DUB)
Medical:
o
Mild DUB
o
NSAIDs
Anti-fibrinolytic (e.g. Cyklokapron) at time of menses
Combined OCP
Progestins (Provera) on first 10-14 days of each month if oligomenorrheic
Mirena IUD
Danazol (pseudo-menopause)
Clomiphene citrate: consider in patients who are anovulatory and who wish to get
pregnant
Surgical:
o
Endometrial ablation; consider pre-treatment with danazol or GnRH agonists
o
o
If finished childbearing
Repeat procedure may be required if symptom recurrence
STIs
Bleeding tendencies
Trauma
Management:
Polyp: Sonohysterogram
Biopsy
Early menarche
Nulliparity
Weight gain
HRT / estrogen therapy
Unopposed estrogen
Management:
OSCE-guide-III.doc
Physical Examination
Amenorrhea
CC
To diagnose PCOS: must have 2 of 3 criteria: (1) oligomenorrhea / irregular menses for 6
months, (2) hyper-androgenism (hirsutism or blood level), (3) PCOS by US
Investigations: -HCG / US / High LH:FSH ratio > 2:1 / Fasting blood sugar
Treatment:
o Lifestyle modification ( BMI, exercise) to peripheral estrone formation
o Metformin 500 mg PO tid
o Clomiphene citrate; if she wants to become pregnant
o Tranexamic add (Cyklokapron); for menorrhagia only
o OCPs; if she does not want to become pregnant
Dysmenorrhea:
OSCE-guide-III.doc
Physical Examination
Infertility
Transitional statement before going in details with the history:
In order for a couple to achieve pregnancy, both partners should be capable of having children
and relatively healthy. For that reason, I am going to ask some questions about your health and
your partner health; some of these questions are personal, but it is important to ask. And I would
like to assure you that all the conversation is strictly confidential and I will not release any
information without your permission!
Introduction
CC
Analysis of CC
For how long have you been trying to conceive?
- Anovulation (irregular cycles / painless / no pre-menstrual syndrome)
HPI DD
- PCOS: Do you have excessive hair growth? Acne? Did you notice any
weight changes? Hx of DM / thirsty / frequency? Fm Hx of PCOS?
- Tubal occlusion: surgeries / STIs and PID / IUD
- Endometriosis: dysuria / dyspareunia / dyschezia / back pain
- History of chemotherapy and radiotherapy
- Do you have hx or were diagnosed with any gyn disease (e.g. polyps)?
Gynecology
- Did you use contraception? What? Since when? When was the last time?
Hx
- Have you ever had Pap smear before? When was the last time? Any
reason (if long time)? What was the result?
- Have you ever been pregnant before? Any abortions (termination)? Or
Obstetric Hx
miscarriages (spontaneous abortion)?
- Family history of: repeated abortions / CS / congenital anomalies / twins
Coital history - For how long are you in this relation? For how long have you been
trying to achieve pregnancy?
- How frequent? Regularity?
- Are you aware of sexual cycle and ovulation (both you and your partner)
- Was he sexually active before? Did he father kids from another partner
Partner
before?
history
- Did he receive any chemo or radio therapy?
- Does he complain of any testicular problem; varicose veins,
inflammation?
- Does he complain of any penile discharge?
- Did he go through any investigations; e.g. semen analysis?
PMH
- Allergies
- DM
FH
Infertility
SH
Investigations:
Semen analysis
If the woman is > 40 years start investigations after 1 months of trying to conceive
OSCE-guide-III.doc
Physical Examination
Counselling pre-eclampsia
36 weeks pregnant lady comes for f/u visit, BP 160/110, +++ protein in urine, Manage.
Like the B12 results case
Introduction
I will discuss results with you
Ethical challenge: travel permission
History
Last visit history / pre-eclampsia
Make sure the mother and baby are stable
U/S
Obstetric history / Gynecological history
PMH / Social history
Counselling
Explain what is pre-eclampsia
Serious concerns with pre-eclampsia
Management
Hospitalize
If insisting to leave sign a LAMA
Introduction
- Good afternoon Ms I am Dr I understand that your blood pressure was measured and urine
test was done, I have the results with me and I will discuss it with you. However, because this is
my first time to see you, I need to ask you some questions, to get a better understanding of your
health condition, is that ok with you?
- Is this you first time to have these checks during your pregnancy?
- Are you under regular follow-up?
o Yes proceed to history
o No any reason? My husband had a car accident! I am sorry to hear that; was he hurt?
Was anyone else hurt? When was that? It must be difficult, how did this affect your life?
Ethical challenge: travel permission
o Actually I am here to get a note.
- What type of notes?
o Travel note, I really need to travel.
- It looks like it is an important trip for you; usually pregnant ladies do not travel during this time of
pregnancy!
o It is a business trip that would save our financials.
- I see it is important for you, however, before we proceed, let me check your health condition first,
and I will start by asking you some questions:
History
Last visit history / pre-eclampsia
- When was your last f/u visit?
- What was your BP? Was there any headache?
- Was there leg swelling? Weight gain? Did they do urine test?
- How about before being pregnant? Any hx of high blood pressure?
Make sure the mother and baby are stable: ABCDE
- Activity of the baby, is your baby kicking like before?
- Bleeding
- Contractions / pain
- Dripping / Discharge
- EDD (expected date of delivery)
U/S
- Have you done your U/S? How many times? When was the last time?
- Number of babies?
- Location of the placenta?
- Amount of fluids?
Obstetric history: any pregnancy before / any similar conditions? Gynecological history
PMH: high blood pressure Social history: SAD / support / home environment
OSCE-guide-III.doc
Physical Examination
Counselling
Explain what is pre-eclampsia
- Your blood pressure is 160/110, which is high, and the urine test shows protein in large amount
(+++) which is not normal, the most likely diagnosis is a medical condition called pre-eclampsia
OR pregnancy-induced hypertension.
- I would like to ask more questions to see how it affected you!
o My dad had HTN, and lived with it, I am ok.
- These are different conditions; your dad had HTN, but you have pregnancy-induced HTN,
which is a serious condition, with very serious and may be fatal consequences.
o Have you had hx of headache? OCD / PQRST (not detailed)
o Nausea / vomiting
o Change in your vision? Flashing lights? Flying objects?
o Any abdominal pain in your upper right part of your abdomen?
o Any bruises? Yellowish discoloration / itching / dark urine / pale stools?
o Any chest pain / heart racing / SOB?
o Any weakness / numbness?
o Any swelling in your body / face/eyes? Did you feel your shoes tight?
o Did you gain weight?
o Any changes in the urine? Frothy? Burning sensation?
- Based on all this, the most likely explanation for your increased is pre-eclampsia; and this is a
very serious condition, we need to admit you to the hospital to monitor you. Then, the obstetrician
will assess you and may consider delivering the baby now.
o But doctor, I need to travel, just 2 days and I will come back.
- I understand your concern about traveling, but we have a serious situation here.
- We do not know exactly why patients have pre-eclampsia. We believe it is imbalance of
hormones, or it might be related to placenta, however the only treatment is delivering the baby.
Serious concerns with pre-eclampsia
- What happens is that there is a narrowing of blood vessels, this leads to the amount of blood
reaching the baby, subsequently the amount of oxygen and nutrients. On the long term this will
lead to some injury and even damage to the baby AND the mother.
o This includes your heart and blood vessels, that is why you have BP,
o This includes your kidney, that is why you have +++ protein in urine,
o This includes your liver, that is why you may have abdominal pain,
o This includes your brain, that is why you have headache, visual changes,
o This includes your baby, that is why he is not kicking like before
This is not because of your pregnancy; all of these are due to this condition.
- The concerns we have is that we can not predict the outcome, without the proper medical care,
patients having pre-eclampsia will end up going to the next stage which is eclampsia; do you
any idea what is e0clampsia?
- A condition in which, the patient will start to seize, lose conscious, will not be able to breath and
turn blue. The only resolution for this is delivering the baby.
- Imagine that I give you the note, and they allow you to take the trip, 2 hours later while you are in
the plane, you start to fall down and seize. What will happen? Nobody will be able to help you.
- By this you endanger your life and your babys life.
Management
- What we need now is to admit you to the hospital and arrange for obstetrical assessment.
- If insisting to leave sign a LAMA (leaving against medical advice)
- Suggest solution for her business travel, like giving a doctor note that she needs to be hospitalized.
Treatment Plan
- Assess severity including good history and physical exam focusing on heart, lungs, reflexes, fetus,
urine analysis and BW (important CBC, liver function tests, Uric Acid)
- If all above are stable, consider daily check, urine dips and fetal kick counts as outpatient. If any
of above unstable may need to hospitalize as inpatient for close monitoring
- Measure L/S ratio of the baby, give corticosteroids for lung maturation
- MgSO4 and delivery
- Blood pressure controlled often with labetalol, Ca channel blockers
OSCE-guide-III.doc
Physical Examination
OSCE-guide-III.doc
Physical Examination
U/S
-
Have you done your U/S? How many times? When was the last time?
Number of babies?
Position of the placenta?
Amount of fluids?
I will give you some brochures and web sites so that you can read more about that.
I will connect you with the social worker.
And if at any time you have any questions or concerns, you can come to see me.
OSCE-guide-III.doc
Physical Examination
OSCE-guide-III.doc
Physical Examination
Bleeding
Contractions / pain
Dripping / Discharge
EDD (expected date of delivery)
U/S
- Have you done your U/S? How many times? When was the last time?
- Number of babies?
- Location of the placenta?
- Amount of fluids?
Obstetric history: GTPAL
- Other than the pregnancy that you had CS 3 years ago; any pregnancy before? Any abortions or
miscarriages?
- What were the circumstances? How many weeks?
- How did you feel about it? How did you cope with that?
Gynecological history
PMH: Medications / allergy / blood transfusion
Social history: SAD / support / home environment
Counselling
What is CS? The two types of CS
- I would like to ask you; what is your understanding of CS?
- It is commonly used obstetrical intervention, used when there is a problem or contraindication for
vaginal delivery and if there is an emergency situation that necessitates immediate delivery; and in
these cases it is life saving; for both the mother and the baby!
- There are two types of CS:
o The transverse (done at the lower segment of uterus); it is the most common type; its
advantages include: smaller scar and better healing.
o The classical or vertical type; it is done less common; as we cut through the muscle fibers
of the uterus it produces weaker scar; but it is indicated and actually needed in urgent
case, like yours. As it allows quick access and fast delivery, because in some cases (like
cord prolapse) we can not afford even few minutes more.
Risks of vaginal delivery post CS
- Due to the scar formed after the CS procedure; it is always recommended to deliver by CS, to
avoid the tearing pressure of the uterine contractions during vaginal delivery.
- If you decide to go for vaginal delivery, my concern is that the scar might undergo severe tearing
pressure and might rupture, which will lead to massive bleeding. This is an obstetrical emergency
that necessitates immediate intervention. Because you may end up losing your life and/or losing
your baby.
- I do not want to scare you, but the risks of having uterine rupture after classical CS is 12%, of
which 10% of cases end up losing their lives.
- For that reason: once classical CS, it is always CS.
In case of counselling transverse CS:
- Risks of having uterine rupture after transverse CS is 1%.
- Even though, if you want to try vaginal delivery, we can not take the risk to try this at home, we
can try this in the hospital, so that just in case any emergency might happen, we can intervene in
the proper time.
Management
- I will ask someone to prepare a copy of your file
- Speak with your midwife:
- I am sure that your midwife is highly trained and qualified, and we share the same guidelines. I
would recommend that you take your file and speak with your midwife, and I am sure she will
explain the situation to you.
- I will give you some brochures and web sites so that you can read more about that.
- And if at any time you have any questions or concerns, you can come to see me.
OSCE-guide-III.doc
Physical Examination
History
Exclude
pregnancy
M
G
O
S
Definition: birth control is an umbrella term for several techniques and methods used to prevent
fertilization
Post-coital contraception
OCPs prevent ovulation, increase thickness Available forms: Copper / hormoneof cervical secretion
coated
History of PID(s)
Risky behaviour
Migraine
Benefits
Regulate periods
Longevity
dysmenorrhea
Available
methods
OSCE-guide-III.doc
Physical Examination
Side effects
Heavy periods
risk of DVT / CAD
Breast tenderness
Weight gain
Headache
Nausea / vomiting
0.1% 5%
0.5% 2%
OCPs
IUD
Will do physical and pelvic examination, and document blood pressure, pap smear
Failure rate
Plan
NOTES
OSCE-guide-III.doc
Physical Examination
OCPs
IUD
IM
Injection
Advantages
- Regulate periods
ABCD:
- Improves anemia (
bleeding)
- benign breast lesions
- ovarian cysts and cancer
- risk of uterine cancer
- dysmenorrhea
- Longevity
- Independence to coitus or
compliance
- Dysmenorrhea
- Effective
- Independence
Contraindications
Pregnancy
Un-dx vag bleeding
Cerebro-vascular dis / CAD
Active liver disease
Hormone-dep cancer
Smoker > 35 yrs
Hx of DVT / PE
Migraine
Pregnancy
Un-dx vag bleeding
Structural uterine anomalies
Hx of PID(s)
Risky behaviour
Hx of ectopic pregnancy
Condoms
Diaphragm
Behavioural
OSCE-guide-III.doc
Available
Combined pills (E+P):
low dose estrogen (20,
35, 50)
Failure rate
0.1% 5%
TRANSIENT:
- Breast tenderness
- Weight gain
- Headache
- Nausea / vomiting
- Heavy periods
- Copper
- If hormonal coated: prog - Hormone coated
side effects: headache /
wt gain / mastalgia
0.6% 2%
- NO absolute contraindications
- Irregular bleeding
- Amenorrhea after 1 year
- Delayed post-use
fertility
Every 3 months
< 1%
- Irregular bleeding
- Headaches
- Mood changes
Every 5 years
< 1%
Depoprovera
SC implants - Longevity
- Effective
Nor-plant
- Independence to coitus or
compliance
Side effects
- Does not prevent STIs
- risk of DVT / CAD
14%
20%
- High failure rates up to 25%
- To decrease the failure rate, can combine 2 methods
OB-GYN
HRT counselling
Introduction / overview
History
General
M
G
O
S
Menopausal
symptoms
Indications for HT
Contraindications to HT
Pre-treatment evaluation
Adverse effects and risks
Any concerns?
OSCE-guide-III.doc
Estrogen alone
Combined estrogen and progestogen
Selective estrogen receptor modulator (SERM)
Menopausal symptoms For SHORT term only, 1 2 years
Osteoporosis
Hx / PE / baseline investigations
Media spoke that HRT increases incidence of stroke, heart attacks
and breast cancer, this was done by the (Women's Health
Initiative), on the other hand, smoking, obesity, cholesterol
increases the risk of these dis much more than HRT. In your case,
you do not have the risk factors for cancer, and it will be
beneficial for your hot flashes, vaginal dryness, and will protect
you against osteoporosis In medicine we always weight risk /
benefits
OB-GYN
Introduction / overview:
- The reproductive years of a womans life are regulated by production of the hormones
estrogen and progesterone by the ovaries. Estrogen regulates a woman's monthly
menstrual cycle and secondary sexual characteristics (e.g. breast development and
function). In addition, it prepares the body for fertilization and reproduction.
Progesterone concentrations rise in a cyclical fashion to prepare the uterus for possible
pregnancy and to prepare the breasts for lactation.
- Toward the end of her reproductive years when a woman reaches menopause, circulating
levels of estrogen and progesterone decrease because of reduced synthesis in the ovary,
which may lead to several symptoms, the severity of which can vary widely.
- Hormone therapy (HT) involves the administration of synthetic estrogen and
progestogen. HT is designed to replace a woman's depleting hormone levels and thus
alleviate her symptoms of menopause. However, HT has been linked to various risks, and
debate regarding its risk-benefit ratio continues
Contra-indications of HRT:
No absolute contraindications of hormone therapy have been established. However, HT is
relatively contraindicated in certain clinical situations (similar to OCPs):
- Breast and/or endometrial cancer
- Undiagnosed vaginal bleeding
- Acute liver disease
- Thromboembolic disorders / DVT
- Endometriosis / Fibroids
- Diabetes, HTN, Heart disease
Required baseline investigations
- CBC
- Urinalysis
- Blood sugar levels
- Fasting lipid profile
- Electrocardiography
- Pap test
- Ultrasonography to measure endometrial thickness and ovarian volume
- Mammography
Possible adverse effects are as follows (similar to OCPs):
- Nausea / bloating
- Fluid retention
- Weight gain (equivocal finding)
- Mood swings (associated with use of relatively androgenic progestogens)
- Breakthrough bleeding
- Breast tenderness
- HT may slightly increase the risk for breast cancer
- There is association between HT and uterine hyperplasia and cancer
- There is increased risk of thromboembolism with HT
OSCE-guide-III.doc
OB-GYN
Inform the
patient about
HIV
Plan
Workup
What is HIV?
- Human immunodeficiency virus (HIV) is a blood-borne, sexually transmissible virus.
The virus is typically transmitted via sexual intercourse, shared intravenous drug
paraphernalia, and mother-to-child transmission (MTCT), which can occur during the
birth process or during breastfeeding.
- The major pathogens of concern in occupational body fluid exposure are HIV, hepatitis
A, hepatitis B, hepatitis C, and hepatitis D. These pathogens are viruses that require
percutaneous or mucosal introduction for infectivity. The major target organs are the
immune system (HIV) and the liver (hepatitis).
OSCE-guide-III.doc
OB-GYN
OSCE-guide-III.doc
OB-GYN
I understand you are here because you have some inquiries/worries about your
last PAP test, is this right? How can I help you today?
HPI
M
Previous Pap test? How many? How frequent? Any abnormal Pap test?
G
Any previous colposcopy?
Contraceptive history
GTPAL
O
RISK factors for cervical dysplasia:
S
- Early age of sexual activity
- Risky behaviour: unprotected sex / multiple partners
- Smoking
AS
Same system
- Any pain? With intercourse?
- Discharge? Itching? Redness?
- Any blisters / warts / ulcers?
- Inguinal swellings?
Nearby systems
- Urine changes? Dysuria, frequency?
- Bowel movements changes? GIT symptoms
- Abdominal pain OCD / PQRST /
General
- Constitutional symptoms
PMH
Any allergy / medication / disease
FH
Gynecological tumours
SH
If teenager: HEAD SSS
COUNSELLING:
- What do you know about (LGSIL)? What would you like to know?
- Have you had any experience with in the past?
- Have you [read / talked to someone / searched the internet] about this issue?
Worried about PAP results
- PAP smear or test is done to screen for any changes that might happen in the cervix,
before it turns to serious disease (to early detect pre-malignant lesions).
- At the cervix there is transitional zone between two types of cells, it undergoes rapid
growth, if there is irritation due to HPV, it might turn malignant. It takes years from the
moment it begins to grow abnormally to the moment it becomes malignant, that is why
we do frequent PAP tests, to detect it before it turns into malignant tumour.
- The results come back from PAP test either ASCUS (Atypical squamous cells of
Undetermined Significance) / LG-SIL (low grade squamous intra-epithelial lesion) / or
HG-SIL (high grade squamous intra-epithelial lesion)
OSCE-guide-III.doc
OB-GYN
For ASCUS:
o Woman 30 yrs HPV DNA testing
If negative repeat cytology after 1 year
If positive colposcopy
o Woman < 30 yrs repeat cytology in 6 months
If negative repeat after 6 months still negative routine screening
If ASCUS colposcopy
For LG-SIL:
o Colposcopy
o Or repeat cytology after 6 months
If negative repeat after 6 months still negative routine screening
If ASCUS colposcopy
For HG-SIL:
o We send you for colposcopy
For colposcopy, we will refer you to the gynaecologist who will perform special
procedure, during which, the gynaecologist will take a biopsy, and send it for further
investigations;
o If the biopsy is negative, we will repeat the PAP after 6 months
o If the biopsy is positive, we will do more investigations to establish a diagnosis
and may need to do another larger biopsy called cone biopsy
Treatment options:
- Laser
- Cone biopsy
- LEEP (loop electrosurgical excision procedure)
Colposcopy
- Colposcopy is a magnification of the cervix (10-12 times), the procedure may cause some
discomfort but is not painful.
- The gynaecologist will insert a speculum (the same instrument used for Pap test), and
then she/he will use a special magnification device (the colposcopy) to visualize the
cervix.
- The gynaecologist will apply acetic acid (vinegar) that helps make the vascular patterns
more visible, application of this acetic acid may give an itchy sensation.
- Then if the gynaecologist suspects a lesion, she/he will need to take a biopsy, you will
feel a punching sensation, and you might experience a little discomfort and spotting for
few days.
- You need not to have anything inserted into your vagina for 24 hours before and 2 days
after the procedure (no vaginal intercourse, no douching), and you might need to take
some OTC medications (Advil) for few days after the procedure.
OSCE-guide-III.doc
OB-GYN
Antenatal Counselling
o
Ms XX has missed her period for 2 wks; she did a home preg test which was positive. This is
her first experience. In the next 10 min, please talk to her and give her necessary advices
about her pregnancy.
A 38 yrs old pregnant lady came to you because she is concerned about problems during
advanced-age pregnancy, counsel
Pregnancy
M
G
O
S
PMH
FH
Social Hx
Concerns
OSCE-guide-III.doc
OB-GYN
Counselling:
To ensure healthy outcome of the pregnancy I need to see you on scheduled visits, every 4
weeks till the 28th week, then every 2 weeks till the 36th week, and then every week thereafter
and till delivery
Today well do physical examination including pelvic exam, Pap smear if more than 6
months, blood work including CBC, Lytes, INR/PTT, Urea, Creatinine, Blood Type, VDRL,
Rubella antibody, Hepatitis, HIV, Urine dip and microscopy, ECG.
Anatomy US at 20 weeks. Glucose challenge test at 24 weeks
Risks of Down syndrome are: 1/400 at 30 yrs of age, 1/200 at 35 yrs of age, and 1/100 above
40 yrs of age we try to anticipate it by US and integrated prenatal screening then confirm it
by amniocentesis
U/S for nuchal translucency: at 12 weeks
IPS I: 11-14 wks /+/ IPS II: 15-18 wks (Maternal serum alpha-fetoprotein, -hCG, uE3
Unconjugated estrogen)
Amniocentesis (U/S-guided trans-abdominal extraction of amniotic fluid / for identification
of genetic anomalies): at 15-16 wks, 0.5% risk of spontaneous abortion and risk of fetal limb
injury
You need a well balanced diet; Canada's Food Guide to Healthy Eating suggests 3-4 servings
of milk products daily (greater if multiple gestation), a daily caloric increase of -100 cal/d in
the 1st trimester, -300 cal/d in the second and third trimesters and -450 cal/d during lactation.
If you do not consume an adequate diet, you can take daily multi-vitamins (avoid excess
vitamin A)
Important nutrients during pregnancy: folate; 0.4-5 mg per day / calcium; 1200-1500 mg per
day / iron: 1 mg/d in T1, 4 mg/d in T2 and > 6 mg/d in T3
Pregnant ladies tend to have constipation, you can take Lactulose for this, avoid raw or
processed meat
Haemorrhoids, back pain, heartburn and increased vaginal discharge are common
Will gain weight; 5-10 pounds in 1st half, 1 pound /week in 2nd half, total of 25-35 pounds in
average
Exercise is OK walking, swimming, avoid strenuous activities
Stay away from cats litter
No medication without asking your doctor, no x-rays
Smoking increase the risk of abortion, LBW, premature delivery
No safe level of alcohol during pregnancy, better to avoid it totally
Offer brochures, connect to support groups and classes for pregnant women
OSCE-guide-III.doc
OB-GYN
Endometriosis
You are covering for your colleague Dr. Smith. You are about to meet Mrs. XX to discuss the
result of her laparoscopy & inform her that she has endometriosis. For the next 10 minutes, please
talk to her& address all her concerns.
-
Introduction: I would like to discuss the result of your laparoscopy but I need to get some
information.
o Why did you have laparoscopy done and what was your doctors concern?
o You have endometriosis:
During periods, this outside tissue also begins to bleed. This explains the
painful periods.
Infertility: I understand your frustration. For how long have you been trying
to conceive? Are you currently sexually active? How frequent?
Frequency
Past medical history: HTN, Diabetes, kidney disease, blood group & Rh. Allergies /
medications / hospitalization / surgeries / blood transfusion
Family history of abortion
Social history: smoking, alcohol, drugs / work / home environments / support
16
Conclusion: endometriosis
Plan:
o Will do physical and obstetric examination
o Give her treatment options
Medical:
NSAIDs e.g. naproxen sodium (250 mg PO bid)
16
Pseudo-pregnancy: OCPs trial for 6-12 months (Ovral 1 tab PO od)
Pseudo-menopause (only short-term <6 months): Danazole (weak
androgen / Side effects: weight gain, fluid retention, acne, hirsutism,
voice change)
Surgical treatment:
Conservative laparoscopy: laser ablation / resection of implants
Definitive: bilateral salpingo-oophorectomy hysterectomy
o Brochure & support groups
Ovral is progestin (levonorgestrel) and estrogen (ethinyl estradiol) combination OCP
OSCE-guide-III.doc
OB-GYN
History
Pregnancy
Social
Abortion
Depression
Pregnancy (LMP, symptoms, how did you find out, Rh status) How do
you feel? How is the feeling of your partner about the pregnancy?
SAD
Counselling
Pregnancy
Social
Abortion
Depression
OSCE-guide-III.doc
Close follow-up
OB-GYN
Weight < 57 Kg
Current smoker
Premature ovarian failure (female on Tamoxifen for breast cancer / surgical menopause)
Male on androgen-deprivation therapy for prostate cancer
Heparin or anti-epileptic use or biologics (anti-cancer treatment)
Investigations:
- BMD:
Age group
When to do BMD
-
< 50 years
If > 2 of the first (5)
risk factors
50 65 years
If > 2 of any from the list
of risk factors
> 65 years
Always do BMD, screen
even there is no C/O
Blood work:
o Serum calcium and phosphate levels
o Alkaline phosphatase
o Creatinine
o SPEP (serum protein electrophoresis)
o PTH (para-thyroid hormone)
o Give vitamin D for 2-3 months, then assess the level, if > 0.75 nanogram it is normal and
do not repeat it again
Treatment:
- Based on BMD, risk factors, age of patient Fracture Risk Stratification low, moderate, or high
LOW
MODERATE
HIGH
- Life style
If fragility fracture (in thoraco-lumbar x-ray) OR prolonged
- Life style
modifications use of corticosteroids
modifications
- F/U DEXA
Medical
NO
YES
after 5 yrs
treatment
- Life style modifications
- Life style modifications
- F/U DEXA after 2 yrs
- Medical treatment
Life style modifications
- Weight-bearing exercises (walking, jogging)
- Ca 1200 mg/d (including the dietary intake,
avoid Ca)
- Vit D 1000 IU/d if < 50 yrs, and 2000 IU/d if >
50 yrs
- Smoking cessation
- alcohol and caffeine
OSCE-guide-III.doc
Medical treatment
- Bisphosphonates
- SERM (Raloxifene): agonistic effect on bone
but antagonistic effect on breast and uterus
- Parathyroid hormone (PTH)
- Calcitonin (if back fragility fracture + pain)
- HRT
OB-GYN
Pediatrics
OSCE-guide-III.doc
OB-GYN
Introduction:
Chief complaint
1234567-
Analyze the CC
Impact
Rule out infection
Differential diagnosis
BINDE
Past medical history
Family history
1- Analyze the CC
- BINDE screening
- Mother attitude!
-
2- Impact
3- Red flags
Rule out infection
4- Differential
diagnosis
5- BINDE
6- Past medical history 7- Family history
0-6 years
BINDE
Pregnancy / Birth
Immunization
Nutrition
Developmental
Environmental
OSCE-guide-III.doc
14-18 years
HEAD SSS
Home
Education
Activity
Diet
Suicide
Sexual activity
SAD (smoking / alcohol / drugs)
OB-GYN
BINDE
Pregnancy:
- Was your pregnancy planned? If no social issues
- Were you having regular follow-up visits? How about U/S? Was it normal?
- During your pregnancy, did you have any illness? How about any fever or skin rash? Have
you ever been in contact with sick kids? Kids with skin rash or fever? Have you ever been in
contacts with pets?
- Did you take medications? Even OTC? Did you smoke? Drink alcohol? Have you ever tried
recreational drugs? What about before pregnancy?
- Were you screened for Hepatitis B virus? HIV? other diseases? There is screening test that
we do a vaginal swab at 36 weeks called GBS, did u have it?
- What is your blood group? What is your baby blood group?
Birth:
- Was your baby full term or not?
- Was it a vaginal delivery or c-section?
o If c-section why? Was there any complication? Abnormality?
o If vaginal was it difficult labour? Prolonged labour? How many hours? Was
there any early gush of water? How many hours? Did you need any help to make
it easier; e.g. vacuum?
- Did your baby cry immediately or not? Do you know what his Apgar score was? Did he need
special attention? When did you leave the hospital?
- Were there any bruises or swellings on your babys body?
- Were you told that your baby had any special features?
- After delivery, did you have any fever / discharge? Did you take any medications?
Immunization:
- Are your babys shots up-to-date?
o Yes when was the last shot?
o No any reason for that?
Our religion prohibits vaccination: ok, that is fine
We think vaccines cause autism: correct this info, vaccines are safe
We were busy neglect concern what is baby weight?
Nutrition:
- Weight:
o
o
o
o
Weight calculation:
What is your babys weight today?
What was his weight at birth?
What was his highest weight?
Do you have access to growth charts?
If below 3rd percentile: underweight
If (at any time) he crossed (down)
two major lines: failure to thrive
At birth : x
5 months
1 year
2 years
Kg
:2x
:3x
:4x
Kg
Kg
Kg
OSCE-guide-III.doc
OB-GYN
Height:
o
o
-
To calculate height:
At birth
X cm
50 cm
1 year
1 X cm
+ 25
75 cm
2 years
1 X cm
+ 12.5
87.5 cm
3 years
1 7/8 X cm
+ 6.5
94 cm
4 years
2
X cm
100 cm
For each year: the baby gains () of the previous year increase, so the baby gains
X by the first year, X by the second year, 1/8 X by the third year.
Diet:
o
Developmental:
Now I would like to ask you some questions about the kind of activities that your child can do,
and other questions to assess his development.
Gross motor
Fine motor
Sit alone / roll over
6 months
Draw line
15 months
Crawling
9 months
Draw cross
2 years
Standing / cruising
1 year
Draw circle
3 years
Walking
15 months
Draw square
4 years
Go upstairs holding
18 months
Draw triangle
5 years
Go downstairs 2 feet
2 years
Tricycle
3 years
Social
Social smile
Stranger anxiety
Separation anxiety
Says NO
6 weeks
6 months
9 months
2 years
Speech / verbal
Mama / papa
2 words beyond Ma, Pa
2-3 words phrases
Short sentences
Speaks fluently
9 months
1 year
2 years
3 years
5 years
N.B. (autism / Down syndrome / child abuse): there is no stranger or separation anxiety.
OSCE-guide-III.doc
OB-GYN
Environment:
- How do you feel being a new mom? How do you feel about your baby?
o How is your mood? You look down for me, any chance you are being depressed?
Did you have depression before?
- With whom do you live? How is the relation between you?
o How is the relation between you and the baby?
o How is the relation between your partner and the baby?
- How do you support yourself financially?
- Do you live in home (basement: mold) or apartment? Is it an old building (lead)?
- Any other children in the house?
- Do you or any body in the home smoke? Drink? Use recreational drugs?
- Is anyone of your family seeing a psychiatrist? Has mental illness?
- In ABUSE cases: tell me more about your childhood
HEAD SSS
Home:
- With whom do you live?
- How is the relation between you? Are they supportive?
- Any siblings?
Education:
- Do you go to school? Do you like going to school?
- Which grade? Which subjects do you study?
- How about your marks, what marks do you get? What about in the past?
Activity:
- What kind of hobby do you have?
- Have you travelled recently?
- In EPILEPSY case: do you operate machines / drive / go hiking?
Diet:
- How about your diet? What do you eat? Do you follow special diet?
- What is your weight? What was your weight before?
Suicide:
- How is your mood?
- Any chance that you might hurt yourself?
Sexual activity:
- Are you dating? Are you in relationship?
- Are you sexually active? When did you start? When was the last time?
- How many partners do you have? Do you practice safe sex?
Smoking / Alcohol / Drugs:
- Now, I would like to ask you some personal questions, it is important to ask it, and it is
confidential, do you Smoke? Drink Alcohol? Have you ever tried recreational drugs?
- Sometimes people at your age might start to smoke, drink, or use recreational drugs. Do you
know any of your friends doing this? How about you? Have you tried that?
- For IV drugs: When was the last time? Did you share needles?
OSCE-guide-III.doc
OB-GYN
Jaundice
A new born 5 days old, with jaundice since day 2
Introduction
Differential diagnosis of newborn jaundice
- Physiologic (usually days 2-7)
CC
unconjugated
- Analyze the jaundice (OCD)
- Breast milk jaundice
- Impact / consequences
- Breast feeding jaundice
- Red flags / rule out infection
Pathologic
(anytime)
- DD
- Hemolysis (unconjugated)
- BINDE
- Infection sepsis (conjugated or
- Birth pathological
unconjugated)
- Nutrition physiological
FH
Introduction:
Good morning Mrs , I am Dr , I am the physician in charge today, I understand that you are
here because your son has jaundice (or is yellow). In the next few minutes I will be asking you
some questions to help me figure out the condition, before I proceed, I would like to know the
name of your child? This is a nice name.
1- Analyze the CC:
- When did it start? Early in the 2nd day (or before: pathological) or late (pathological or
physiological)?
- Who noticed it? You or someone else? When? Where did you notice it? How about his eyes?
How about his feet? Is it spreading? Is it or ?
- How about his urine, is it darker? And stools, is it pale?
2- Impact / Consequences:
- Is he drowsy? Floppy?
- Does he cry? Is it high pitched cry?
- Did you notice his suckling is weaker than before?
3- Red flags / Rule out infection:
- Did you notice if your child has fever or skin rash? Cough / wheezes? Discharge from his
ears? Runny nose? Foul smelling urine? Abdominal distension?
- Any night sweats / chills? Any lumps or bumps in his body? Tender points?
4- Differential diagnosis:
Physiological
Pathological
How do you feed him? Breast milk? Formula? Infection should be ruled out or
Biliary atresia
Hepatitis: neonatal
OSCE-guide-III.doc
OB-GYN
5- BINDE
Birth:
Nutritional history:
- How do you feed him? Breast milk? Formula?
- Breast:
o How many times do you feed him?
o Do you use 1 breast or both of them? How long each?
o After feeding him, do you feel your breast engorged?
- Formula:
o Any reason to choose formula feeding?
o Which type of formula? Do you know how to prepare it?
Environment:
- Any other children? Did any of them develop jaundice after birth before?
6- PMH?!
7- FH:
- Jaundice
- Liver disease
- Blood disease
- Disease called cystic fibrosis
Diagnostic
workup:
When to
suspect
pathological
jaundice?
Treatment
OSCE-guide-III.doc
OB-GYN
IUGR
A newborn 3 hours old with IUGR, counsel the mother
Introduction
News
BINDE
Obstetrical history
Mother PMH
Good morning I understand that you just gave birth, my colleagues are
taking care of your baby. And I would like to ask you some questions
regarding your child health, but first tell me;
- How do feel right now?
- Have you seen the baby?
- Did you pick a name?
Your baby has just been diagnosed with a condition called intra-uterine
growth retardation or low birth weight For that reason; I would like
to ask some questions about your pregnancy!
-
GTPAL
Were you pregnant before? How many times? Any abortions?
Miscarriages?
Any history of chemo therapy or exposure to radiation
Any family history with congenital anomalies
TORCH infection,
OSCE-guide-III.doc
OB-GYN
Crying Baby
Introduction
CC
Analysis of CC
What improves or decreases the crying? When he cries, what do you do?
o Did you try to hug / hold / burp / sooth / play music / give him a
walk?
o Did you try to rock him? Shake him? What happened to him?
When he cries, does he pull his legs? Is he passing gases? Is his abdomen
distended? Is it related to feeding? How are you coping with this?
How does this affect your life? And your partner life? Are you able to go
to work?
Is he drowsy? Floppy?
Did you notice if your child has fever or skin rash? Cough / wheezes?
Discharge from his ears? Runny nose? Foul smelling urine? Abdominal
distension? Diarrhea?
Infantile colics (crying > 3 hrs/day for > 3 days/week for > 3 weeks),
between the age of 3 weeks and 3 months, without another explanation
reassure
Child neglect
Mental problem
Parent SAD
Impact
BINDE
FH
Investigations (not including those for suspicious child abuse): CBC / urinalysis / stool analysis
OSCE-guide-III.doc
OB-GYN
Analysis of the
CC
Cough
Impact
Red flags
Cough
Os Cf D /+/ COCA + B + Phlegm
Certain time of the day? Night?
Acute phase
Chronic phase
Continuous / productive /
Intermittent / dry cough / on and off /
fever / loss of appetite
no fever
Seen by a doctor? What SOB, noisy breathing, wheezes,
diagnosis? Treatment?
chest tightness, nausea / vomiting
Anti-biotic history!
Does he cough to the extent of
vomiting or LOC
Did you renew it? From
the same doctor? Was
Pertussis vaccination?
he examined? Any xrays were done?
How did this affect his life? Daily activity?
Constitutional symptoms
Triggers of Asthma: any thing that this cough?
Chronic diarrhea cystic fibrosis
Any allergy
Brief
Other allergic diseases: atopic dermatitis / allergic rhinitis
Allergic diseases: asthma / skin allergies
Differential diagnosis
BINDE
PMH
FH
Triggers
Infection
Medications
Outdoor
Indoor
Stress
OSCE-guide-III.doc
OB-GYN
Questions:
Diagnosis:
Investigations:
Treatment:
Counselling:
The most likely explanation for that is a condition called: hyper-reactive airways disease.
It is a term used to describe asthma-like symptoms in infants (< 6 years old) that may
later be confirmed to be asthma when they become old enough to participate in asthma
tests (spirometry and bronchodilators).
It may be self limited; however, we need to start treatment with puffer (steroids puffer
for 4 weeks).
When the child becomes older than 6 years, and if the condition is still persistent for
more than 10 weeks, we send the child for investigations (spirometry and
bronchodilators) to confirm the diagnosis of bronchial asthma.
If this condition happens in adults, we treat with puffer for 4 weeks, if no improvement;
we send to investigate for asthma (spirometry and bronchodilators then metacholine
challenge test).
OSCE-guide-III.doc
OB-GYN
Anemia
6-9 months, mother complains he is pale?
1- Analyze the CC
- Clarify CC: What do you mean he is pale? Is he yellow?
- Os Cf D
- Who noticed it? You or someone else? Is there any chance that
he had this pallor before and you were not aware of it?
2- Impact
- Is he drowsy? Floppy?
- Does he cry? Is it high pitched cry?
- Did you notice his suckling is weaker than before?
Signs of
- Is he active / playful like before? What can he do? Is he crawling?
anemia
- If he is doing activity, did you notice any SOB? Fainting?
- Is he gaining weight?
3- Red flags: rule out
- Constitutional symptoms!
infection
- Did you notice if your child has fever or skin rash? Cough /
wheezes? Ear pulling or discharge? Runny nose? Foul smelling
urine? Abdominal distension? Diarrhea?
4- Diff diagnosis:
- Rule out child neglect
- Bleeding disorders: nose / gums / coughing / vomiting / bruises
Iron def. anemia
on body / blood in urine / stools / joint swelling
Thalassemia
Leukemia: Constitutional symptoms / Bone pain [if he walks,
Hemolytic disorders
does
he limp? if you carry him, does he complain of tender
Bleeding disorders
points
in his body] / cough / repeated infection
Chronic diseases
Lead intoxication
Leukemia
5- BINDE
7- Family history
Investigations: lab works; CBC / differential / lytes / serum iron studies (ferritin, TIBC) /
hemoglobin electrophoresis / KFTs / INR / PTT
Treatment: iron supplement
OSCE-guide-III.doc
OB-GYN
Vomiting
The mother of (6 weeks 3 months) old baby came to the clinic complaining of childs repeated
vomiting.
Introduction
Chief complaint
1- Analyze
the CC
2- Impact
3- Red flags -
4- DD
GERD
Wrong formula OR not preparing
it well
Overfeeding OR NOT burping
OSCE-guide-III.doc
BINDE screening
Mother attitude!
Family history of pyloric stenosis
Appear at age of 2 4 weeks
Projectile / non-bilious / baby still
hungry after feeds
Continuous
Other symptoms / neurological:
weakness / neck stiffness / seizures
After feeds
Not all feeds
No in weight
OB-GYN
5- BINDE
6- PMH
7- FH
Pyloric stenosis DD: duodenal atresia / tracheo-esophageal fistula
Management plan:
- Investigations: lab works (CBC, lytes, ABG) / US
- If dehydrated: admission
- If suspicious child neglect: contact CAS
Potential risk factors for child abuse:
- SAD parents (smoking / alcohol / drug use)
- Pregnancy not planned
- Preterm baby
- Congenital anomalies
- Baby who needed special attention after delivery
- Separation from the child
- Difficult child
- Young couple
- Parents with history of abuse
- Stress or financial difficulties in the family
Investigations for child neglect
- Full blood work / CBC / albumin level
- Fundoscopy
- Skeletal survey
OSCE-guide-III.doc
CONTACT CAS
OB-GYN
Diarrhea
Diarrhea
Failure to thrive FTT
What about his/her appetite?
What other associated symptoms? (Respiratory / Gluten)
Cystic fibrosis
Celiac disease
Milk protein
HIV
allergy
From cow milk
- Good appetite - Poor appetite
- Respiratory
- Gluten
Should not be
given < 1 year
NO FTT
Toddlers diarrhea
Infections
Lactase Deficiency
(lactose intolerance)
A 50 years old father comes with 9 months child with 6 weeks of diarrhea (CHRONIC)
1- Analyze the - Os Cf D
CC
- COCA + BLOOD + others:
- Watery / loose / bulky
- Any undigested food
- Difficult to wipe?
- Factors: Juice (Excess fruit juice)
- Identify FTT weight: What is weight today? At birth? Last visit? The
highest weight? Not gaining weight?
- Other GIT symptoms: vomiting
- APPETITE
2- Impact
- Is he drowsy? Floppy?
- Does he cry? Is it high pitched cry?
- Did you notice his suckling is weaker than before?
- Dehydration: do you feel his lips / skin dry? Does he tear? How many
diapers
- Failure to thrive: what about his weight, do you know his weight? What
was his weight at birth? Do you have access to his growth charts?
- Long period malabsorption anemia and rickets
3- Red flags:
- Constitutional symptoms!
(R/O infection) - Did you notice if your child has fever or skin rash? Cough / wheezes? Ear
pulling or discharge? Runny nose? Foul smelling urine? Abdominal
distension? Diarrhea?
4- Differential
DD for ACUTE diarrhea:
diagnosis
- Use of antibiotics
- Infectious:
- Camping / travelling
- Any body else at home with diarrhea?
- Does he go to day care?
DD for CHRONIC diarrhea without failure to thrive:
- Toddlers diarrhea: does he drink too much juice daily?
- Infectious parasitic / travellers diarrhea
- Lactose intolerance:
- Does he pass a lot gas?
- Does he have any redness / skin rash at his buttocks?
OSCE-guide-III.doc
OB-GYN
5- BINDE
6- PMH
7- FH
Questions:
- What is your differential diagnosis:
o Cystic fibrosis
o Celiac disease
- If the biological mother called, want to know about her son, do you tell her or no?
o In order to determine whether I should release any information or no, I would
like first to know who has the legal custody (guardian) of this child. It might be
the adopting father, a social worker (case manager)
Notes:
- If the child was adopted, and you are speaking with one of the new parents:
o Are you the biological mother/father?
o Is this adoption or foster home?
o When was the child adopted? At which age? From where?
o What were the circumstances?
o Do you have information about the biological parents?
o Was he screened for HIV?
OSCE-guide-III.doc
OB-GYN
Weight analysis:
- Weight today, birth, last visit, highest
- When did you start to worry about that? Why?
- Who noticed it?
- Who is the primary care giver? For how long have you been with him?
- Do you have his growth chart? If no: if you do not mind, I need to
contact his family physician to take a look at his charts
Height analysis:
- Height today, birth, last visit
2- Impact
5- BINDE
6- PMH
7- FH
Is he drowsy? Floppy?
Is he playful? Active like before? Any limitations? Does he turn blue
with activity?
Constitutional symptoms!
Any congenital or long term disease?
Review of systems: cardiac/ chest/ GIT/ urinary/ MSK/ skin/ allergy/
pale/ bleeding
Rule out child neglect
Difficulty swallowing (CP, Cleft Palate)
Chronic loss: chronic Diarrhea (Celiac disease, CF, pancreatic
insufficiency) / chronic vomiting (pyloric stenosis in a younger child)
Diabetes mellitus (drinks too much water, pees a lot, tired)
Chromosomal abnormalities / inborn error of metabolism
Scan for risk factors of potential child abuse / neglect
Apgar score at birth
Diet in details: breast feeding/ formula/ cow milk? Any reason? For
how long? Any supplements? Any solid food?
Developmental milestones
Environment: with whom do you live? Who takes care of the baby? Is
he/she capable of doing this?
SAD during pregnancy and now
Under weight:
- Failure to thrive (FTT): weight decreases first then height will be affected later
- Endocrine causes: fat and short
- Congenital: everything is small / short, thin with small head
Failure to thrive
- Weight < 3rd percentile or falls across 2 majors percentiles
- Most common cause is inadequate intake
OSCE-guide-III.doc
OB-GYN
Case: A 2 years old boy does not want to eat. The father carries a bag!
History:
o When you ask about the bag, he says it is for the boy lunch, it is full of candy and a coke.
o Details about breakfast, lunch, dinner and snacks
o Review of systems will be negative
Case: A 6 years old developed severe allergy to peanut, child is now stabilized, counsel the
father.
Is it first time to eat peanuts? Any similar reaction before? Any known food allergy?
Management:
Epi-pen
OSCE-guide-III.doc
OB-GYN
Fever
Introduction
CC
1- Analyze the CC
2- Impact
3- Red flags
SKIN RASH
4- Differential
diagnosis:
Review of systems
FEVER
- Os Cf D
- Any flu at that time?
- Any diurnal variation? More at morning or night?
- Any special pattern? More every 2nd or 3rd day?
- Do you measure it? How many times daily? How do you measure
it?
- Did you try to give any medications to help? Did it help?
- Is it the first time?
- Other constitutional symptoms
- Other persons at home with the same symptoms?
- Is he drowsy? Floppy?
- Does he cry? Is it high pitched cry?
- Did you notice his suckling is weaker than before?
- The fever and constitutional symptoms are already analyzed
- Review of systems: DD
- Is he tired?
- Did you notice any skin rash?
OCD / distribution / color / do you feel it elevated?
Are his shots up-to-date?
- Buttocks / abdomen henoch schonlein purpura /
Investigations: urinalysis Treatment: steroids
- Trunk vesiculo-papular chickenpox
- Face: measles / rubella
- Cheek: fifth disease
- Headache / drowsy / neck pain / rigidity / nausea / vomiting? Does
he recognize you? Talk to you?
- ENT
- Chest: cough / phlegm / SOB / wheezes
- Abdomen (pain, distension, diarrhea) / liver (yellow color, itching,
dark urine, pale stools) / urinary (urine changes, crying while
peeing, loin pain)
- Joints: pain / swelling / mouth ulcers
- Scan for risk factors for child abuse / neglect
5- BINDE
6- Past medical history
7- Family history
OSCE-guide-III.doc
OB-GYN
5- BINDE
6- PMH
7- FH
Physical exam
OSCE-guide-III.doc
Mouth
ENT
LNs
Chest exam
OB-GYN
Rash
Clinical Presentation
Fever, headache, parotitis (bilateral; pushes earlobes up and out), myalgia,
malaise
Measles
Appearance: erythematous maculo-papular rash; Koplik spots
Timing: 10-14 days incubation, rash 3 days after start of symptoms
Distribution: starts at hairline, spreading downwards; palms and soles
typically not involved
Rubella
Appearance: pink, maculo-papular rash.
Timing: 14-21 day incubation; rash 1-5 days after start of symptoms.
Distribution: starts on face spreading to neck and trunk.
Chickenpox
Appearance: macules papules vesicles crusting; all stages apparent
(varicella)
at once (polymorphous rash) very pruritic
Timing:
10-21 days incubation;
1-3 days prodrome: (fever and respiratory symptoms),
Then rash
Distribution: face, trunk, extremities, mucosa, palms and soles.
Erythema
Appearance: uniform, erythematous maculo-papular rash
Infectiosum
Timing: 4-14 days incubation, rash 10-17 days after symptoms
(fifth disease) Distribution: bilateral cheeks with circum-oral sparing, can affect trunk
Roseola
Appearance: pink maculo-papular rash (faint).
Timing: 5-15 days incubation; rash 3-5 days after symptoms.
Distribution: starts at neck and trunk spreading to face and extremities
Management: rest / anti-pyretics / fluids / good nutrition
Mumps
Reye Syndrome:
Acute hepatic encephalopathy and non-inflammatory fatty infiltration of liver and kidney
Mitochondrial injury of unknown etiology results in reduction of hepatic mitochondrial enzymes, diagnosis by liver biopsy
Associated with aspirin ingestion by children with varicella or influenza infection.
40% mortality
OSCE-guide-III.doc
Pediatrics
Delayed Speech
Introduction
Verbal assessment
Rule out any serious condition
BINDE
PMH
FH
Hearing loss
Autism
Anatomical: tie tongue / cleft palate
VERBAL ASSESSMENT
- Would you please tell me more about that!
- When did you start to have concerns? Did you seek medical attention before?
- Is the child able to speak at all? How many words is your child capable of using? When
did he start to say it? Can he use many words in one sentence?
- Was he able to use more words (talk better) and lost them?
- How can he communicate with you? What does he do if he wants something?
I would like to ask you some questions in order to reach to the cause of this condition:
HEARING:
- How do you describe his hearing? Does he have hearing difficulties?
- If you call him, would he respond and reply? What if you are behind him? What if you
are in another room?
- Did you notice that he keep increasing the volume of the TV?
- Did he get repeated ear infections? Fluids in the ears? Discharge?
- Did he take any medications? Any antibiotics (aminoglycosides)?
- Was he ever screened for hearing test, when he was born?
AUTISM:
- Does he maintain eye contact? Does he show emotions?
- Is he aggressive? Does he play with other kids?
- Does he do repeated movements like rocking, or head banging?
- Does he have a favourite toy? How does he play with it? (train / spinning wheels)
- Any family history of autism?
BINDE:
- Start with the development: to rule out MR
Developmental (mile stones):
- What can he do? When did he start to sit? Crawl? Stand? Walk? Climb stairs?
- As a child, did strangers make him nervous?
- Does he control his urine / bowel movements?
Environment:
- Screen for neglect: how many hours you spend with him? Is he a difficult child?
- Family factor: how many languages do parents and other family speak at home?
Pregnancy / Birth:
- Did you have skin rash during pregnancy? TORCH infection? SAD during preg?
- Was it complicated labour? Apgar score?
- Did he have any special features? Congenital malformations? Cleft palate?
OSCE-guide-III.doc
Pediatrics
Counselling
Introduction:
Based on what you have told me, the most likely explanation of your child seizures is a
medical condition we call benign febrile seizure
What do you know about febrile seizures? Do you want me to clarify some information
about it? In details?
Febrile seizures:
This condition usually affects kids 6 months to 6 years, it is not uncommon, and a lot of
children (around 3%) might have attacks.
We do not know exactly the reason for it, but it is related to fever and may be because the
children brain is not fully developed at that age, and can not tolerate high fevers.
Usually it is self-limited, benign, typical attack is less than 15 minutes, and will not recur in 24
hours. Most children will outgrow their condition after the age of 6 years.
Another attack(s):
From the studies we know it might happen again; for each 100 child who got 1
febrile seizure attack:
o 65 children will not have it again
o 30 children will have another attack
o 3 children will have many other attacks even without fever
o 2 children will develop seizure disorder
The best treatment for it is the prevention that is why it is important to make sure that
whenever he gets a fever, to seek medical attention and to decrease the fever ASAP
using Tylenol or cold foments. Then find the source of fever and treat.
I will give you some brochures and web sites in case you want more information.
OSCE-guide-III.doc
Pediatrics
ADHD counselling
The father comes to you saying that his son was diagnosed with ADHD two days ago and he has
concerns about ADHD and Ritalin. Counsel for 10 minutes.
Introduction
To diagnose ADHD:
- 2 settings (school / home)
Address concerns
- > 6 months duration
Diagnosis (symptoms of ADHD)
- < 7 years old child
Impact
Differential diagnosis:
Differential diagnosis
- ODD /+/ Conduct disorder
BINDE
- Specific learning disability
PMH
- Seizures (petit-mal epilepsy)
FH ADHD / MR / autism / depression
- Depression
Conclusion
Introduction:
- Who diagnosed it? Usually teachers recognize it first (pick it), but to make a diagnosis a
psychiatrist, paediatrician, or a specialized nurse assessment is needed
Concern do you give Ritalin (which is amphetamine) to children?
- Actually yes. A lot of children use Ritalin, it is the first line of treatment for ADHD, and it is
effective and has been used for long time.
- It is not exactly amphetamine, it is the same family, it is called methylphenidate and it is
approved for this indication.
- In children, it helps them to focus as increases their concentration and channels their energy,
this is crucial for children, as it allows them to do better in schools. Even though we might
not be able to cure all children with ADHD, by we try to help them with education, so that
they can have career and live independently in the future, without problems with the law.
- It is generally a safe medication in children. It is not addictive, and we can stop it at any time.
However, like any other medication, it has its side effects, that include: insomnia (that is why
we give it early), abdominal pain, and not all children improve on it.
Before talking further about ADHD and Ritalin, let me first ask you some questions to see if your
child meets the criteria of ADHD or any other developmental challenge:
Diagnosis (hyperactive / inattentive / impulsive):
- Did the teachers complain that your child is full of energy? Spinning all the time? Refuse to
stand still? Talk all the time? Answers even if he is not asked? Does he stand in-line or does
he break the queues?
- Can he focus on one subject for > 30 minutes? Can he finish his tasks (e.g. the homework)?
Does he jump from one activity to another without finishing it? Does he lose his stuff? Does
he forget his belongings?
- Is this only at school or also at home?
- Did you notice that yourself?
- How much time do you spend with him? How about the mother, is she involved?
- How about before? Did anyone mention that or no?
IMPACT:
- Impact on functioning, school performance, relationship with peers
OSCE-guide-III.doc
Pediatrics
Differential diagnosis:
ODD
Conduct
disorder
Learning
disability
Petit-mal
epilepsy
Depression
Autism
MR
-
OSCE-guide-III.doc
Pediatrics
Vaccination counselling
New comer to Canada, comes to you as she has some concerns about vaccinations
Introduction / welcome her / how do you feel?
Speak with enthusiasm (to
encourage) with three
Identify the language barrier
counselling sessions:
Identify concerns
- Pap smear
- Deal with concerns one by one
- Breast feeding
- Pose frequently and ask if she has any questions
- Vaccination
Candidacy for vaccination
Mother vaccination
Otherwise, speak neutrally
How do we vaccine?
OSCE-guide-III.doc
Pediatrics
OSCE-guide-III.doc
Pediatrics
Counselling
Complications
Management
OSCE-guide-III.doc
Pediatrics
4- DD
5- BINDE
6- PMH
7- FH
OSCE-guide-III.doc
OS CF D:
- When did it start? How did it start? Sudden or gradual?
- Frequency
- Primary or secondary (dry period(s) of time)?
- Is it continuous or on and off? How often? Day and night? Every
day? Every night?
Factors: stress / drinking too much fluids before bedtime
How does Mom feel about it?
How does the child feel about it (impact of this on child)?
Constitutional symptoms!
Did you notice if your child has fever or skin rash? Odd smell or
colour of urine? Pulls his penis? Cries while peeing?
Rule out child
neglect / abuse
Medical conditions
BINDE screening
Parent attitude!
DM (drinking too much water / going more
often to pee / feeling tired / losing weight)
- Diabetes insipidus (history of meningitis /
brain infection / head trauma)
- UTI (detailed in No 3)
- Neurological: trauma or surgery to back /
bowel dysfunction / leg weakness or
numbness
- Seizure disorder
Stressors
- New sibling
- Home / school change
- School performance
Very briefly because the child is more than 6 years old
- Scan for risk factors for child abuse / neglect
How is his school performance?
Who is the primary care giver, who else does live with them at home,
is he the only child, any sisters or brothers?
Kidney disease
Kidney disease
Bed wetting
DM
Seizure disorder
Pediatrics
Counselling
Management
OSCE-guide-III.doc
Pediatrics
A lot of enthusiasm
Congratulation for the news, how do you feel being a (prospective) mother? It is good to hear
that you plan to breast feed. Do you have any concerns?
I need to ask some questions
If still pregnant:
If already delivered:
OSCE-guide-III.doc
Pediatrics
3- Advice:
- Mother should get enough nutrition, fluids, vitamins and rest.
- Give supplementations of:
o Vitamin D from day 1
o Iron from 4 6 months
o Start solid food from 4 6 months, I will give you a table with the recommended
time and types to start solid food
- Mother can use OCP but it will reduce amount of milk OR use an IUD
- Avoid using any medication without asking your Doctor
- Avoid smoking & alcohol
- Care of the breast: frequent cleaning with water and proper hygiene, warning signs:
engorgement, tenderness, redness, hotness
- I will give brochures & information about BF classes
- I will give you the immunization schedule so that you remember to bring him for followup and for vaccination
- Do you have any questions or concerns?
4- Frequently asked questions about breast feeding:
How often you should feed your child?
- On demand at the beginning
- Then the child will adapt to a schedule of every 3 4 hours
How long should the baby stay on each breast? (10 minutes)
How can you breast feed & work at the same time?
- Use pump & keep the milk in a bottle for 3 6 hours outside and 24 hours in a fridge,
you can keep it in the freezer
OSCE-guide-III.doc
Pediatrics
Psychiatry
OSCE-guide-III.doc
Pediatrics
OSCE-guide-III.doc
Pediatrics
Perception
Hallucinations:
- Visual:
o Usually organic (tumour / epilepsy / cocaine and amphetamine)
o Brain tumour /+/ alcohol intoxication / DT /+/ cocaine / hallucinogens
o Do you see objects / things that others do not see?
o Can you describe what do you see?
o Do they give you any messages?
o Are these messages asking you to harm yourself or anyone else?
- Auditory:
o Usually schizophrenia
o Do you hear voices / things that other people do not hear? When you are alone,
do you hear voices coming from your head?
o How many voices
o Are they familiar or not?
o Are they talking to you or about you? What are they telling you?
o Did they ever ask you to harm yourself or somebody else? What is preventing
you from doing this?
o How do you feel about these voices?
- Tactile:
o Cocaine chronic use (most probably) OR delirium tremens
o Do you feel ants / insects crawl on your body / skin?
- Smell: usually epilepsy
Though
Processing:
o
Content:
+ Obsessions:
- Repeated intrusive thoughts that the patient knows it is wrong, and he can not resist, if he
resists anxiety take actions to try to anxiety (compulsions)
- Mostly regarding: cleanliness, contamination / order / checking /
o Do you have any repeated thoughts or images that you find difficult to resist?
About what? What do you do?
+ Suicidal / homicidal ideation:
o Do you have any thoughts or ideas of harming yourself?
o Or harming other people?
o Any access to weapons?
- If the patient is suicidal / homicidal / can not take care of himself admit, if he/she
refuses form 1 (for involuntarily admission for 3 days for psychiatric assessment
by another physician). Form 1 has to be filled within 1 week from seeing the patient.
- I want to file form 1 for the patient and call the hospital security to bring the patient back.
I have concerns about safety of the patient and other people.
OSCE-guide-III.doc
Pediatrics
+ Delusions:
- False fixed believes, that do not match with the patient cultural and religious background
- You can not convince the patient it is wrong, even with proof
- The ideas
o Believable (could be) non bizarre
o Unbelievable (could never be) bizarre
o Do you believe that other people would like to harm you? OR conspire against
you?
o Do you think that others would like to control you?
o Read your mind?
Thought broadcasting
o Put thoughts into your head?
Thought insertion
o Steal thoughts from your head?
Thought withdrawal
o If you are watching the TV or reading the newspaper, do you believe that they
are talking about you?
Delusion of reference
o Do you believe that you are a special person? With a special talents? Or special
power? Do you believe that you have a special mission to do in life? Do you
think you deserve to be treated specially?
Grandiosity
o Do you feel other people are falling in love with you?
Eromantic
o Do you believe any part of your body is rotten?
Cognition:
- Are you becoming forgetful? Are you losing your staff?
- Assess abstract vs. concrete thinking!
Insight:
- Do you think that you are doing well? Or do you need help?
Judgement:
- If there is a fire in the building, what are you going to do?
- If you find a stamped and addressed envelop on the ground, near the mail box, what
would you do?
General screening:
- Depression:
o What is your mood? How do you feel?
o Did you lose interest in things that were interesting to you before (e.g. certain
hobby, playing something)?
- Anxiety:
o Are you the kind of person who worries too much?
o Do you have excessive fears or worries?
- Psychosis:
o Do you hear voices or see things that others do not?
o Do you think that someone else would like to hurt you?
OSCE-guide-III.doc
Pediatrics
DSM-IV-TR
Diagnostic and Statistical Manual of Mental Disorders 4th Ed/2000 Text Revision
Multi-axial system (5 axes)
The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to
different aspects of disorder or disability:
- Axis I: Clinical disorders, including major mental / psychiatric disorders, and learning
disorders, Substance Use Disorders
- Axis II: Personality disorders and intellectual disabilities (although developmental
disorders, such as Autism, were coded on Axis II in the previous edition, these disorders
are now included on Axis I)
- Axis III: Acute medical conditions and physical disorders
- Axis IV: Recent stressors, i.e. psychosocial and environmental factors contributing to the
disorder
- Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for
children and teens under the age of 18 (a questionnaire)
Example of a full proper psychiatric diagnosis:
- Bipolar I / Anti-social personality / DM+HTN / Divorce / global assessment was not
done because the patient was not cooperative
Diagnosis of diseases based on DSM-IV-TR is based on CRITERIA and TIME.
- Depression:
o MI PASS ECG or MIS GE CAPS
o You need to find at least 5 of the 9 for > 2 weeks, including at least one of the
Mode or Interest.
o If not fulfilling these criteria: non-specified mood disorder
o In teenagers: we do not need M or I, we can replace it with agitation OR drop in
school performance + other 4 criteria.
- Schizophrenia:
o 4 positive symptoms: hallucinations, delusions, disorganized speech,
disorganized behaviour.
o 1 other category; negative symptoms: mood, catatonia
o At least 1 month of active symptoms (2 of 5) + 6 months of deterioration in
functioning.
o 1 active symptom (not 2) is accepted in the following cases:
If the hallucinations are > 2 voices (commanding or commenting)
The delusions are bizarre
- Anxiety:
1- Panic attack vs. panic disorder:
a. In panic disorder, there is at least ONE panic attack with at least ONE month
of worries and fears of having it again
b. Panic attack might be one or more attacks
c. If patient is avoiding going outside with agoraphobia
2- Phobias specific to certain objects
3- OCD
4- GAD: excessive unrealistic fears for more than 6 months PLUS other manifestations
5- PTSD (acute or chronic): Have you ever encountered a situation in which your
personal or mental safety and wellbeing were endangered? When? Do you have
flashbacks or nightmares?
OSCE-guide-III.doc
Pediatrics
OSCE-guide-III.doc
Psychiatry
Mood disorders:
OSCE-guide-III.doc
Psychiatry
Psychosis
Pt comes to the clinic complaining of strange feelings in his right hand
Clarify the CC
OSCD
Criteria :
Hallucinations
Delusions
1st time or did you have it
before?
Past psychiatric history
Organic
Mood / Anxiety
Serious conditions
Social history
Family history
123456
Differential diagnosis:
- Schizophrenia (a mental disorder that impairs the way you perceive reality. It could be
very disabling)
- Brief psychotic disorder
- Post-partum psychosis
- Drug-induced
- Brain tumour
- HIV
- Delirium / dementia
- Mood disorder
Investigations:
- CBC / toxicology screen
- HIV / syphilis test
- Septic workup
- CT / MRI brain
Pay attention to patient cues
- Poor hygiene
- Looking at wall or ceiling
- Paranoid
- Talking to some body.
OSCE-guide-III.doc
Psychiatry
Management:
Will start medication which is helpful in reducing the symptoms (Risperidone). Explain
about side effects: weight gain / blood glucose level / cholesterol / drowsiness
Whenever you suspect substance abuse: after you ask have you ever tried recreational
drugs? ask what about crack cocaine? Do you sniff? Do you inject? Did you share
needles
o
If shared needles scan for hepatitis (liver symptoms), HIV (repeated
infections / repeated diarrhea)
If the patient came because his parents or roommate have concerns, you can ask the
patient: what kind of concerns does have?
Difficult situations:
If the patient with hallucinations tells you that he sees a radiation and gives you a photo and asks:
do you see it doctor? For me it does not look like radiation, but I can understand that you see
this as radiation
At any time the patient starts to agitate and worries about special hallucinations!
o
You are safe here, no body will harm/hurt you
If the patient is away:
o
Do not chase him/her around the room, stand by your chair
o
I would like to assure you that you are safe here, no one will harm you
I do not like Egyptian people, by the way, are you Egyptian doctor?
o
Why are you concerned about that?
o
Whether I am Egyptian or not will make no difference in this situation
I do not like gays, by the way, did you see a gay patient today doctor?
o
Why are you concerned about that?
o
As a physician, I deal with all patients, regardless their race, religion, sex, sexual
orientation or anything else!
Do you think I am crazy doctor?
o
There is no medical term called crazy. However sometimes some people have
difficulties in the way they handle their thoughts and the way they interact with and
perceive reality, we call that schizophrenia. It is a mental illness like any other illness that
can affect the body, that we can treat with medications
Case: A young man can not move his neck, DD acute dystonia:
Trauma
Meningitis
Subarachnoid hemorrhage
Cervical disc
Muscle spasm
The doctor should get the phone number and address and ask the nurse to call 911
Ask her if you can speak with the patient psychosis patient
OSCE-guide-III.doc
Psychiatry
Delusions
Magical believes
Limited number of friends that share the same believes
Ethical challenges:
- Will you hook me to the cleaning machine that cleans the blood? I am glad you came
here today, I think you need help, but not with the machine.
- Will you admit me doctor? We need further psychiatrist assessment then we may need to
admit you.
OSCE-guide-III.doc
Psychiatry
Panic attack
Patient comes to the clinic complaining of dizziness
Clarify the CC
Analysis of CC
HPI
Criteria
during
attack
(AS)
Between
attacks
Anxiety
MOAPS
Past psychiatric
history
Serious conditions
Hypoglycemia
Thyroid disease
Pheochromocytoma
SAD (cocaine / amphetamine / alcohol withdrawal) / Caffeine
Arrhythmias / MVP
Anemia (fatigue / light headedness / heavy menses / PMH anemia)
Constitutional symptoms
Self care
Suicide
AMPLE
Heart diseases / thyroid / abdominal tumours
PMH
Family history
Social history
17
Any heart racing, ask the patient can you tap it for me, then comment to the examiner: it
looks regular / irregular for me
OSCE-guide-III.doc
Psychiatry
COUNSELLING
-
With what I heard from you today, the most likely diagnosis to your symptoms is a
medical condition that we call panic attack. We still need to do physical examination,
some investigations like blood works, urine analysis, electrical tracing of your heart
(ECG), to exclude other medical conditions and to confirm our diagnosis.
o Now Mr what do you know about panic attacks?
o Do you want me to explain this in details over the next few minutes?
Inform the patient:
o Explain the pathophysiology: panic attack or panic disorder is a kind of severe
anxiety, it happens suddenly, in attacks. Usually it is related to stress.
o It is due sympathetic over-activity, imagine you are crossing the road, and a
speedy car is approaching you, normally, our body reacts to this by enhancing the
sympathetic nervous system, which leads to some changes: increase in the heart
rate, rise in blood pressure, and you feel alert. This is normal and useful reaction.
o The same reaction might happen suddenly without any external trigger, and this
would be stressful, and this is what we call a panic attack.
o Consequences: this might happen again / may cause significant limitations
Preventive measure:
o Life style modification (caffeine and alcohol / better sleep hygiene)
o Relaxation techniques (e.g. breathing techniques / meditation)
Treatment:
o Like many other conditions, it could be treated.
o Treatment varieties include:
Talk therapy
Medications: 2 types
Anti-anxiety: Lorazepam 0.5 mg qhs x 2 weeks (it is important
to use it on schedule, not irregularly)
SSRIs: Paroxetine 10 mg od x 4 weeks similar to what we
usually use with depression. Like any other medication, they
have their side effects; GIT disturbances, headache, some sexual
dysfunction. And this improves by time.
Follow-up 2-3 weeks
Offer more information: brochures / web sites
Whenever you suspect social problems involve the social workers
OSCE-guide-III.doc
Psychiatry
Os Cf D
Tiredness
- Is it weakness? Can not do?
- Lack of energy? Tiredness?
- Limitation of activity? How many
blocks are you able to walk?
- Not being refreshed after sleep? Do
you have any special concerns?
Timing:
- Morning or all day: ?depression
- End of the day: organic
- How many hours? And before?
- Find difficulty falling asleep?
- Do you wake up during night?
- When you wake up, do you feel
refreshed? Do you need naps?
sleep / insomnia
? depression
Criteria : MI PASS ECG
1st time or did you have it before?
What about the opposite?
Past psychiatric history
Organic //
Anxiety / psychosis
Serious conditions
Social history
Family history
Counselling on depression
MI mood / interest
PMH of cancer
Social history SAD
Family history
Diabetes Mellitus:
- Hx of DM
Fluctuations (acute)
- Symptoms:
Complications (chronic) vascular
MICRO
MACRO
- Eat more
- Blurred vision
DKA
- Nephropathy
- CAD
- Drink more - Tired
Hypoglycemia
- Neuropathy
- CVS screen
- Pee more
- Weight loss
- Retinopathy
- PAD /
impotence
N.B. -blockers are contraindicated in DM: it causes hyperglycemia / and it masks hypoglycemia
OSCE-guide-III.doc
Psychiatry
OSCE-guide-III.doc
4- Fatigue
- Depression / PTSD
- Domestic abuse
- Hypothyroidism
- Fibromyalgia
- Anemia:
- Old person: think cancer & occult blood
- Young female: think menorrhagia
- Diabetes Mellitus, polyuria
- Anorexia nervosa
Psychiatry
Insomnia
A lady complaining of insomnia
Common presentation to: domestic abuse / depression / anxiety
Introduction
CC
Clarify the CC
Insomnia / Tiredness
- Difficulty falling sleep
- Waking up
Analysis CC: Os Cf D
- More at certain time of the week?
- Did you try anything to help? Did it work?
Ask about sleep Sleep hygiene questionnaire
Anxiety - Do you have too many worries?
- What comes in your mind before falling asleep?
- Any changes / stresses in your life?
- Do you wake up with nightmares?
Depression - Screen with MI; if positive screen MI PASS ECG
PMH
Social
- With whom do you live? Support?
Screen for domestic violence or spouse abuse
- Children?
- Financial support?
Notes
Did you ever think to hurt yourself? NO, my kids need me,
o What about if they are not around? Maybe!
o This means: implicit yes to suicidal ideation
OSCE-guide-III.doc
Psychiatry
ASSURE confidentiality: I would like to assure you that our conversation is completely
confidential, whatever you will tell me here, I will not release any information, unless
otherwise required by the law!
With whom do you live? How do you describe this relationship? Supportive?
o How long have you been in this relation?
o Do you feel safe at home? In this relationship?
Do you or your partner go through stressful times?
o Do you sometimes have conflicts? Arguments?
Is there any chance that you partner drinks or uses drugs? How often? When he drinks,
does he become angry? Lose control? When was the last time?
Verbal / emotional:
- Does he start to shout at you? Swear at you?
- Does he call you names? How does this affect your self-esteem?
Physical:
- Did he ever get angry to the extent that he became physical?
- Did he try to put you down? Does he try to control you? How did this affect you?
- Did he try to push you? Hit you? How many times?
- Any visits to the ER? When was the last time?
Financial:
- Who is controlling the spending at home?
- Do you have access to financials? Do you take permission?
- Did he ever to try to take you money against your wishes?
Sexual:
- Did he ever force you to do sexual activity against your will? How do you feel?
-
Children involvement:
- Did he ever mistreat / abuse you in front of the children?
- Did he ever mistreat / abuse the children?
Fatality:
- Do you have access to weapons at home?
- Did you ever have thoughts to put an end to this all by ending your life or his life?
- Did you ever talk to anyone about this?
OUTCOME:
- The patient decides to end the relationship and leave you must provide support and
shelter
- The patient decides to continue: either with OR without police involvement
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Psychiatry
Wrap-up:
- Based on what you have told me, what you are experiencing (or have gone through) is
called domestic violence or spouse abuse, and it is common. It is an illegal crime, and it
is against the law.
- It is not your mistake, and you should not feel guilty about that. It is unacceptable, and
nobody deserves to be treated in this way.
- We know from studies that the situation will not improve, on the contrary, it will
deteriorate, and you do not need to accept this. The studies show that the longer you stay
in this relationship, the higher the chance of abuse.
- Consequence to the children (if any): psychological trauma
- It is important that you consider reporting the situation to the police for your safety. It is
difficult decision to leave or stay.
- The husband needs help, check willingness to get counsel.
-
OSCE-guide-III.doc
Psychiatry
Child Abuse18
The child came to the ER with femur fracture, the skeletal survey showed multiple healing
fractures, counsel
Introduction
BINDE
Other children
PMH of the child
18
Good TWO screening questions: immunization (not up-to-date) / weight (FTT or under
nutrition)
OSCE-guide-III.doc
Psychiatry
Wrap-up:
-
OSCE-guide-III.doc
Psychiatry
Domestic abuser
You are bout to see a 55/60 years old gentleman, whose wife is recovering in the ER, she has
bruises, and he asked to speak with you. In the next 10 minutes counsel him
Introduction
Analysis
SH / Safety
Counsel
Domestic violence
Anger control
Stress management and relaxation techniques
Drinking problem rehabilitation
Marital counselling
Introduction:
If the patient asked to see you: I understand that you are here because you are accompanying
your wife, she has bruises and my colleagues are taking care of her right now. How can I help
you today?
If the patient is inquiring about her status: I can assure you that she is stable and in safe hands
now.
If the patient asks to see her: After we will finish, I will ask her, if that is ok with her, I can
take you there.
Analysis:
Do you have any idea how did she end up having all these bruises?
Was there any argument / disagreement / shouting? Did you lose control? Did it end up that
you physically hurt her?
Is this the first time or happened before? Any repeated visits to the ER before?
Social history:
How long have you been together? What is the nature of your relationship? Stable? Was there
and significant conflicts before?
Was there any recent change or stressor in your life? How do you support yourselves
financially? Do you have enough resources?
Do you have anybody else at home? Any family support? Do you have children? How is the
relation with them?
SAD
Safety:
Criminal record / access to weapons at home
If you go home now and face the same situation, how would you react?
Any chance that you might hurt yourself or any other one?
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Psychiatry
Counselling:
I can see that you are going through stressful period of time. It must be difficult for you and
your wife. Sometimes this stress might present by changes in behaviour and/or personality.
If you do not have enough support at home, things might get out of control.
What happened is what we call domestic violence; it is a kind of physical abuse. It is not
acceptable, and it is considered illegal crime. However, this is your wife decision. If she
chooses to report you, that is her right, and nobody can prevent her. She can press charges
against you, and they will take you to the court, in this case you might need legal help, this
might have serious consequences.
On the other hand, if she decides not to take any measure, may be you should try to improve
the situation by taking steps to decrease the stress in your life, and you can consider reducing
your alcohol drinking. Drinking alcohol might leads to what we call disinhibition in which
one might lose control on his reactions and usually this leads to violent and serious
consequences.
I can help you by referring you to attend:
o Alcohol rehabilitation programs
o Stress management and anger control programs
I recommend also that you consider attending family marital counselling; they have good
experience in dealing with couples going through difficult times.
Finally, I can help you to contact the social services. They might be able to help; you can
speak with them and see what they might be able to do! Is that ok with you?
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Psychiatry
Depression
Screen: MI PASS ECG
Organic:
Illness: hypothyroid, anemia / pernicious anemia, M.S, cancer / cancer pancreas
Medication B Blockers, Anti-parkinsonian
SAD
Actually, Mr as I told you, I have concerns about your safety, we can not
compromise your safety. And by allowing you to leave today, we will be
compromising your safety.
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Psychiatry
Dysthymia
COMMON CASE IN THE EXAM
Depression presentations:
o Sad (low mode), weight loss, insomnia, tired
Scale the sadness 0 10
o Indecisiveness: difficulty making decisions
o Low self esteem how do you feel about yourself?
o If good days: ask for periods (check for gaps 2 months)
Screen MI:
o If positive MI PASS ECG
If positive assess SAD PERSONS
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OSCE-guide-III.doc
Psychiatry
Analyze
the CC
AS
Impact
Red flags
DD
Medical problem
PMH
FH
SH
Somatisation
MOAPS screening (screen for depression)
PMH: HEAD SSS
FH of psychiatric disease
SH
Counselling
Physical examination
Notes:
- Somatisation disorder: (4 pains / 2 GIT / 1 neuro / 1 sexual) complains
- If the pain is only during the day, and not nights mostly non-organic
OSCE-guide-III.doc
Psychiatry
Somatoform disorders DD
General Characteristics:
Physical signs and symptoms lacking a known medical basis in the presence of psychological factors
Cause significant distress or impairment in functioning
Symptoms are produced unconsciously
Symptoms are not the result of malingering or factitious disorder which are under conscious control
Primary gain: somatic symptom represents a symbolic resolution of an unconscious psychological
conflict; serves to reduce anxiety and conflict; no external incentive
Secondary gain: the sick role; external benefits obtained or unpleasant duties avoided (e.g. work)
Management of Somatoform Disorders:
Brief frequent visits
Limit number of physicians involved in care
Focus on psychosocial not physical symptoms
Minimize medical investigations; co-ordinate necessary investigations
Biofeedback
Psychotherapy: conflict resolution
Minimize psychotropic drugs: anxiolytics in short term only, antidepressants for depressive symptoms
Somatization disorder
Conversion disorder
Pain disorder
Hypochondriasis
Fibromyalgia
Chronic fatigue
syndrome
Factitious disorder /
malingering
OSCE-guide-III.doc
Patient education
Exercise program (walking, aquatic exercises), physical therapy
(good posture, stretching, muscle strengthening, massage)
Stress reduction, CBT
Amitriptyline 10 25 mg qhs
Gabapentin 300 mg tid
Psychiatry
OSCE-guide-III.doc
Psychiatry
Drug seeker
If you find a man searching in the drawers of the hospital, firmly ask him to stop, tell him this is private
property and he is not allowed to go through this medical stuff
I wish it could be that simple, but I need more information and physical exam before I can write any
prescriptions to you, as I am a little bit concerned about the amount you have been taking, which might
have been harmful to you
Introduction
HPI
Analyze
the CC
AS
Impact
Red flags
Analyze Tylenol 3
Other medications
Counselling
Analyze Tylenol 3
-
OSCE-guide-III.doc
Psychiatry
Given the benign history with no suspicion of ICP or focal deficits, and description of headache
consistent with the common tension headache, full neurological examination is not indicated, I
would like to perform a brief neuro screening exam move on.
Counselling:
- I understand that you are here to renew your Tylenol 3; we will discuss that, but before
that let me ask you: what is your understanding of Tylenol 3?
- Tylenol 3 is a good medication when it is used for particular indication. Do you know
what does it contain? It contains 2 medications:
o One of them is the regular Tylenol as you buy it from the pharmacy
o The other one is codeine
- Tylenol itself is a safe and effective drug, and can be used for long time, however, if there
is no strong indication to use it, it is better to it as it might cause liver and kidney injury.
- On the other hand, the other medication codeine it is a drug belongs to the family we
call narcotics which is similar to morphine. It is an excellent pain killer if used for short
term, but, if it is used for long term, this is concerning for us, do you know why?
o First of all, people need to keep increasing the dose in order to obtain the same
effect; we call that tolerance.
o Also, if you stop using it suddenly, you will have withdrawal symptoms,
similar to that you have now; running nose, tearing, N/V, diarrhoea, drowsiness,
muscle aches, sweats, shaking, and heart racing.
- For these reasons, people get easily hooked on Tylenol 3, and can not stop it. Not only
that, they will need to keep increasing the dose. We call that a habit forming
medication.
- If I renew your medication, I will not be helping you, it will be like a vicious circle, and
the more I renew your medication; the more dependent you will be on it; the more you
will need it. For that reason it is not the right step to renew it.
o Can you give me just few pills; I have a very important interview?
o Even if I give you few pills, this is not the solution, this will be temporarily, and
the problem will keep increasing. We must stop the drug
o I can help you with sick note
o I can give you another non-narcotic medication that can help you with your pain
- I appreciate your trust to give me all the information, but based on what you described,
you are having dependence on narcotics.
- It sounds like you have been going through a lot of stress in your life. I am wondering
that if you would be interested in talking to one of our social works here, who is expert to
find out the community resources for you.
There are also some numbers you can call; they are professionals to help people deal with
medications or drugs. Or if you like, I can refer you to a detoxification center, where they
will help you to quit.
The seeker may be seeking Fiorinal
-
Fiorinal is a combination preparation of (barbiturate / caffeine / ASA) properly used only for the
relief of occasional tension headaches.
It is a habit-forming medication; that can precipitate withdrawal symptoms: agitation, delirium
and seizures.
The fact that patient consumes a lot suggests overuse due to dependence.
The patient may also develop analgesic headache syndrome, in which inappropriately used
analgesics actually cause headache.
Suggest a drug holiday, with weaning from caffeine and alcohol, proper sleep hygiene, diet
control, exercise, and stress management.
OSCE-guide-III.doc
Psychiatry
Lithium discontinuity
Introduction
Mania
History
Have been diagnosed with bipolar 3 years ago, and would like to
discontinue your medication.
What is the medication you want to stop?
Why would you like to stop your medication?
I am glad you came here to discuss it, any other concerns
Today
Lithium
Scan for
depression
History
Side effects
MOAPS
Do you feel: DIG FAST (distractibility, impulsiveness (with painful consequences), grandiosity,
flight of ideas, activity, sleep, talkative)
D Do you have a lot of projects? Were you able to finish it to the end? Can you focus on
multiple projects?
Are you spending more money than before? Are you borrowing money that you can not
I
pay back? Are you over-using your credit cards?
With whom do you live? Many sexual partners?
SAD: what started 1st; feeling high or talking drugs?
Have you had problems with the law? Fighting? Arrest? Speeding tickets?
G Do you feel very special? Have special mission?
Do you feel a lot of thoughts? Ideas?
F
A How much time do you spend on your projects?
How many hours do you sleep? Any changes?
S
T Did anybody mention that you are talking fast?
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OSCE-guide-III.doc
Psychiatry
Manic patient
If the patient is psychotic:
First step is to detect early what is his mood?
- If high mood:
manic attack, with psychotic feature
- If no high mood:
brief psychotic disorder / schizophreniform
Usually patient brought by police or family member or asked to come by family members
Patient is talking fast and a lot, laughing, moving around
Ask whether the patient has been on medication before or not, e.g.: Lithium
Ask about any side effects of lithium medication N/V / Diarrhea / tremors / polyuria
Obtain history in the usual format
Introduction
Ask about the Mood
Assure the patient
Red flags
HPI
MOAPS
PMH / FH
SH
Assure the patient: you are safe here, you are in the hospital and no
one will hurt you
Fever / headache / nausea & vomiting / head injury
OCD
Mania (DIG FAST)
Depression (MI PASS ECG)
Suicide (SAD PERSONS)
If you leave what will happen? What would you like to do?
Screen
SAD: alcohol / substance abuse / amphetamine
Medical conditions; hyperthyroidism: history of thyroid
problems, symptoms (heart racing, sweating, heat intolerance,
neck swelling, visual field changes)
Psychiatric disease
N.B. if any patient has mood disorder; go through DIG FAST and MI PASS ECG
Management:
Explain that the patient has recurrence of his mania or bipolar. This is because he stopped
taking the Lithium.
Will examine and do some tests.
Will start medication. If Lithium is causing some troubles, we can start another medication.
Usually you need to admit the patient to control the symptoms of mania (from what you have
told me, you are meeting the criteria of what we call manic episode and I have concerns
about your safety).
OSCE-guide-III.doc
Psychiatry
Suicidal attempt
Introduction
Before
After
Psychiatric assessment
Risk
MOAPS
LOTS OF EMPATHY
And to see what should be the next step, first, I would like
to know how you feel about being saved.
o If happy, I am glad for that
o No!
Assure confidentiality
Can you tell me more about what happened?
What is the name of the medication? How many tablets? Any
alcohol with it?
Why did you do that?
Is it the first time?
Who saw you and brought you to the hospital?
Assess the plan here, was it organized? Or it was an impulse?
Did you leave a note? Recently, have you been giving your
belongings away?
What is going in your mind now?
If you leave the hospital, what are your plans? Where do you
want to go? What do you want to do?
If another crisis may happen, are you going to hurt yourself?
Were you seen by a psychiatrist? Were you given a diagnosis?
Do you see your psychiatrist? Take meds?
Assess the risk factors: Analyze SAD PERSONS
Screen for anxiety
Screen for psychosis
Screen for suicidal / homicidal ideation / self care
Past medical history / allergy / medications /
Decision
Conclusion / Counselling
SAD PERSONS
S
A
D
Sex Ag Depressio
Mal e
n
e
>
65
P
E
Previou Ethano
s
l
attempts
SAD
3-4
>5
E
R
N
R
Rationa
l
thinkin
g lost
S
Suicid
e in
the
family
O
Organize
d plan
N
NO
suppor
t
S
Seriou
s
illness
HEAD PMH
SSS
SAD
What did you think will achieve by ending your life?
Sometimes people hear voices asking them to end their life, did you hear this?
HEAD SSS
H: With whom do you live? Anybody else? Anybody else? If there is a stepparent in the image, ask about the relations with him and with other parents. Do you
feel safe at home? Then ask gradually, if there is a chance that this parent might get
angry when he drinks? May shout, may swear at, may push, and may hurt?
- Past medical history
OSCE-guide-III.doc
Psychiatry
Decision:
- If still depressed and/or SAD PERSONS (>3-5) admit
- It she is ok, regrets the accidents, no SAD PERSONS release
Conclusion / Counselling:
HOSPITALIZE
- Based on our interview, I have concerns about your safety, because you have more than
THREE risk factors for suicide as per the screening test. Do you mind to stay with us in
the hospital for few days, so we can do the required investigations and start the
medications, until you feel ok, what do you think about that?
RELEASE
- Based on our interview, it is ok if you would like to leave, but you have to arrange a
follow up meeting with your family doctor within 3 days.
- However, I would like you to know that life sometimes could be challenging, and you
may face challenges in the future. It is important that you learn how to deal with
challenges. If you feel over whelmed, talk to somebody, and ask for help
- I can arrange a meeting with a social worker, a psychiatrist!
- I would also like you to promise me that if at any time you want to harm yourself or end
your life, you will seek medical help immediately; you can come to my office or call 911.
If multiple suicidal attempts borderline personality disorder do NOT admit
Notes:
- If no eye contact, wasting time, no pt interaction assure confidentiality
- Whenever you hear car accident show empathy / did you hurt yourself / ask about
who was in the car / was any one injured?
- If the person driving was < 18 and was driving alone be curious this must be an
important meeting / person that you really did not want to miss!
- The girl asks you to tell her mother that she crashed mothers new car! She does not want
to directly (herself) inform the mother!
o I can not do this.
o Why do you think this would help? She will not be angry
I see, however, life is full of challenges, it is better that you try to learn how to
deal with challenges yourself.
o We can help you to tell your mother by yourself, we can arrange a meeting with
your mother, I can be present, or we can ask a nurse or a social worker to be
there.
- The girl does not want to inform her parents that she did attempt suicide!
o You assess her and if she is to be released, e.g. she regrets what happened, she is
happy to be saved, no SAD PERSONS risk factors she is competent
respect her wishes.
OSCE-guide-III.doc
Psychiatry
Eating disorder
Young female, her parents brought her because they have concerns about her weight
Anorexia nervosa
Restrictive
Bulimia nervosa
Binge-purge
Under weight
Distorted self image
Amenorrhea
Weight analysis
Diet
Exercise
Extra measures
Impact
MOAPS
- Mood:
scan for depression
- Organic: DM / hyperthyroidism / constitutional symptoms (cancer)
- AP:
screen for anxiety / psychosis
- S:
HEAD SSS
FH
Eating disorder / psychiatric illness / suicide
Weight analysis:
- What is your weight today?
- When did you start to lose weight? What was your weight at that time? How much did
you lose? What was your highest weight? What is your target weight?
- Why are you losing weight?
- Are you losing weight alone? Or someone else is encouraging you?
- When do you look at yourself in the mirror, how do you perceive yourself? How do you
perceive your weight?
- Do you like to dress in baggie?
- It looks like you lost a lot of weight in short period of time; I would like to know how did
you achieve that?
Diet:
Let us talk about your diet;
- How many meals do you eat per day? How about snacks?
o What do you eat in breakfast? How about the amount?
- Do you calculate calories? How much calories do you eat per day?
- Do you eat alone or with other people?
- Do you like to collect recipes? To cook?
OSCE-guide-III.doc
Psychiatry
Exercise
- How about exercise? Do you exercise?
- How many times a week?
- Do you dance? Practice any sports?
Extra measures:
- Do you take anything else to help you to lose weight?
- Do you take stool softeners? Do you take water pills?
- Did you try before to induce vomiting?
- Do you sometimes exceed the amount of food you intended to eat? How many times a
week?
- How do you feel after that? How do you compensate?
Impact / consequences:
Because you have lost a lot of weight, I would like to know the impact of this on you!
- Do you have amenorrhea? When was the LMP? Regular?
- Do you feel cold / tired / swelling in your legs?
- Pigmentation on your skin? Fine hair growth? Skin changes?
- Any bony pains? Fractures?
- Muscle cramps? Calf pain?
- Heart racing? Light headedness, dizziness, fainting?
Conclusion:
- I am concerned that you have a condition called Anorexia Nervosa (explain)
- It is affecting your body, without treatment it could be fatal
- The treatment is to start eating and to gain weight. It is a tough task but I will refer you to
a multi disciplinary team to start treatment
- Would you like to discuss that with your parents
Management of anorexia nervosa:
- Anorexia patient is to be admitted to hospital if:
o <65% of standard body weight (<85% of standard body weight for adolescents),
o Hypovolemia requiring intravenous fluid,
o Heart rate <40 bpm
o Abnormal serum chemistry or if
o Actively suicidal
- Agree on target weight on admission and reassure this weight will not be surpassed
- Psychotherapy (individual/group/family): addressing food and body perception, coping
mechanisms, health effects
- Monitor for complications of AN
- Monitor for re-feeding syndrome: a potentially life-threatening metabolic response to refeeding in severely malnourished patients resulting in severe shifts in fluid and electrolyte
Bulimia nervosa:
- Criteria for admission: significant electrolyte abnormalities
- Treatment: biological (treatment of starvation effects, SSRIs), psychological (cognitive
behavioural therapy, family therapy, recognition of health risks)
Notes: So doctor do you agree with me that I am overweight? Or do you see me like my parents I am not
good?
- I will share your parents concern, it looks like you lost significant weight in short period of time,
and this is concerning.
- If the patient lost interest slow down summarize and start again slowly
OSCE-guide-III.doc
Psychiatry
12
15
20
13
16
21
23
24
26
Close your eyes!
17
18
3 steps command
Aphasia (pen / watch)
Read / execute
Write
Copy
Repeat
1-5 / Orientation to place: do you know which country we are in? Province? City? Hospital (or
street) name? Which floor (or suit number)?
6-10 / Orientation to time: do you know which year we are in? Season? Month? Day of the
month? Day of the week?
11-13 / 3 words recall immediate: I am going to tell you 3 objects, and I would like you to
repeat after me and memorize it, and I will ask you about it later! (penny/ tree/ car)
14-18 / Concentration: can you spell the word world backwards? He gets -1 for each nonmatching letter (first check if he can spell it correctly forward)
19-21 / 3 words recall delayed: can you tell me the 3 words that I told you before
22-24 / 3 steps command: give all the instructions at once; are you left or right handed? Can you
please take this paper by the hand / fold it into halves / give it back to me?
25-26 / Aphasia (pen / watch): what is the name of this? What is this?
27 / Read and execute: can you read this sentence and do what is written in it!
28 / Write: can you write a sentence for me!
29 / Copy: can you copy these two shapes!
30 / Repeat: can you repeat after me; no ifs, ands, or buts!
MMS score < 24 incompetent
OSCE-guide-III.doc
Psychiatry
Dementia
Difficulty with memory for 6 months
Introduction
Analysis of CC
Behavioural
changes
MMS
DEATH
SHAFT
MOAPS
Let us take a day of your life; I would like to see how did it affect your life?
Activities of daily living (ADL)
Instrumental Activities of Daily Living (IADL)
Organic in details and screen the rest (especially mood for pseudo-dementia)
Memory assessment: Can you tell me more about this difficulty! OCD +
- Any fluctuations in memory level?
- This deterioration is gradual slowly progressive, or is it you feel ok for a while then you
have attack then you are fine then you have another attack? (step ladder)
- Are you having difficulty memorizing numbers?
- Do you have difficulty finding words?
- Do you have difficulty reading? Writing? Calculating?
- Do you lose your stuff?
- Do you make lists to remind you to do things you used to do on regular basis? Do you
have difficulty organizing your schedule?
- Do you have difficulty doing tasks you used to do before; like tying a tie?
- Do you feel difficulty for new events, or old events?
o Recent: What did you have for breakfast? Confirm from partner!
o Remote: Who was the USA president during WWII? (Roosevelt)
ADL DEATH:
- Dressing:
- Eating:
- Ambulatory:
- Toileting:
- Hygiene:
IADL SHAFT:
- Shopping:
who is responsible for shopping? You or your wife?
- House keeping: how about house keeping, are you able to help your wife?
- Accounting:
who is responsible for banking at home?
Did you ever give cheque without balance?
- Food:
do you cook? Did you ever forget the stove on?
- Traffic: do you drive? Difficulty driving? Have you ever lost your way?
OSCE-guide-III.doc
Psychiatry
MOAPS screening:
Mood:
- Depression pseudo-dementia?
Organic:
- Do you have nay long term disease? Kidney? Lung? Heart?
- SAD
History of stroke? Difficult with vision / hearing? Weakness / numbness? Loss of
balance? Urinary incontinence?
Head trauma? Injury?
Brain tumour / infection
- Medications? OTC? Sleeping pills?
- Any history of thyroid disease? Symptoms of hypothyroidism?
Hx of surgeries? In stomach?
Are you vegetarian? For how long? Do you take supplements? pernicious anemia
Anxiety
Psychosis
Self care / suicide
Dementia cases:
- 69 years old man comes to your clinic because he is keeping forgetting for the last few
months. In the next 5 minutes; take history and assess (this is too long for 5 minutes, but
during taking history, and if you mention: I would like to do the MMS exam, the
examiner will give you the score) Alzheimer.
- 55 years old patient comes to your clinic because he has difficulty in memory. His MMS
score is 21. In the next 5 minutes, take history thyroid.
- 67 years old man, comes to your clinic complaining of difficulty with memory. In the
next 10 minutes take history and assess (make MMS exam) Dementia.
The cases could be:
- Thyroid disease (especially if pt is younger than 60 years)
- Alzheimer disease
- Dementia
- Depression pseudo-dementia
- HIV
- Pernicious anemia
- NPH (normal pressure hydrocephalus): if the patient has difficulty in AT of the
DEATH; i.e. falls due to ataxia and urinary incontinence
OSCE-guide-III.doc
Psychiatry
Delirium
Delirium cases:
- A middle aged gentleman comes to your clinic because his dad is not himself for the last
3 days. Take history by proxy
- A middle aged gentleman comes to your clinic because his mom is in seniors home; they
gave her 15 units of insulin instead of 5 units, and she is not herself. Counsel him!
(insulin induced hypoglycemia stressful event decompensate a border line
delirium)
- Patient has surgery 3 days ago, not feeling himself. Patient will be aggressive.
- Patient has surgery 3 days ago, not feeling himself. Patient will keep repeating: I do not
know! mini-mental status exam
Case 1: Dad has not been himself / not sleeping well
Introduction
I will ask some questions in order to reach a working plan
Analysis of the CC
How old is he? What are your concerns?
Tell me more! Any recent stress? OCD
Did you notice if your dad is angry / aggressive?
Does it look like your dad is seeing things do not exist? Hearing
voices? Complaining of insects crawling on his skin?
Does he sleep during night? What a bout during the day?
Is he eating? Taking care of himself?
With whom does he live? How is he capable of keeping life? How
does this affect his / their life?
Is it first time?
Constitutional symptoms
Causes
DD Any headache / vomiting / neck pain / skin rash / red eyes / any ear
discharge / runny nose / teeth pain / diff swallowing / SOB / cough /
Infection
urine changes / abd pain / calf pain / swelling
Trauma Head trauma? Injury?
Surgery Recent surgeries? Pain at site of injection? Dressing change?
SAD SAD
Medications What about medications, do you have a list with medications? Go one
by one!
- Is he hypertensive? Controlled? Regular measurements?
- I can see that he is diabetic; for how long? Controlled? Regular
f/u and measurements? HbA1c?
- Cholesterol / Water pills / Anti-depressants
- Sleeping pills; if more than 1; ask if it was prescribed by the
same doctor
- Erythromycin!!! Why was he taking it? Pneumonia!
Conclusion
It looks like your dad has a medical condition called delirium it is a
serious condition. Your dad needs to be seen by a doctor ASAP, can you
bring him to see me. If he is too far, he needs to be taken to the nearest
ER; we will need to decrease or stop some of his medications, and restart
them gradually.
Theophylline (for asthma): stop and take beta 2 agonist instead
Erythromycin (for pneumonia): change the antibiotic
Lorazepam: discontinue
OSCE-guide-III.doc
Psychiatry
Case 2: DT
Patient is agitated, delirious and uncooperative
I can assure you that are safe here, you are in the hospital and no one will
Introduction
hurt you, we would like to help you
I can see that you are looking to the wall, do you see anything? Do
you see anything else? Do you hear voices?
Doctor, do you see the spiders I see? For me, it does not look like
spiders, however, I understand that you can see them at the moment,
but I can assure you that nothing will hurt you!
Analysis of CC
I can see you are scratching; do you feel anything? Do you hear / see
anything?
Do you think any one would like to hurt you? Assure safety!
When did that start? OCD?
How was your sleep?
Full MMS exam
Constitutional symptoms
Causes
DD Any headache / vomiting / neck pain / skin rash / red eyes / any ear
discharge / runny nose / teeth pain / diff swallowing / SOB / cough /
Infection
urine changes / abd pain / calf pain / swelling
Trauma Head trauma? Injury?
Surgery Recent surgeries? Pain at site of injection? Dressing change?
SAD SAD: any shaking / sweating
Medications What about medications, do you have a list with medications? Any
sleeping pills?
Do you have nay long term disease? Kidney? Lung? Heart?
Conclusion
It looks like you have a medical condition called delirium it is a serious
condition. It is reversible, fluctuating, impairment of LOC. It affects 25%
of Hospitalized people.
Will give medication to help you calm down
Will have a nurse close by if you need any thing
Will keep the room quiet and well lit
Will come back again to see you
Notes:
- It the patient is not cooperative, keeps repeating I do not know; start to ask the questions of the
MMS exam, they will go with you. After you finish, you can continue the rest of your exam
- If the patient is starring at the wall; ask him: I can see that you are looking to the wall, do you see
anything there?
- Mental status exam = psychiatric interview
- For delirium; we do the MMS exam daily until he improves
- For dementia; we do the MMS exam every 3-6 months; for follow-up
If confused patient (long case examination)
GCS: only if the patient is poorly responsive
MMS
Cranial nerves
Body:
- Pronator drift
- Hoffmans reflex thumb flexion UMNL
- Cerebellar tests: finger to nose, rapid alternating movements
- Power / sensation / reflexes
Patient standing: gait, Romberg test, planter flexion power
Patient supine: tone
OSCE-guide-III.doc
Psychiatry
2- Smoking history:
When did you start smoking? For how many years?
How many cigarettes per day?
3- Reasons (motivations): to seek smoking cessation
4- Previous attempts: How many times? Why did you fail? When was the last time?
EMPATHY: failure is a normal part of trying to stop
5- Is there any other smoker in your home? Is she/he willing to quit? It will be a great idea if
both of you tried to quit at the same time, this will increase the success rate of your trial.
If she/he would like to know more information or need help, I will be more than happy to
meet her/him, we can arrange a meeting
6- Impact (complications of smoking):
Cancer (lung hemoptysis, tongue, nasopharynx, urinary bladder, other cancers)
Cardio vascular hazards (myocardial ischemia)
7- Red flags:
Constitutional symptoms
Risk factors (personal history or family history) of:
Heart disease / attack / HTN
Diabetes mellitus / hyper-cholesterolemia
8- Plan:
STAR:
i. Set a quit date, print papers with this date and stick it under your vision
so that you see it frequently during the day
ii. Tell your family, friends, they will be your support
iii. Anticipate the challenges you will face (nicotine-withdrawal effects:
headache, nausea and a craving for tobacco, insomnia, irritability,
anxiety, and weight gain)
iv. Remove cigarettes and other tobacco products (e.g. ashtrays) from your
home, car, and work
Nicotine Replacement Therapy:
i. Nicotine patch [21 mg (if smoking > 25 cig/day), 14 mg, 7 mg]
ii. Nicotine gums
iii. Nicotine inhaler
Psychological support for smoking cessation (to the craving):
i. Zyban (Bupropion):
+ used with tapering smoking for 2 weeks, then stop smoking
+ 150 mg qAM x 3 days then 150 mg bid x 3 months
+ Contra-indications: epilepsy, seizure disorder, eating disorders, patients
undergoing abrupt discontinuation of ethanol or sedatives
ii. Champix (Varenicline): urge to smoke and withdrawal symptoms
+ 0.5 mg qAM x 3 d then 0.5 mg bid x 4 d then 1 mg bid x 3 months
Investigations:
i. CBC / urinalysis / lipid profile
ii. If there is risk factors for heart diseases: stress ECG test
iii. If patient is worried, or if there is hemoptysis: chest x-ray
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Psychiatry
A 71 years old with cancer colon, patient concerns: afraid of living with colostomy / concerned about
being a burden to the family / afraid of complications of the surgery (a friend died in similar surgery)
A 70 years old lady with lung cancer, refusing the surgery because her husband died 30 years ago in a
surgery (she does not know why) / she thinks that people die from the anesthesia
OSCE-guide-III.doc
Psychiatry
Truth telling
Usually a son or daughter asking you not to inform the patient (parent / grandparent) about his
terminal illness or advanced condition
Introduction:
- Well, it is not unusual for families to have that request!
- Why you do not what her/him to know? (cant handle the bad news, fragile personality,
depression, )
- Does the patient have advanced directive? Will? Have discussed this before?
Explain patient must be told:
- Well, you know your loved one the best, given her/his previous reaction, it is reasonable
to have that concern.
- On the other hand, the patient has the right to know, we can not hold this right, besides,
usually; people will go through different stages when they react to bad news, we have
specialists here who can really help the patient and family to go through these stages.
Explain the reasons to tell:
- Patient has the right to know
- Patient will have suspicion about his own condition
- We need to discuss the treatment options, and it is the decision on the patient
- Patient may need to start some arrangements
Explain the implications not to tell:
- It is difficult to hide, it is a team work, will eventually know or find out
- Patient will lose the trust to doctors in general
Decision:
- Will talk to the patient to see if she/he wants to know all the details or not?!!
o If yes, we have to tell her/him
o If no, we will ask if she/he would like us to inform someone else
- In all cases, if the patient asks, we have to tell her/him
Conclusion:
- I can tell that the patient has a very caring family, it must be very hard on the family as
well, if they need someone to talk to cope, I can arrange that if they want
- I can give the family a little bit more time to think and we will talk again, patient will
eventually need to know the truth.
OSCE-guide-III.doc
Psychiatry
Organ Donation
Explain resuscitation effort
- What has been done to the patient resuscitation
- When he came in, he was not breathing, we put down a tube, his heart was not beating,
we did the compression
- What is the outcome, patient is not responding to treatment due to the severe trauma to
the head.
Explain the condition: brain death
- Patient is in a state called the brain death, (check with the relatives if they know this
terminology)
o Irreversible brain damage, no functioning at all
o Not responding to light, to pain
o No spontaneous breathing, will never gain consciousness, when we stop the
machine, he does not breathe
o Legal term for death.
- Confirmed by two nerve specialists: neurologist / neurosurgeon:
- Show empathy: sorry for the loss, patient was young / healthy / family needs him /
Give time to family to recall how active and how nice he was
Bring the issue of organ donation:
- He was healthy, good candidate for organ donation
- If he had advanced will, driver license
- What familys view about this
- It is familys decision now, the decision is a life gift
Explain how to do it
- We have a team to do that, they will respond very quickly
- Many organs can be used
- There is time limit; decision should be made within the next 24 hrs
- You will be notified which organ used and where to go, but you wont get the
individuals name
Explain funeral
- It wont affect the arrangement for funeral
- Still can have the open casket, wont affect the face
Address any questions or concerns
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Psychiatry
OCD
-
Obsessions:
- Type of obsession: dirt and contamination, orderliness, religious, checking and
rechecking?
- Do you feel that these obsessions are not real?
- Do you want to get rid of them?
- What do you do to overcome the stress created by these ideas?
- How many times do you wash your hands? How long do you take in a shower?
- Impact on life, work,
MOAPS:
- Screen for mood disorders
- Screen for organic causes
- Screen for other types of anxiety disorder,
- Screen for psychosis
- Screen for suicide, homicide, self care
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Psychiatry
NOTES
OSCE-guide-III.doc